Search

Highlights • Takotsubo syndrome (TTS) has become a globally recognized disease and its spectrum has been widened based on the observations using multimodality images. • Despite the long-standing clinical experience and efforts in basic research, its pathophysiology and specific treatments have not been well established. • We should always remember possible cardiovascular complications such as coronary artery disease, thromboembolism, myocarditis, and TTS in patients with COVID-19., Takotsubo cardiomyopathy or takotsubo syndrome (TTS) has become a well-known disease not only in Japan but also in the rest of the world. Early reports suggested that TTS is a self-limiting disease with better prognosis than acute coronary syndrome. However, recent data showed that TTS is not a benign disease as compared with acute coronary syndrome. In addition to the apical ballooning, several other types of wall motion abnormalities have been classified as variants of TTS. In particular, right ventricular involvement, or biventricular TTS, is not uncommon and is associated with poor in-hospital as well as long-term outcomes. With respect to the pathophysiology, modulation (desensitization) of the beta-adrenergic receptor is suspected as a possible mechanism for transiently depressed myocardial contraction. Although specific treatments to improve prognosis of TTS are still uncertain, observational data suggest favorable impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Finally, in the era of COVID-19, we should pay attention to a variety of cardiovascular conditions related to COVID-19. TTS is one of these conditions that can be triggered by both emotional and physical impact of the COVID-19 pandemic.

We report a case of atrial trigeminy induced only at a specific pacing cycle length in a patient with residual pulmonary vein conduction gap.

BACKGROUND The aortic valve area index (AVAI) in aortic stenosis (AS) is measured by echocardiography with a continuity equation using the stroke volume index by Doppler (SVIDoppler) or biplane Simpson (SVIBiplane) method. AVAIDopplerand AVAIBiplaneoften show discrepancy due to differences between SVIDopplerand SVIBiplane. The degree of discrepancy and utility of combined AVAIs have not been investigated in a large population of AS patients, and the characteristics of subjects with larger discrepancies are unknown.Methods and Results:We studied 820 patients with significant AS (AVADoppler

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase. Electronic supplementary material The online version of this article (10.1007/s12574-020-00480-y) contains supplementary material, which is available to authorized users.

Highlights • We demonstrated the first patient with COVID-19 developing an isolated SCC lesion on brain MRI, suggestive of mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). • We showed that cerebellar ataxia could be developed as the initial manifestation of COVID-19. • MERS can be considered as a differential diagnosis for neurological symptoms of COVID-19, especially when patients develop transient cerebellar ataxia or disorientation.

AIMS: Resting echocardiography is a valuable method for detecting subclinical heart failure (HF) in patients with diabetes mellitus (DM). However, few studies have assessed the incremental value of diastolic stress for detecting subclinical HF in this population. METHODS AND RESULTS: Asymptomatic patients with Type 2 DM were prospectively enrolled. Subclinical HF was assessed using systolic dysfunction (left ventricular longitudinal strain 10). Metabolic equivalents (METs) were calculated using treadmill speed and grade, and functional capacity was assessed by percent-predicted METs (ppMETs). Among 161 patients studied (mean age of 59 ± 11 years and 57% male sex), subclinical HF was observed in 68% at rest and in 79% with exercise. Among characteristics, diastolic stress had the highest yield in improving detection of HF with 57% of abnormal cases after exercise and 45% at rest. Patients with revealed diastolic dysfunction during stress had significantly lower exercise capacity than patients with normal diastolic stress (7.3 ± 2.1 vs. 8.8 ± 2.5, P 10 (beta = −0.17) were independently associated with peak METs (combined R(2) = 0.46). A network correlation map revealed the connectivity of peak METs and diastolic properties as central features in patients with DM. CONCLUSION: Diastolic stress test improves the detection of subclinical HF in patients with diabetes mellitus.

Tenascin-C (TNC) is an extracellular matrix protein that is transiently expressed in close association with tissue remodeling in various organs. Expression of TNC in patients with tubulointerstitial nephritis (TIN) is not well-characterized. Using renal biopsy specimens from 25 patients with TIN and 8 patients with thin basement membrane disease (controls), we assessed immunohistochemical staining for TNC and investigated its relation with clinicopathologic data. TNC was undetectable in the controls, but TNC was observed in the interstitium of specimens from all patients with TIN, and strong TNC staining was detected within active tubulitis lesions. TNC was not principally expressed in glomeruli, and it was also absent from scar tissue. Comparison with Sirius red staining revealed that TNC was present where collagen fibers had not yet formed. The percent area of TNC within the interstitium (% TNC-positive area) showed a significant negative correlation with illness duration and significant positive correlations with the serum CRP level and eGFR aggravation, both of which reflect disease activity. On the other hand, no correlation was found between % TNC-positive area and eGFR recovery during 2 years of follow up. Examination of renal biopsy specimens from TIN patients revealed that TNC appears during the active stage of inflammation and then disappears with healing. This suggests that TNC expression reflects TIN disease activity, but not prognosis.

Nutcracker syndrome (NCS) refers to compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA). The clinical presentation of NCS includes hematuria, abdominal and left flank pain, gonadal varices, and varicocele formation. Theoretically, thrombosis can occur in the LRV in patients with NCS. However, an isolated solitary left renal vein thrombus (LRVT) complicating NCS is rare. In addition, the clinical features of an LRVT complicating NCS remain unclear. We describe a 43-year-old woman presenting with an asymptomatic LRVT complicating NCS. She was referred to our hospital for investigation of dysfunctional uterine bleeding, and detailed examination revealed endometrial cancer. Computed tomography angiography (CTA) and Doppler ultrasonography revealed compression of the LRV between the aorta and the SMA, as well as an LRVT. CTA performed 4 months after the administration of an anticoagulant showed complete disappearance of the LRVT. We have also included a review of published reports describing LRVT complicating NCS and discussed the clinical features of such a presentation.

Background: The association between guideline adherence and long-term outcomes in patients with acute myocardial infarction in real-world clinical practice remains unclear. Methods: We investigated 3283 consecutive patients with acute myocardial infarction who were selected from a prospective, nation-wide, multicentre registry (J-MINUET) database covering 28 institutions in Japan between July 2012 and March 2014. Among the 2757 eligible patients, we evaluated the use of seven guideline-recommended therapies, including urgent revascularisation, door-to-balloon time of 90 minutes or less, and five discharge medications (P2Y12 inhibitors on aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, lipid-lowering drugs). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure and urgent revascularisation for unstable angina up to 3 years. Results: The overall median composite guideline adherence was 85.7%. Patients were divided into the following three groups: complete (100%) adherence group (n=862); moderate adherence (75% to Conclusion: The use of guideline-based therapies for patients with acute myocardial infarction in contemporary clinical practice was associated with significant decreases in adverse long-term clinical outcomes. Trial registration: UMIN Unique trial Number: UMIN000010037

Previous studies have demonstrated that use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) was associated with lower incidence of death, myocardial infarction, and target vessel revascularization. Recently, optical coherence tomography (OCT) has emerged as an alternative intravascular imaging device with better resolution. The aim of this study was to investigate frequency and prognostic impact of IVUS or OCT-guided PCI during urgent revascularization for acute myocardial infarction diagnosed by the universal definition. A total of 2788 patients who underwent urgent PCI were selected from a multicenter, Japanese registry of acute myocardial infarction diagnosed by universal definition (J-MINUET). Frequency, clinical characteristics and prognostic impact of the IVUS-, or OCT- guided PCI were investigated. Clinical endpoint was in-hospital death. Angiography-, IVUS-, and OCT-guided urgent PCI were performed in 689 (24.7%), 1947 (69.8%), and 152 (5.5%) patients. In-hospital death in each group was 10.4%, 5.1%, and 3.3%, respectively (P

Background The appropriate number of board-certified cardiologists (BCC) for the treatment of acute myocardial infarction (AMI) has not been thoroughly examined in Japan. This study investigated whether the number of BCC/50 cardiovascular beds affects acute outcome in AMI treatment. Methods and Results: Data on 751 board-certified teaching hospitals and 63,603 patients with AMI were obtained from the Japanese Registry Of All cardiac and vascular Diseases (JROAD) and JROAD Diagnosis Procedure Combination (JROAD-DPC) databases between 1 April 2012 and 31 March 2014. The hospitals were categorized into 3 groups based on the median number of BCC/50 cardiovascular beds: first tertile, 5.0 (IQR, 4.0-5.7); second, 8.3 (IQR, 7.4-9.8); third, 15.3 (IQR, 12.5-22.7), and the patients with AMI admitted to the categorized hospitals were compared (first tertile, 12,002 patients; second, 23,930; third, 27,671). On hierarchical logistic modeling, the adjusted OR for 30-day mortality were 0.86 (95% CI: 0.74-1.00) for the second tertile and 0.75 (95% CI: 0.65-0.88) for the third tertile. Conclusions Patients with AMI admitted to hospitals with a large number of BCC/50 cardiovascular beds had a lower 30-day mortality rate. This tendency was independent of patient and hospital characteristics. This is the first study to provide new information on the association between the number of BCC and in-hospital AMI-related mortality in Japan.

Precordial lead T‐wave inversion subsequent to early repolarization is thought to be a normal variant in African athletes and that additional testing is unnecessary. With the increasing number of foreign people living in and traveling to Asian countries, it is becoming crucial for Asian physicians to comprehend the abnormal ECG change in African athletes.

A 64-year-old woman presented to the hospital with a complaint of dyspnea on effort. The 12‑lead electrocardiogram showed a baseline complete left bundle-branch block, in which the right bundle developed >2:1 block. The subsequent blocked sinus impulse resulted in a ventricular pause that caused the ventricular escape presenting as a QRS complex with right bundle-branch block pattern. However, some of them disclosed typical fusion beats and led to interference dissociation. Although other possibilities including Lenegre's disease or myocardial disease were not excluded, the effective refractory period of both bundle branches degenerated by myocardial ischemia might be attributed to this rhythm.

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 (

Background Various unfavorable echocardiographic findings other than apical ballooning, such as right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus, occur in takotsubo cardiomyopathy. Occasionally, these findings are observed simultaneously in a single patient. This study was performed to investigate the prevalence and characteristics of patients with multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy and their associations with adverse outcomes. Methods The echocardiographic images of 113 patients with takotsubo cardiomyopathy (mean age, 72.7 ± 11.4 years; 29 men) were retrospectively reviewed. According to the number of unfavorable echocardiographic findings, patients were classified into a low-risk group (zero or one finding), an intermediate-risk group (two findings), and a high-risk group (three or more findings). In-hospital events were defined as a composite of acute heart failure, shock, ventricular tachyarrhythmia, and in-hospital death. Results Apical ballooning, right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus were observed in 92 (81.4%), 21 (18.6%), 17 (15.0%), 11 (9.7%), and three (2.7%) patients, respectively. There were 77 (68.1%), 25 (22.1%), and 11 (9.7%) patients in the low-, intermediate-, and high-risk groups, respectively. Logistic regression analysis indicated that being in the high-risk group had a significant association with in-hospital events (odds ratio, 8.74, P = .003) and death (odds ratio, 16.9; P = .027) compared with being in the low-risk group. Net reclassification improvement indicated that adding this risk group classification to known clinical factors that are associated with adverse outcomes could yield incremental information regarding patients with takotsubo cardiomyopathy with in-hospital events (net reclassification improvement, 0.59; P = .002). Conclusions Multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy are not uncommon and are associated with increased in-hospital events and mortality.

Background We previously reported that pulmonary capillary wedge pressure (PCWP) was noninvasively evaluated by 2D speckle tracking echocardiography (STE). Recently, novel software was introduced to examine volume and function of left ventricular and left atrium (LA) by 3D-STE automatically. Purpose We sought to compare the PCWP estimated by conventional 2D-STE (2D-ePCWP) and by novel 3D-STE (3D-ePCWP), and validate those values by cardiac catheterization. Methods Echocardiography and catheterization were performed in 29 patients (age 72±2) (7 ischemic heart disease, 2 hypertensive heart disease, 5 dilated cardiomyopathy, 12 valvular heart disease and 3 primary pulmonary hypertension).The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 x Log (left atrial active emptying function/minimum volume) as we previously reported. Echocardiography was performed just before the catheterization and we analyzed the 2D and 3D data by novel off-line software. 3D data was automatically analyzed and the border settings were fixed at default (ES60, ED30) (Figure). Results 2D-ePCWP and 3D-ePCWP had a good correlation with PCWP invasively obtained by catheterization (r=0.87 and 0.83, respectively, both p Conclusion This study demonstrated that PCWP might be noninvasively assessed by not only 2D-STE but also 3D-STE with reasonable accuracy and 3D-STE might have utility and value in the routine clinical practice.

Background Left ventricular (LV) relaxation (eTau) and pulmonary capillary wedge pressure (ePCWP) were reported to be estimated by speckle tracking echocardiography (STE). LV camber stiffness (e-c stiffness) may be estimated with the use of 2 diastolic pressure-volume coordinates. The minimum diastolic pressure (mP) is reported to have a strong correlation with Tau. Purpose We sought to examine the impact of hypertension on LV diastolic function and LA properties and to elucidate the feature of hypertensive heart failure with preserved EF (HFpEF). Methods The e', E/e', Tau, PCWP, LVEDP, LV stiffness, LAV, LA emptying function (LAEF) and LA strain were examined in 53 controls (age 66±11), 136 hypertensive patients (HTN) with normal EF (69±11) and 39 HFpEF (77±14). ePCWP and estimated EDP (eEDP) was calculated as previously reported. Tau was calculated as isovolumic relaxation time/(ln 0.9 x systolic blood pressure − ln PCWP). Myocardial stiffness (e-m stiffness) was estimated as LVED stress/LV strain. LV c-stiffness was calculated as LV pressure change (from mP to EDP) obtained by catheterization divided by LV volume change. Estimated LV c-stiffness (e-c-stiffness) was noninvasively obtained using e-mP and e-EDP. The eTau, eEDP and e-mP by STE were validated by catheterization (n=126). Results The mP had a good correlation with Tau (r=0.70, p LV diastoric function Variables Control HTN HFpEF LVEF, % 68±6 68±8 63±9*+ LV longitudinal strain x (s–1) 19.1±3.0 16.8±4.3* 14.5±5.1*+ E/e' 9.2±2.6 11.6±4.5* 15.9±7.9*+ eTau, ms 35±12 48±17* 59±17*+ ePCWP, mmHg 7.3±2.7 8.3±4.3 15.0±4.4*+ eLVEDP, mmHg 9.4±2.2 10.4±3.5 15.9±3.7*+ LV e-myocardial stiffness, kdynes/cm 0.56±0.25 0.69±0.56 1.27±0.71*+ LV e-chamber stiffness, mmHg/ml 0.19±0.06 0.20±0.08 0.36±0.19*+ Maximum LAVI, ml/m2 42±15 50±21* 68±17*+ Total LAEF, % 55±7 51±11 36±12*+ LA peak strain 41±15 40±17 19±8*+ *p Conclusion We demonstrated that LV diastolic function in HTN may be accurately and noninvasively evaluated by STE.

Background Left ventricular (LV) diastolic function is mainly composed of LV relaxation and LV stiffness. We reported that pulmonary capillary wedge pressure (ePCWP) and LV relaxation assessed by Tau (eTau) are noninvasively evaluated by speckle tracking echocardiography (STE). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau. Therefore, LV chamber stiffness (c-stiffness) may be assessed with the use of two LV diastolic pressure-volume coordinates: the mLVP and volume and the end-diastolic pressure (EDP) and volume. Purpose We sought to noninvasively assess LV stiffness using STE and validate the value by cardiac catheterization. Methods Echocardiography and catheterization were performed in 124 patients (age 72±8) (70 angina pectoris, 20 prior myocardial infarction, 19 hypertensive heart disease, 11 congestive heart failure and 4 paroxysmal atrial fibrillation). The ePCWP (mmHg) is noninvasively obtained as 10.8 − 12.4 × Log (left atrial active emptying function/minimum volume) and the eTau (ms) is obtained as isovolumic relaxation time/(ln 0.9 × systolic blood pressure − ln ePCWP) as previously reported. The mLVP (e-mLVP) was estimate using Tau. The estimated EDP (e-EDP) was calculated as 12.3 − 10.1 × Log (left atrial active emptying function / minimum volume). LV c-stiffness (mmHg/ml) was calculated as LV pressure change (from mLVP to EDP) obtained by catheterization divided by LV volume change during diastole which equals to stroke volume by echocardiography. Estimated c-stiffness (e-c-stiffness) was noninvasively obtained using e-mLVP and e-EDP. Furthermore, LV myocardial stiffness (m-stiffness) was calculated by LVED stress / LV longitudinal strain by STE, where LV stress (kdynes/cm2) was calculated as 0.334 × pressure × dimension / [thickness (1 + thickness/dimension)]. The estimated m-stiffness (e-m-stiffness) was calculated using e-EDP. Results The eTau and e-EDP estimated by STE had a good correlation with Tau and EDP invasively obtained by catheterization (r=0.75 and 0.63, respectively, both p Conclusion This study demonstrated that LV stiffness may be noninvasively assessed by STE with reasonable accuracy and may have utility and value in the routine clinical practice for the diagnosis and treatment in patients with diastolic dysfunction.

Background Left ventricular (LV) pressure-strain and pressure-volume (P-V) loop area reflect global myocardial work (MW) and stroke work (SW), but clinical use of these indexes is limited by the need of invasive pressure measurement. A noninvasive method to obtain LV pressure-strain loop area was recently introduced to examine MW by speckle tracking echocardiography (STE). Purpose We sought to evaluate the impact of preload change on MW and SW obtained using this novel method and to examine the utility to assess LV contractile performance by the SW and end-diastolic volume (EDV) relation (SW-VED) in patient with hemodialysis (HD). Methods LV pressure in a cardiac cycle was estimated using systolic blood pressure (SBP), LV minimum diastolic pressure (mDP) and end-diastolic pressure (EDP) in 20 HD patients (age 67±9)and 25 controls (age 67±9) by utilizing the profile of an empiric, normalized reference curve adjusted according to the duration of LV isovolumic and ejection phases as defined by timing of aortic and mitral valve events by echocardiography. Pulmonary capillary wedge pressure (ePCWP) is estimated as 10.8 – 12.4 × Log (left atrial active emptying function/minimum volume): KT index as previously reported. LVEDP were estimated as 12.3 – 10.1 × KT index. We examined the relation between LV pressure decline (Tau) and mDP by catheterization in 126 patients. Tau is estimated as isovolumic relaxation time/(ln 0.9 × systolic BP − ln ePCWP) as previously reported. SW was obtained by P-V loop area using the combination of pressure (SBP, mDP and EDP) and LV volume by 3D-STE. Echo parameters and BP were measured before and after HD and before and after leg up in controls. Results The mDP obtained by catheterization had a good correlation with Tau (Tau = 33.7 + 2.06 × mDP, r=0.70, p Conclusion LVSW noninvasively obtained by P-V loop area was increased in controls associated with increased preload and decreased in HD with decreased preload and SW-VED was deceased in HD. This novel and noninvasive method may be of potential utility to assess LV contractility and have a clinical interest and value to assess LV function.

Background Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) has been widely used in clinical settings. Although favorable results of imaging-guided percutaneous coronary intervention (PCI) compared with angio-guided PCI were observed in several studies, impacts of institutional-based usage frequency, about imaging-guided PCI, have not been well elucidated. Methods To elucidate the impact of imaging-guided PCI and the effects of frequency of its usage, we analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48 hours of onset from July 2012 to March 2014. Clinical follow-up data was obtained for 3 years. In this sub-study, a total of 2,788 patients who underwent urgent PCI having detailed procedural information were enrolled. We analyzed the differences of utilization rates of imaging-guided PCI among the participating institutions and the impacts for the clinical events. The participating institutions were divided into 3 groups by the frequency of IVUS usage: low frequency institutions: under 50%; moderate frequency institutions: 50% to 90%; and, high frequency institutions: over 90%. Results In this cohort registry, patients were enrolled from 28 institutions. The utilization rate of coronary imaging varied widely depending on each institution from 15.4% to 100% (mean 85.7%±24.3, median 97.4%). When the institutions were divided into 3 groups by the frequency of intravascular imaging usage, four low frequency institutions enrolled 295 patients, five moderate frequency institutions enrolled 624 patients, and 19 high frequency institutions enrolled 1,491 patients. Although the incidence of MACE (death, MI, stroke, cardiac failure, or revascularization for unstable angina) decreased stepwise (33.2%, 23.7%, and 19.7%) (gray bar in the Figure), the event rates of the imaging-guided PCI cases among the 3 groups were comparable (21.6%, 21.9%, and 19.6%) (white bar in the Figure). On the other hand, a gradual event reduction between the 3 groups was observed in the angio-guided PCI cases (black bar in the Figure). In comparison of MACE rate between imaging-guided and angio-guided PCI, there were statistically significant differences in the low frequency and moderate frequency institutions (p=0.001 and p=0.012, respectively). In contrast, comparable event rates were observed in the high frequency institutions (p=0.441). MACE rate by imaging usage frequency Conclusions In Japanese ACS patients treated with imaging-guided PCI, better suppression of clinical events during 3-year was found in the institutions with the more frequent use of intravascular imaging, mainly due to stepwise event suppression in the cases of angio-guided PCI. On the other hand, the clinical benefit of coronary imaging was obtained independently of the frequency of use and its experience.

Introduction Left ventricular (LV) pressure-volume (P-V) loop area reflects stroke work (SW), but clinical use of this index is limited by the need of invasive pressure measurement. A noninvasive method to obtain LV pressure-strain loop was recently introduced to assess myocardial work (MW). The minimum LV diastolic pressure (mLVP) was reported to have a strong correlation with Tau and we reported that Tau was noninvasively evaluated by speckle tracking echocardiography (STE). Purpose We sought to evaluate the impact of preload change by leg lifts on LV SW noninvasively obtained by the novel method and to examine the utility to assess LV contractility by SW and end-diastolic (ED) volume relation (SW-VED). Methods Thirty six controls (age 71±10) and 30 patients with heart failure with reduced ejection fraction (EF) Results LVEF and longitudinal strain in HF before leg up by 3D-STE were lower compared to normal (LVEF; normal: 58±5 vs HF: 39±10*% and strain; −12±3 vs −8±3%*, *p Conclusion LV SW noninvasively obtained by P-V loop area was increased after leg up in both normal and HF but SW-VED in HF was smaller than normal, indicating reduced contractility in HF. This noninvasive method may be a new echocardiographic approach for quantification of LV SW and contractility.

We report a 55‐year‐old man who was resuscitated from out‐of‐hospital cardiac arrest and subsequently developed three episodes of ventricular fibrillation (VF) on the same day. Early repolarization (ER) pattern was not significant (

Background Little evidence is available about the number of cardiologists required for appropriate treatment of heart failure ( HF ). Our objective was to determine the association between the number of cardiologists per cardiology beds for treating patients with acute HF and in‐hospital mortality. Methods and Results This was a cross‐sectional study, and we used the Japanese Registry of All Cardiac and Vascular Diseases Diagnosis Procedure Combination discharge database. The data of patients with HF on emergency admission from April 1, 2012, to March 31, 2014, were extracted. The patients were categorized into 4 groups by the quartiles of the numbers of cardiologists per 50 cardiovascular beds (first group: median, 4.4 [interquartile range, 3.5–5.0]; second group: median, 6.7 [interquartile range, 6.5–7.5]; third group: median, 9.7 [interquartile range, 8.8–10.1]; and fourth group: median, 16.7 [interquartile range, 14.0–23.8]). Using multilevel mixed‐effect logistics regression, we determined adjusted odds ratios for in‐hospital mortality. We identified 154 290 patients with HF on emergency admissions. There were 29 626, 36 587, 46 451, and 41 626 patients in the first, second, third, and fourth groups, respectively. HF severity, on the basis of New York Heart Association classification, was similar in the 3 groups. Adjusted odds ratios (95% CIs) for in‐hospital mortality were 0.92 (0.82–1.04; P =0.20), 0.82 (0.72–0.92; P P Conclusions Patients hospitalized for HF in hospitals with larger numbers of cardiologists per cardiovascular beds had lower 30‐day mortality.

Secondary or functional mitral regurgitation (FMR) has been reported associated with poor prognosis in patients with ischemic or non-ischemic cardiomyopathy. Prognostic impact of the FMR in myocardial infarction with preserved ejection fraction (MIpEF) is unknown. The aim of this study was to investigate predictors and prognostic impact of FMR in MIpEF. A total of 556 patients with MIpEF were selected from the Bell Land General Hospital MI (BELAMI) registry (n = 953). Patients were grouped according to the presence or absence of severe FMR. Clinical endpoint was all-cause death. Severe FMR was present in 26 patients (4.7%) (FMR group) and absent in 530 patients (control). FMR group was older (77.5 ± 7.2 vs. 67.3 ± 11.3 years, P

Takotsubo cardiomyopathy (TC) is characterized as a transient segmental cardiac dysfunction mimicking acute coronary syndrome triggered by emotional or physical stress. Although neurological disorders, infection, malignant diseases, trauma and surgery are known triggers for the development of TC, role of cardiac diseases as underlying conditions for the development of TC is uncertain. The aim of this study was to investigate incidence and clinical characteristics of TC among critically ill cardiac disease patients and to verify that TC may coexist with other cardiac diseases. Between November, 2015 and September, 2017, 862 echocardiographic examinations were recorded from 413 patients who were admitted to the CCU. All echo images, electrocardiograms as well as medical records were reviewed. TC was diagnosed according to the modified Mayo criteria. Takotsubo cardiomyopathy was diagnosed in 29 of 413 patients (7%). TC was a primary diagnosis in 18 patients (group P) and the other 11 patients (group S) were not diagnosed as TC during the CCU stay. Primary diagnosis of these patients was acute myocardial infarction (n = 5), acute decompensated heart failure (two aortic stenosis, one cardiac amyloidosis, and two tachycardia induced cardiomyopathy), and ventricular tachycardia (n = 1). Takotsubo cardiomyopathy may develop in critically ill cardiac diseases but are often underdiagnosed. Careful echocardiographic examination is needed to unveil these “hidden” TC.

BACKGROUND: Ambulatory electrocardiogram (ECG)‐based microvolt T‐wave alternans values measured by the modified moving average method (MMA‐TWA) can be disrupted by T‐wave changes that mimic true repolarization alternans. METHODS: We investigated potential sources of measurement error by studying 19 healthy subjects (12 men; median age, 25) free of known heart disease with 36‐month follow‐up to establish freedom from significant arrhythmia or syncope. All participants underwent 24‐hr continuous 12‐lead ECG monitoring. Causes of automated MMA‐TWA ≥42 µV episodes were classified based on visual inspection. RESULTS: A total of 2,189 episodes of automated MMA‐TWA episodes ≥42 µV were observed in all subjects (peak MMA‐TWA: median, 94 μV; interquartile range, 81–112 μV). All episodes included one or more beats with T‐wave deformation which lacked “repeating ABAB pattern” and therefore were identified as TWA measurement error. Causes of such error were categorized as: (a) artifact [72.6% (1,589/2,189), observed in 19 (100%) subjects], more frequently in limb than precordial leads; (b) T‐wave changes due to changes in heart/body position [25.5% (559/2,189), observed in 14 (73.7%) subjects], frequently observed in leads V1‐2; and (c) postextrasystolic T‐wave changes [1.9% (41/2,189), observed in 2 (10.5%) subjects]. CONCLUSIONS: Relying only on automated MMA‐TWA values obtained during ambulatory ECG monitoring can lead to incorrect measurement of TWA. Our findings offer the potential to reduce false‐positive TWA results and to achieve more accurate detection of true repolarization alternans.

During the past three decades, since the invention of intravascular ultrasound (IVUS), it has become increasingly important as daily clinical applications. However, it evolved with no Japanese standards for the measurement of images, the index of percutaneous coronary intervention (PCI) procedures, and the reporting of results. Accordingly, the purpose of this review article is to provide an optimal and consistent approach to IVUS usage during PCI for clinicians and investigators.

We describe a 41-year-old man with a prior history of myocardial infarction, whose surface 12-lead electrocardiogram did not show typical left bundle-branch block pattern or wide QRS complex. However, electrophysiological study showed distinct left ventricular electrical conduction delays. The surface 12-lead electrocardiogram modified to the paper at 50 mm/s and double standard (20 mm equals 1 mV) revealed obvious notches of the terminal forces of the QRS in leads II, III, aVL, aVF, V3, V4, V5, and V6, these might be partially consistent with left ventricular electrical conduction delay in the scar lesion of the infero-posterior of the ventricle.

Background With aging of the population, the economic burden associated with heart failure (HF) is expected to increase. However, little is known about the hospitalization costs associated with HF in Japan. Methods and Results: In this cross-sectional study, using data from The Japanese Registry of All Cardiac and Vascular Diseases (JROAD) and JROAD-Diagnosis Procedure Combination databases between 2012 and 2014, we evaluated hospitalization costs for acute cardiovascular diseases (CVDs), including HF. A total of $1,187 million/year (44% of the hospitalization costs for acute CVDs) was spent on patients with HF. We identified 273,865 patients with HF and the median cost per patient was $8,089 ($5,362-12,787) per episode. The top 1% of spenders accounted for 8% ($80 million/year), and the top 5% of spenders accounted for 22% ($229 million/year) of the entire cost associated with HF. The costs associated with HF for patients over 75 years of age accounted for 68% of the total cost. Conclusions The costs associated with HF were higher than the hospitalization cost for any other acute CVD in Japan. Understanding how the total hospitalization cost is distributed may allow health providers to utilize limited resources more effectively for patients with HF.

Prognosis after acute decompensated heart failure (ADHF) is poor. An appropriate risk score that would allow for improved care and treatment of ADHF patients after discharge, however, is lacking. Methods and Results: We used 2 HF cohorts, the NARA-HF study and JCARE-CARD, as derivation and validation cohorts, respectively. The primary endpoint was all-cause death during the 2-year follow-up, excluding in-hospital death. Age, hemoglobin (Hb), and brain natriuretic peptide (BNP) at discharge were identified as independent risk factors. We determined 3 categorizations on the basis of these parameters, termed AThe user-friendly A

Aims Excess sodium causes the development of cardiovascular diseases in conjunction with enhancing renin-angiotensin-aldosterone system (RAAS). Natriuretic peptides are sodium regulators and prevent pathological cardiac alterations by counteracting RAAS. However, it is unknown whether natriuretic peptides inhibit the sodium effect in adverse cardiac alterations. Here, we investigated whether excess salt intake could exacerbate cardiac remodeling in mice with impaired natriuretic peptide signaling. Materials and methods Mice lacking the gene encoding the natriuretic peptide receptor, guanylyl cyclase-A (GC-A), and wild-type mice were administered with either a vehicle substance or a subpressor dose of aldosterone (100 ng/kg/min), alongside low salt (0.001% NaCl), normal salt (0.6% NaCl), or high salt diets (6.0% NaCl) for four weeks. Mice were then sacrificed and the hearts were evaluated by histology and RT-PCR. Key findings Salt load did not induce cardiac changes in vehicle and aldosterone groups in wild-type mice. On the other hand, cardiac hypertrophy and interstitial fibrosis were significantly exacerbated in a salt dependent manner in GC-A knockout (KO) mice administered aldosterone, and were associated with enhanced gene expression relevant to hypertrophy, fibrosis, and oxidative stress conditions. Of note, excess salt intake increased the expression of Sgk1, serum and glucocorticoid responsive kinase-1, in aldosterone-administered GC-A KO mice. These molecular changes were not observed in wild-type mice. Significance The results of the present study demonstrate that excess salt intake induced cardiac remodeling in conjunction with aldosterone administration in GC-A KO mice, indicating that GC-A signaling attenuated the deleterious salt effect in aldosterone-induced cardiac remodeling.

Soluble fms-like tyrosine kinase-1 (sFlt-1), an endogenous inhibitor of vascular endothelial growth factor and placental growth factor, is involved in the pathogenesis of cardiovascular disease. However, the significance of sFlt-1 in heart failure has not been fully elucidated. We found that sFlt-1 is decreased in renal failure and serves as a key molecule in atherosclerosis. In this study, we aimed to investigate the role of the decreased sFlt-1 production in heart failure, using sFlt-1 knockout mice. sFlt-1 knockout mice and wild-type mice were subjected to transverse aortic constriction and evaluated after 7 days. The sFlt-1 knockout mice had significantly higher mortality (52% versus 15%; P =0.0002) attributable to heart failure and showed greater cardiac hypertrophy (heart weight to body weight ratio, 8.95±0.45 mg/g in sFlt-1 knockout mice versus 6.60±0.32 mg/g in wild-type mice; P

Objective A high proportion of uncovered stent struts is associated with late stent thrombosis after drug-eluting stent (DES) implantation, which frequently results in myocardial infarction or death. However, the predictors of uncovered stent struts remain unknown. Here, using optical coherence tomography (OCT), we studied the baseline tissue characteristics of the target coronary segment and evaluated their influence on the neointimal coverage of the strut in the chronic phase. Methods We analyzed 118 coronary lesions treated with OCT-guided DES implantation. OCT examinations of target lesions were performed before and after DES implantation, and tissue characteristics were evaluated within 5 mm outer segment of both stent edges. At follow-up, stent strut coverage was assessed within 5 mm inner segment from each stent edge. On the basis of the proportion of uncovered stent struts in the chronic phase, target segments were divided into poorly covered (the highest quartile with % uncovered struts, n=29) and well-covered (the remaining lower quartiles with % uncovered struts, n=89) groups. Results Clinical parameters were similar between the two groups. On baseline OCT images, thin-cap fibroatheroma (TCFA) and large calcification were more frequently observed in the poorly covered group than the well-covered group (10.3 vs. 0.0%, P=0.0032, and 27.6 vs. 9.0%, P=0.017, respectively). Furthermore, multivariable analysis showed TCFA and large calcification at the proximal edge, but not at the distal edge, were predictors of uncover stent struts. Conclusion TCFA and large calcification at the proximal stent edge are strong predictors of uncovered stent struts. OCT is useful for selecting stent landing sites in terms of future occurrence of uncovered stent struts.

Progressive neointimal proliferation may lead to late restenosis and/or neoatherosclerosis after drug-eluting stent (DES) implantation. Late neointimal response may be different among different tissue characteristics. The aim of this study was to assess impact of in-stent neointimal characteristics on late neointimal response following DES implantation.Serial (median 270 days and median 551 days after stent implantation) optical coherence tomography (OCT) examinations were performed in 42 stented lesions from 26 patients. In-stent neointimal tissue was categorized as either homogeneous or heterogeneous neointima based on the OCT appearance at 1st follow-up. Serial changes in neointimal area (NIA) were compared between lesions with homogeneous neointima and those with heterogeneous neointima.At first follow-up, homogeneous neointima was observed in 22 (52%) and heterogeneous neointima in 20 (48%) lesions, respectively. During follow-up, NIA in lesions with homogeneous neointima decreased significantly (1.8±0.93 mm(2) to 1.5±0.88 mm(2), p0.001). On the other hand, NIA in lesions with heterogeneous neointima did not change significantly (2.7±1.8 mm(2) to 2.8±1.6 mm(2), p=0.658). Homogeneous neointima was the only predictor of late neointimal regression (late neointimal regression defined as NIA at first follow-up - NIA at second follow-up0) by multivariable analysis (odds ratio=7.591, 95% confidence interval: 1.616-35.67, p=0.010).OCT characteristics of neointima after DES implantation may be related to late neointimal progression or regression.

Although hyponatremia on admission is a predictor of poor prognosis in acute heart failure (AHF) patients, little is known about the association between changes in sodium level in acute phase and in-hospital mortality. This study was performed to clarify the impact of sodium level improvement in the early phase on prognosis in AHF patients.A total of 882 consecutive hospitalized AHF patients were retrospectively enrolled in this study. Sodium levels were evaluated on days 1 and 3 of admission, and patients were classified into three groups: patients with hyponatremia on admission and day 3 (hypo-hypo group); patients with hyponatremia on admission and normonatremia on day 3 (hypo-normo group); and patients with normonatremia on admission (normo group).Hyponatremia (sodium ≤135 mEq/L) was observed in 14.3% of cases. In multivariate linear regression analysis, age (standardized beta=0.084), male gender (standardized beta=-0.072), history of ischemic heart disease (standardized beta=-0.069), baseline sodium level (standardized beta=-0.435), and tolvaptan use (standardized beta=0.093) were independent determinants of changes in sodium level from day 1 to day 3. In-hospital mortality rates were significantly higher in the hypo-hypo group (23.7%) and hypo-normo group (9.7%) than the normo group (6.9%) (p0.001). After adjustment for covariates, both hypo-normo (OR: 0.28, 95% CI: 0.08-0.93, p=0.038) and normo (OR: 0.42, 95% CI: 0.20-0.88, p=0.022) groups showed significantly lower in-hospital mortality rates than the hypo-hypo group.Early recovery from hyponatremia in AHF patients is associated with lower in-hospital mortality rate.

It has been >25 years since the first report of the takotsubo cardiomyopathy (TC). Although left ventriculography was originally used to depict its typical and impressive wall motion abnormality mimicking "takotsubo", or octopus pot, echocardiography plays a pivotal role in detecting not only its left ventricular (LV) wall motion abnormality, apical ballooning, but also various other findings. First of all, apical ballooning is not an essential finding for TC anymore. Mid-ventricular LV asynergy with or without apical involvement is a basic pattern of the LV wall motion abnormality. Distribution and time course of the asynergy may be best detected by echocardiography and echo provides useful information to differentiate between TC and acute coronary syndrome or acute myocarditis. In addition to the wall motion assessment, echo detects complications of TC such as systolic anterior motion of the mitral leaflet with or without LV outflow obstruction, mitral regurgitation, LV thrombus, right ventricular (RV) involvement. In particular, RV involvement is not an uncommon finding and is associated with worse short-term as well as long-term prognosis. Finally, coronary flow measurements and speckle tracking by echo may offer additional and useful information about pathophysiology and prognosis of TC. In conclusion, echocardiography is a standard imaging modality for detecting various dynamic findings beyond apical ballooning in patients with TC.

High platelet reactivity (HPR) on clopidogrel may be related to stent thrombosis after drug-eluting stent (DES) implantation [(1)][1]. To investigate the relationship between HPR and intrastent thrombi following DES implantation, 202 lesions treated with DES from 109 patients were studied. Coronary

OBJECTIVES The aim is to investigate the usefulness of longitudinal reconstructed optical coherence tomography (OCT) images in selecting the reverse wire (RW) technique for inserting a guidewire into a side branch (SB). BACKGROUND It is sometimes necessary to protect the SB with a guidewire to prevent SB complications in PCI for bifurcation lesions. The RW is a novel method for guidewire insertion into an extremely angulated SB when the standard antegrade wire (AW) approach is difficult. METHODS This retrospective study included 46 consecutive patients who underwent OCT-guided PCI in bifurcation lesions with significant SB stenosis. Patients were divided into two groups: 36 patients with successful guidewire crossing using the AW (AW group) and 10 patients with unsuccessful AW but successful RW guidewire crossing (RW group). SB angle and branch point (BP) slope, defined as the angle between the line connecting the proximal and distal BPs and the vertical, were measured using longitudinal reconstructed OCT images. RESULTS The RW group had a significantly larger SB angle and higher BP slope than the AW group (108.7 ± 11.4° vs. 76.2 ± 14.9°; P

ObjectivesAlthough there are 14 097 board-certified cardiologists in Japan, it is unknown whether the number of institutional board-certified cardiologists is related to the prognosis of cardiovascular disease patients.DesignCross-sectional analysis.SettingData were collected from the nationwide database of acute care hospitals in Japan (2371 hospitals) between 2012 and 2013.ParticipantsA total of 1 422 703 consecutive patients were initially included in this study, but 518 610 patients were excluded due to age Main outcome measuresThe primary outcome was in-hospital mortality due to any cause. For the per-hospital analysis, Poisson regression models were used to estimate the association of board-certified cardiologists with in-hospital mortality, adjusted for hospital facilitation. For the per-patient analysis, hierarchical logistic regression models were used to estimate the ORs of the number of institutional board-certified cardiologists, adjusted for patient demographics, diagnoses, therapies and hospital facilities.ResultsThe regression model of the per-hospital analysis indicated that the number of board-certified cardiologists was associated with a lower rate ratio of in-hospital mortality (rate ratio, 0.988; 95% CI 0.983 to 0.993; pConclusionsAmong cardiovascular disease patients admitted to acute care hospitals in Japan, the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality. These results have implications for national and institutional strategies for determining the required number of board-certified cardiologists.

Accumulating evidence indicates alteration of the β-adrenoceptor (AR), such as desensitization and subtype switching of its coupling G protein, plays a role in the protection against catecholamine toxicity in heart failure. However, in human takotsubo syndrome (TTS), which is associated with a surge of circulating catecholamine in the acute phase, there is no histologic evidence of β-AR alteration. The purpose of this study was to investigate the involvement of alteration of β-AR signaling in the mechanism of TTS development. Left ventricular (LV) biopsied samples from 26 patients with TTS, 19 with normal LV function, and 26 with dilated cardiomyopathy (DCM) were studied. G protein-coupled receptor kinase 2 (GRK2) and β-arrestin2, which initiate the alteration of β-AR signaling, were more abundantly expressed in the myocardium in acute-phase TTS than in those of DCM and normal control as indicated by immunohistochemistry. The percentage of cardiomyocytes that showed positive membrane staining for GRK2 and β-arrestin2 was also significantly higher in acute-phase TTS. Sequential biopsies in the recovery-phase for two patients with TTS revealed that membrane expression of GRK2 and β-arrestin2 faded over time. This study provided the first histologic evidence of the involvement of alteration of β-ARs in the development of TTS.