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Received October 8, 2014; accepted October 22, 2014; released online November 20, 2014 Time for primary review: 13 days Division of Cardiology, Kawasaki Medical School, Kurashiki (T.T., H.O.); Division of Cardiology, Sakakibara Heart Institute of Okayama, Okayama (K.Y.), Japan Mailing address: Hiroyuki Okura, MD, Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192, Japan. E-mail: hokura@fides.dti.ne.jp ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1103 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp New Echo Window to Quantify Eccentric Mitral Regurgitation Using a Transgastric Approach on Transesophageal Echocardiography

The authors present 2 cases of acute pulmonary embolism in which intraoperative trans esophageal echocardiography guided successful surgical embolectomy. In their experi ences, transesophageal echocardiography was a safe and useful method of visualizing and detecting mobile thrombi in the operating room. Thus, it should be used as an intra operative guidance for surgical embolectomy.

A 60-year-old man with a previous history of sirolimus-eluting stent implantation was admitted because of chest pain. Coronary angiography revealed nonsignificant in-stent luminal narrowing at the previously stented segment with an unusual linear peri-stent strut contrast staining. Frequency-domain optical coherence tomography showed a cavity at the segment connecting to the coronary lumen at the distal part of the stent. This unusual “ant-colony”-like appearance of the stented segment may be a subtype of the incomplete stent apposition and/or interstrut hollows.

Objective The conventional mid-esophageal observation by three-dimensional transesophageal echocardiography (3DTEE) sometimes fails to visualize the subvalvular apparatus. In this study, we compared the effectiveness of the transgastric approach by 3DTEE in visualizing the mitral valve complex with the conventional mid-esophageal approach. Methods We studied 10 consecutive patients who underwent mitral valve surgery for functional mitral regurgitation. The anatomy of the mitral complex was interpreted from the 3DTEE data acquired by both the mid-esophageal and the transgastric approach preoperatively. The interpretations of the image of the mid-esophageal approach and the transgastric approach were compared with surgical observations. Results In the concordance rate for surgical observation, the interpretation of the number of papillary heads and chordal distribution for the transgastric observation were superior to those for the mid-esophageal observation both for anterior papillary muscle (P

Although previous randomized and non-randomized studies have demonstrated the safety and efficacy of paclitaxel-eluting stents (PES), a higher revascularization rate has been reported in women than in men. A sub-analysis of the TAXUS Japan Post-market Surveillance Study (TAXUS-PMS) was done to assess the influence of gender on clinical outcome. A total of 2,132 PES-treated Japanese patients (women, n=551) from this registry were analyzed. Subjects were stratified by gender to compare 1-year clinical outcome. PES-treated women were older and more likely to have insulin-treated diabetes and hypertension. In contrast, PES-treated men were more likely to be smokers, have a previous history of myocardial infarction, and lower ejection fraction. While cardiac death, myocardial infarction and stent thrombosis were similar between men and women, major cardiac events tended to be lower in women than in men (6.4% vs. 8.8%, P=0.08). Although women had significantly smaller reference vessel size (2.46±0.53 mm vs. 2.59±0.60 mm, P0.0001), the restenosis rate tended to be lower in women than in men (11.5% vs. 14.8%, P=0.11). Subsequently, the target lesion revascularization rate was significantly lower in women than in men (4.2% vs. 6.5%, P0.05). Despite a higher risk profile, Japanese women treated with PES did not have a higher rate of repeat revascularization or major adverse clinical outcome than PES-treated men at 1 year.

OBJECTIVE: To use intravascular ultrasound in vivo to evaluate changes in the intimal thickness of angiographically normal saphenous vein grafts one year after implantation. DESIGN: Fifteen saphenous vein grafts in 12 patients were examined one month and 12 months after aortocoronary bypass graft surgery with intravascular ultrasound using a 30 MHz transducer. None of the grafts examined showed any angiographic abnormalities. The intimal thickness and intimal area of the graft in the proximal portion were measured on intravascular ultrasound images obtained one month and 12 months after operation. SETTING: General hospital. PATIENTS: Twelve patients who underwent aortocoronary bypass graft surgery. RESULTS: The ultrasound images showed a thin-walled graft with a thin intima one month after operation (mean (SD)) (0.31 (0.09) mm). The intimal thickness of the graft increased significantly to 0.65 (0.08) mm (P < 0.001) 12 months after operation. The intimal area of the graft was 0.90 (0.80) mm2 one month after operation. 12 months after operation the intimal area had increased significantly to 5.26 (1.38) mm2 (P < 0.001). CONCLUSION: Intravascular ultrasound in vivo showed that one year after implantation angiographically normal saphenous vein grafts had a thicker intima than one month after implantation.

Aims Positive arterial remodelling is recognized as one of the morphological characteristics of the vulnerable plaque. Limited data are available on a long-term outcome of acute coronary syndrome (ACS) patients with culprit lesion positive arterial remodelling (PR). The aim of this study was to investigate the long-term impact of culprit lesion PR in patients with ACS. Methods and results In 134 patients with ACS, intravascular ultrasound (IVUS) was performed to assess target lesion remodelling before percutaneous coronary intervention. PR was defined as the ratio of the external elastic membrane cross-sectional area at the target lesion to that of at the proximal reference of >1.05, and intermediate or negative remodelling (IR/NR) was defined as that of ≤1.05. Major adverse cardiac event (MACE) was defined as a composite of death, ACS, and target lesion revascularization. During the follow-up (median 5.8 years), MACE-free survival was significantly lower in the PR group than that in the IR/NR group (log-rank, P = 0.005). Survival and ACS-free survival were also significantly lower in the PR group than that in the IR/NR group (log-rank, both P = 0.04). By multivariable Cox regression analysis, PR (hazard ratio = 2.4, P = 0.02) and diabetes (hazard ratio = 1.9, P = 0.03) were independent predictors of MACE. Conclusion Culprit lesion PR was associated with a poor long-term prognosis in patients with ACS. PR may be a marker of vulnerable patients.

Background Both left atrial spontaneous echo contrast (LASEC) and aortic atherosclerotic plaque (AoP) ≥ 4.0 mm in thickness are predictors of cardiovascular events after stroke. The aim of this study was to investigate impact of AoP ≥ 4.0 mm or LASEC on cardiovascular events in patients with atrial fibrillation (AF). Methods and results One hundred and eight consecutive patients with AF were enrolled and studied. Patients were grouped according to the presence or absence of AoP ≥ 4.0 mm in the proximal aortic arch on transesophageal echocardiography (TEE). Cardiovascular events included death, myocardial infarction, ischemic stroke, systemic embolism and congestive heart failure. During a follow-up period (median, 3.9 years), cardiovascular event-free survival rate was significantly lower in patients with AoP ≥ 4.0 mm than in patients without AoP ≥ 4.0 mm (log-rank, P=0.01). In contrast, patients with LASEC showed a trend toward lower cardiovascular event-free survival than those without LASEC (log-rank, P=0.10). Univariate TEE predictors of cardiovascular events were AoP ≥ 4.0 mm, LASEC and left atrial appendage flow velocity. On multivariate Cox regression analysis, AoP ≥ 4.0 mm was the only TEE predictor of cardiovascular events during follow-up (P=0.02, hazard ratio, 2.6; 95% confidence interval: 1.1-6.0). Conclusions In the present unselected patients with AF, AoP predicted long-term cardiovascular events.

Although echo Doppler machines have consistently advanced within a quarter of a century, age related prevalence of valvular regurgitation detected by currently available echo machines remains uncertain. The aim of this study was to investigate the prevalence and correlates of valvular regurgitation in healthy individuals.A total of 1,333 apparently healthy individuals were enrolled in this study. Echocardiographic examinations were performed using a currently available echo machine. Aortic regurgitation (AR) was detected less frequently (10%) in younger subjects. Prevalence of aortic regurgitation increased with advancing age and reached 46% in their 9th decade. Mitral regurgitation (MR) was detected in two-thirds of the subjects30 years old. Tricuspid regurgitation (TR) was frequently (80%) detected in all age groups. In general, prevalence of valvular regurgitation was higher than those reported previously, except for a relatively lower prevalence of AR in the elderly population. Age was an independent correlate of AR and MR, but not of TR. The presence of AR and MR were independent correlates of TR.In healthy subjects, AR, MR or TR are commonly detected by using a current echo machine. These "physiological" valvular regurgitations should not be considered as a "pathological" valvular heart disease.

ObjectivesThe purposes of this study were to examine whether tethering of the mitral leaflets affects coaptation in patients with functional mitral regurgitation (FMR) and to assess the interaction between the mitral coaptation and mitral regurgitation severity.BackgroundFunctional mitral regurgitation causes restriction of leaflet closure as a result of enhanced tethering of the mitral leaflets and papillary muscle (PM) displacement.MethodsThree-dimensional transesophageal echocardiography was performed in 44 patients with FMR related to the bilateral PM displacement and in 56 controls. The distance between the tip of the anterior or posterior PM and the intervalvular fibrosa were measured as the lateral or medial tethering length (TL) in midsystole. To evaluate the degree of coaptation, coaptation length (CL) at medial, middle, and lateral sites of mitral valve and an estimate of coaptation area (CA) were measured.ResultsThe FMR group showed the significantly decreased CA (1.3 ± 0.4 cm2 vs. 1.6 ± 0.4 cm2, p = 0.005) and CL (medial 3.2 ± 0.9 mm vs. 4.8 ± 0.6 mm, middle 3.8 ± 1.3 mm vs. 5.8 ± 0.7 mm, lateral 3.3 ± 0.9 mm vs. 4.8 ± 0.6 mm; all p < 0.0001) compared with the controls. Each CL correlated negatively and significantly with both medial and lateral TL (all p < 0.0001). Annular area (p = 0.004) was significantly smaller and leaflet-to-annular area ratio (p < 0.0001) was significantly larger in patients with nonsignificant FMR than in the patients with significant (moderate to severe) FMR. Significant correlations were found between effective regurgitant orifice area and CA or each CL (all p < 0.0001).ConclusionsCoaptation decreased significantly in patients with FMR. The CL at each region was related to PM displacement and the indexes of coaptation were associated with mitral regurgitation severity.

Presence of allergy to iodinated contrast may prevent percutaneous coronary intervention (PCI) to be performed. We present a 76-year-old male with a history of allergic reaction to iodinated contrast who successfully underwent intravascular ultrasound (IVUS) and a Doppler guidewire-guided PCI. Stent size was determined based on IVUS. After PCI, stent expansion and a lack of edge dissection or incomplete apposition were confirmed by IVUS and a good antegrade coronary flow was confirmed by a Doppler guidewire. Thus, PCI without contrast injection under IVUS and a Doppler guidewire-guidance may be feasible in selected patients with allergy to iodinated contrast.

Two commercial software systems have become available for quantitation of mitral leaflet and annulus geometry based on three-dimensional (3D) transesophageal echocardiographic (3DTEE) images. The aim of this study is to investigate the accuracy and compatibility of the three-dimensional (3D) measurements by Real View(®) and MVQ(®).3DTEE images were obtained from phantom models with saddle-shaped annulus of mitral valve prolapse and mitral valve tenting. From reconstructed 3D data, prolapse and tenting volume were calculated by both Real View(®) and MVQ(®) and compared with the actual volume.The volume of the phantom models with saddle-shaped annulus measured by Real View(®) (tenting r = 0.99, prolapse r = 0.99) and MVQ(®) (tenting r = 0.99, prolapse r = 0.99) showed good agreement with the actual volume. However, significant difference between Real View(®) and MVQ(®) was observed in the result of quantification (tenting 2.27 ± 1.5 ml versus 2.53 ± 1.6 ml, prolapse 2.55 ± 1.7 ml versus 2.31 ± 1.6 ml, both P 0.05).Although the 2 commercially available systems allow accurate quantitative measurements of the 3D volume, discrepancy in the quantified value as a result of differences in the estimation of annular level is observed. Therefore, we should take into account the characteristics of each software when interpreting analytical results.

The purpose of this document is to make the output of the International Working Group for Intravascular Optical Coherence Tomography (IWG-IVOCT) Standardization and Validation available to medical and scientific communities, through a peer-reviewed publication, in the interest of improving the diagnosis and treatment of patients with atherosclerosis, including coronary artery disease.Intravascular optical coherence tomography (IVOCT) is a catheter-based modality that acquires images at a resolution of ~10 μm, enabling visualization of blood vessel wall microstructure in vivo at an unprecedented level of detail. IVOCT devices are now commercially available worldwide, there is an active user base, and the interest in using this technology is growing. Incorporation of IVOCT in research and daily clinical practice can be facilitated by the development of uniform terminology and consensus-based standards on use of the technology, interpretation of the images, and reporting of IVOCT results.The IWG-IVOCT, comprising more than 260 academic and industry members from Asia, Europe, and the United States, formed in 2008 and convened on the topic of IVOCT standardization through a series of 9 national and international meetings.Knowledge and recommendations from this group on key areas within the IVOCT field were assembled to generate this consensus document, authored by the Writing Committee, composed of academicians who have participated in meetings and/or writing of the text.This document may be broadly used as a standard reference regarding the current state of the IVOCT imaging modality, intended for researchers and clinicians who use IVOCT and analyze IVOCT data.

AIMS Optical coherence tomography (OCT) can delineate calcified plaque without artefacts. The aim of this study was to evaluate the ability of OCT to quantify calcified plaque in ex vivo human coronary arteries. METHODS AND RESULTS Ninety-one coronary segments from 33 consecutive human cadavers were examined. By intravascular ultrasound (IVUS), 32 superficial calcified plaques, defined as the leading edge of the acoustic shadowing appears within the most shallow 50% of the plaque plus media thickness, were selected and compared with corresponding OCT and histological examinations. The area of calcification was measured by planimetry. IVUS significantly underestimated the area of calcification compared with histological examination (y = 0.39x + 0.14, r = 0.78, p < 0.001). Although OCT slightly underestimated the area of calcification (y = 0.67x + 0.53, r = 0.84, p < 0.001), it showed a better correlation with histological examination than IVUS. CONCLUSIONS Both OCT and IVUS underestimated the area of calcification, but OCT estimates of the area of calcification were more accurate than those estimated by IVUS. Thus, OCT may be a more useful clinical tool to quantify calcified plaque.

Background— Positive arterial remodeling and thin fibrous cap are characteristics of rupture-prone or vulnerable plaque. The natural course of the fibrous cap thickness and the relationship between serial arterial remodeling and changes in fibrous cap thickness are unknown. Therefore, the purpose of this study was to evaluate the relationship between changes in fibrous cap thickness and arterial remodeling by using optical coherence tomography (OCT) and intravascular ultrasound (IVUS) during 6-month follow-up. Methods and Results— Both IVUS and OCT examinations were performed on 108 vessels from 36 patients with ischemic heart disease who underwent percutaneous coronary intervention. Fifty-eight fibroatheromas were selected from 82 nonsignificant, nonculprit lesions (angiographic diameter stenosis, 25% to 75%; plaque burden, >40% by IVUS). Fibroatheroma was defined by OCT as lipid-rich plaque in >1 quadrant that has lipid. Thickness of the fibrous cap was measured by OCT. IVUS and OCT examinations were repeated at 6-month follow-up. Serial changes and relationships between IVUS indices and fibrous cap thickness were investigated. Overall, fibrous cap thickness (98.1±38.9 to 96.9±44.5 μm) as well as IVUS indices did not change significantly within 6 months. The percent changes in fibrous cap thickness correlated negatively and significantly ( r =−0.54; P r =−0.42; P =0.001) with the percent changes in external elastic membrane cross-sectional area. Conclusions— Arterial remodeling is related to changes in fibrous cap thickness. Positive arterial remodeling is not only an adaptive process, but also related to thinning of the fibrous cap.

Background— Plaque rupture may be present in the peripheral arteries of the patients at high risk for cardiovascular events and is possibly associated with vascular vulnerability. Methods and Results— One hundred one iliofemoral arteries from 101 patients undergoing angioplasty were studied. Intravascular ultrasound imaging was performed before intervention. Plaque rupture was defined as presence of a cavity that communicated with the lumen with an overlying residual fibrous cap fragment. Incidence, numbers, and location of the plaque rupture were investigated. Plaque rupture was found in 42 of 101 arteries (42%). Patients with plaque rupture had significantly higher prevalence of acute coronary syndrome than did patients without plaque rupture (42% vs 16%, P =0.01). By multivariable logistic regression analysis, acute coronary syndrome ( P =0.004) and male sex ( P =0.01) were independent clinical correlates of plaque rupture. During follow-up (median, 14.7 months), the incidence of major adverse cardiac or cerebrovascular events (death, myocardial infarction, and ischemic stroke) was similar between the 2 groups. The incidence of major adverse cardiac or cerebrovascular events plus peripheral vascular events (unplanned vascular intervention and amputation) was significantly higher in patients with plaque rupture than in patients without plaque rupture (46% vs 21%, P =0.008). By multivariable Cox regression analysis, plaque rupture (hazard ratio=2.80, 95% CI: 1.23 to 6.37, P =0.01) and Fontaine stage IV (hazard ratio=3.50, 95% CI: 1.58 to 7.71, P =0.002) were independent predictors of major adverse cardiac or cerebrovascular events plus peripheral vascular events. Conclusions— Ruptured plaque of the iliofemoral arteries is a common finding. Patients with plaque rupture had a higher prevalence of history of acute coronary syndrome and lower major adverse cardiac or cerebrovascular events plus peripheral vascular event-free survival.

Stent underexpansion is still a concern as a cause of drug-eluting stent (DES) failure. Although the amount of coronary calcification is considered as a contributing factor for stent under expansion, a previous intravascular ultrasound (IVUS) study failed to demonstrate relation between stent

To design the rocket motor, thrust and burning rate of propellant are important factors. The large range of burning rate makes the design criteria increase. The range of burning rate is expanded with catalyst or changing the size of oxidizers, however the range of burning rate of ammonium perchlorate composite propellants is small. Black powder has large range of burning rate. The burning rates of propellants are accelerated by conductive heat of reaction zone, therefore it is possible to increase burning rate by evaluating reaction zone. Reaction zone at burning surface of propellant is less than 1mm at 0.1MPa. It is difficult to observe the reaction zone with video camera and to evaluate gas reaction. We measured temperature histories in this reaction zone with small thermo-couple. The temperature fluctuation occurred near burning surface. We also analyzed the temperature vibration. The temperature fluctuation appeared by combustion of solid particles like aluminum or charcoal. Heat of reaction in gas phase is proportional to the partial derivative of the second order with respect to the distance (heat flow) at steady state. The heat flow fluctuated near the burning surface and heat of reaction generated, and the length, l l l l*, from burning surface to fluctuated heat flow, decreased with increasing the burning rate of black powder. The frequency of heat release vibration is 20Hz in the gas phase. The burning rate increases with decreasing the starting time of heat release and period of combustion in gas phase.

The precursor of plaque rupture is known as thin cap fibroatheroma (TCFA). In the present study, the feasibility and accuracy of optical coherence tomography (OCT) for detecting the frequency and spatial distribution of TCFA was investigated ex vivo, and a 3-vessel OCT analysis was conducted to assess the feasibility of this modality in vivo.In the ex vivo study, 108 coronary arterial segments from 38 human cadavers were examined by OCT, intravascular ultrasound (IVUS) and histology. The 3-vessel IVUS and OCT examinations were performed in 11 patients with acute coronary syndrome. By histological examination, 30 of 77 fibroatheromas were diagnosed as TCFAs, which showed a clear pattern of clustering in the proximal part of each coronary vessel. OCT accurately detected TCFA (sensitivity 90%, specificity 79%). The in vivo OCT study showed that 64% patients with acute coronary syndrome had 1 or more TCFAs.TCFAs, clustering in the proximal segments of the 3 major epicardial coronary arteries, are a common finding in unselected autopsy subjects. OCT is a feasible and accurate modality for detecting TCFA both ex vivo and in vivo.

BACKGROUND Direct measurement of plasma nitric oxide (NO) concentration is possible with a newly developed catheter-type sensor. METHODS AND RESULTS Adult mongrel dogs (n=5) were fed a high-fat diet (120 kcal . kg(-1) . day(-1)) for 8 months, then endothelial function was assessed by the change in NO concentration induced by acetylcholine (ACh) (DeltaNO). Simultaneously, average peak velocity (APV) was obtained by Doppler guide wire. Although fasting plasma glucose levels did not change after high-fat diet, fasting plasma insulin levels increased significantly (103+/-36 vs 106+/-27 mg/dl, P=0.89 and 0.15+/-0.15 vs 0.26+/-0.07 ng/ml, P=0.04, respectively). ACh-induced peak APV after high-fat feeding was not significantly different from that at baseline (ACh 0.1 microg/kg; 43+/-17 vs 51+/-7 cm/s, P=NS, ACh 0.4 microg/kg; 45+/-20 vs 47+/-16 cm/s, P=NS, respectively). The DeltaNO was significantly smaller after high-fat diet than at baseline (ACh 0.1 microg/kg; 2.6+/-1.6 vs 1.0+/-0.5 nmol/L, P=0.03, ACh 0.4 microg/kg; 3.8+/-2.3 vs 1.8+/-1.1 nmol/L, P=0.04, respectively). CONCLUSIONS In high-fat-diet-induced obese dogs NO production was impaired in the early stage when the coronary flow response to ACh may be preserved.

The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneous coronary intervention (PCI).Previous single-center studies have demonstrated the anti-restenotic effect of a peroxisome proliferator-activated receptor gamma agonist, pioglitazone, after PCI.A total of 97 patients with type 2 diabetes mellitus (T2DM) undergoing PCI (bare-metal stents only) were enrolled. After PCI, patients were randomly assigned to either the pioglitazone group (n = 48) or the control group (n = 49). Angiographical and intravascular ultrasound (IVUS) imaging were performed at baseline and repeated at 6-month follow-up. Primary end points included angiographical restenosis and TLR at 6 months follow-up. Secondary end point was in-stent neointimal volume by IVUS.Baseline glucose level and glycosylated hemoglobin (HbA1c) level were similar between the pioglitazone group and the control group. Angiographical restenosis rate was 17% in the pioglitazone group and 35% in control group (p = 0.06). The TLR was significantly lower in pioglitazone group than in control group (12.5% vs. 29.8%, p = 0.04). By IVUS (n = 56), in-stent neointimal volume at 6 months showed a trend toward smaller in the pioglitazone group than in the control group (48.0 +/- 30.2 mm(3) vs. 62.7 +/- 29.0 mm(3), p = 0.07). Neointimal index (neointimal volume/stent volume x 100) was significantly smaller in the pioglitazone group than in the control group (31.1 +/- 14.3% vs. 40.5 +/- 12.9%, p = 0.01).Pioglitazone treatment might suppress in-stent neointimal proliferation and reduce incidence of TLR after PCI in patients with T2DM.

Although left ventricular diastolic function has been shown to deteriorate with advancing age, its gender specific change is unknown. The aim of this study was to investigate age and gender specific changes in tissue Doppler derived left ventrisular diastolic index. A total of 1,333 healthy individual without known heart disease (mean age 55 years, range 10–89) and 138 patients with hypertension (mean 65 years, range 50–89) were enrolled and studied. Using Doppler echocardiography, peak early mitral annular velocity (E′) was recorded and measured from apical 4 chamber view. E′ value was compared between male and female in each age group. (Figure ) Among those aged between 10–19, E′ was similar between male and female. E′ progressively decline with advancing age in both gender, but more so in male than in female until age 50. In subjects with age 50–59 years (mean 55 years), E′ become identical in male and female. After 50 years, E′ decline more so in female than in male. Similarly, E′ was significantly lower in elderly women among hypertensive population. Age-related changes in diastolic indices were gender specific. In the elderly population diastolic function deteliorate more significantly in female gender than in male. These results may explaine the relatively higher incidence in elderly female among patients with diastolic heart failure and higher cardiovascular mortality in female gender.

Single center studies have shown that plaque rupture and positive remodeling are prognostic predictors of acute coronary syndrome (ACS). A total of 119 patients with first ACS events were enrolled in a multicenter, prospective, 3-vessel intravascular ultrasound (IVUS) registry. Pre-intervention IVUS imaging was performed in 98 patients. Remodeling index was defined as lesion site external elastic membrane cross sectional area (EEM CSA) divided by the proximal reference. Arterial remodeling was defined as either positive (PR; remodeling index >1.05) or intermediate/negative (IR/NR; remodeling index

Background The Doppler-derived energy loss coefficient (ELCo), which can take into account the pressure recovery phenomenon and reconcile discrepancies between the aortic valve effective orifice area (EOA) obtained by the Gorlin formula using a catheter (EOAcath) and the EOA obtained by the Doppler continuity equation (EOADop), is proposed as an equivalent index to represent EOAcath. Therefore, the purpose of this study was to evaluate the clinical impact of ELCo in patients with severe aortic stenosis (AS). Methods and Results Thirty-three patients with severe AS were assessed by Doppler examination [EOA obtained by the continuity equation (EOADop) ≤1.0 cm2], and referred to the cardiac catheterization laboratory for evaluation of EOA obtained by the Gorlin formula (EOAcath). Patients with ELCo ≤1.0 cm2 (n=26) had significantly lower incidence of symptoms related to AS compared with those having ELCo >1.0 cm2 (n=7) (p=0.002). Superior concordance in severity of AS was demonstrated between EOAcath and ELCo compared with EOAcath and EOADop (κ=0.52, and κ=0.32, respectively). Conclusions In 21% of patients with "severe" AS diagnosed by Doppler echocardiography, the ELCo value indicated moderate rather than severe AS. These patients had significantly lower incidence of symptoms compared with patients who had ELCo ≤1.0 cm2. (Circ J 2008; 72: 1265 - 1269)

Nomenclature Cp = specific heat of propellant Pg = pressure Qs = heat of reaction at the surface R = gas constant Tf = flame temperature Ts = surface temperature T0 = initial temperature ug = gas velocity δ = reaction length λg = heat conductivity in the gas phase ρg = gas density ρp = density of propellant τc = chemical ignition delay time τig = ignition delay time τp = physical ignition delay time Φs+ = temperature gradient near the burning surface in the gas phase

The mechanism of increasing systolic coronary flow velocity of the epicardial coronary artery in patients with aortic regurgitation (AR) has not been well investigated. Thus, an evaluation was made of the flow velocity pattern of the epicardial coronary artery in these patients.In 12 patients with AR, epicardial coronary flow velocity was monitored using Doppler guidewire, and diameter changes of the epicardial coronary artery using intravascular ultrasound (IVUS).The systolic coronary vascular resistance in AR patients was significantly less than that in controls (1.8 +/- 0.9 versus 3.3 +/- 0.7 mmHg/ml/min; p0.01). Likewise, area and diameter changes of the epicardial coronary artery during the cardiac cycle in AR patients were significantly less than those in controls (102 +/- 1% versus 106 +/- 4%; p0.01; and 102 +/- 1% versus 106 +/- 4%; p = 0.03).In patients with AR, the increase in systolic coronary flow velocity of the epicardial coronary artery during the systolic phase was considered to result from a major coronary perfusion of blood into the intramyocardial vessels (which showed a decreased resistance), rather than it being stored in the epicardial coronary artery.

Late incomplete stent apposition (LISA) develops following implantation of conventional bare-metal stents (BMS) or drug-eluting stents, or after adjunctive intracoronary radiation (IR). However, no study has systematically compared the morphology of LISA seen with various treatment modalities.To compare the morphometric features of LISA accompanying BMS, IR or sirolimus-eluting stents (SES) using serial intravascular ultrasound (IVUS).A query of Stanford University's IVUS database of the Cardiovascular Core Analysis Laboratory was performed to identify LISA cases. Dedicated software programs were used for volumetric IVUS analyses.In 30 LISA cases (12 BMS, 6 IR and 12 SES), there was no intertreatment difference in the degree of LISA (lumen area minus stent area at follow up). Serial analyses of LISA segments showed that vessel area of SES and IR showed significant increase at follow up as compared with post procedure, while there was no significant change in plaque area. In contrast, the BMS group showed no increase in vessel area, whereas plaque area revealed significant reduction. Eight of 12 BMS cases were treated by directional atherectomy before stenting; however, there was no difference in the area change between patients with or without pre-stent atherectomy. Post-procedure plaque thickness beneath the stent struts of LISA was thinner for SES as compared with BMS.Plaque reduction primarily contributes to LISA after BMS, whereas vessel expansion is the predominant factor in LISA development for IR and SES. Thus, the mechanism of LISA may vary among different interventional treatments.

Background: Functional mitral regurgitation (MR) occurs as a consequence of regional or global left ventricular (LV) dysfunction despite a structurally normal mitral valve (MV). Degree of MV coaptation should be an important parameter in the assessment of functional MR. Purpose: We sought to investigate the change of MV coaptation and to clarify relationship between MV coaptation and development of MR in LV pressure overload. Methods: Using a canine model, LV pressure overload was induced by staged aortic banding (60 to 120mmHg). Echocardiographic examinations were performed before and during the banding. Degree of MR was evaluated by tracing the color jet MR area (MR area). By using a novel software system (RealView TM ) for 3D quantification, mitral annulus (MA) area, tenting volume, tenting length and 3D tenting surface area were analyzed. MA and surface of MV was manually traced both at the onset of MV closure [O] and at the maximum MV closure [M]. Coaptation index was calculated by the difference in 3D tenting surface area at O and at M devided by that at O. Results: MA area was gradually increased during banding ( p < 0.01). Tenting length and tenting volume tended to increase during banding but they did not reach statistical significance (tenting length; p = 0.17, tenting volume; p = 0.12). MR area increased with decrease in coaptation index (Figure ). The best cutoff value of the coaptation index to predict presence of MR was calculated as 0.24, giving a sensitivity of 82 % and specificity of 86 %. Conclusions: During aortic banding, MA dilated and coaptation of the MV decreased with apparent leaflet tenting. Coptation index might be able to predict the appearance of functional MR.

No reflow following percutaneous coronary intervention (PCI) is a major concern in patients with acute coronary syndrome (ACS) and it may be influenced by the preexisting plaque type.To evaluate the impact of plaque characteristics on coronary reflow following PCI in patients with ACS, a total of 110 patients (89 acute myocardial infarction, 21 unstable angina) were assessed by intravascular ultrasound. Plaque type was categorized as either atherosclerotic plaque without ultrasonic attenuation (group 1) or atherosclerotic plaque with attenuation (group 2). External elastic membrane, plaque plus media, and lumen area were measured. Coronary flow was assessed by Thrombolysis in Myocardial Infarction (TIMI) grade and TIMI frame count. Although the final TIMI frame count was similar between the 2 groups, TIMI frame count immediately after the first balloon inflation was significantly higher in group 2 (p=0.03). Despite the similar final TIMI grade and TIMI frame count, peak creatine kinase level was significantly higher (3,035+/-2,553 vs 1,950+/-1,958 IU/L, p=0.04) and fatal arrhythmia more frequently observed (16.4% vs 2.7%, p=0.04) in group 2 than in group 1.Atherosclerotic plaque with ultrasonic attenuation may be related to a transient deterioration in coronary flow and as a result larger infarct size and higher incidence of fatal arrhythmia following PCI in patients with ACS. These results may help in selecting lesions suitable for distal protection devices.

Objectives The aim of this study was to investigate impact of arterial remodeling on long-term clinical outcome following stent implantation in patients with acute coronary syndrome (ACS). Methods A total of 134 patients with ACS were enrolled. External elastic membrane cross sectional area (EEM CSA) and lumen CSA were measured. Plaque plus media (P+M) CSA was calculated as EEM minus lumen CSA. Final minimal stent area (MSA) was also measured after stenting. Positive remodeling (PR) was defined as the ratio of the EEM CSA at the target lesion to that at the proximal reference of > 1.05, and intermediate or negative remodeling (IR/NR) was defined as that of ≤ 1.05. Results Although final MSA was similar, target lesion revascularization (TLR) rates at 2 years were significantly higher in patients with PR (33.7 %) than IR/NR (13.7 %) (p=0.01). In addition, non-TLR rates was also significantly higher in patients with PR (42.2 %) than IR/NR (23.5 %) (p=0.03). Cardiac events (death, myocardial infarction, TLR and non-TLR)-free survival was significantly lower in patients with PR than IR/NR (Log-rank, p=0.001). By multivariate logistic regression analysis, PR (chi-square 6.57, OR 2.70; 95% CI, 1.27-5.78; p=0.01) and plaque rupture (chi-square 4.17, OR 2.38; 95% CI, 1.04-5.45; p=0.04) were independent predictors of cardiac events. Conclusion In patients with ACS, PR and IVUS findings that may correspond with plaque rupture predict cardiac events including both TLR and non-TLR at 2 years.

Objective The purpose of this study was to evaluate the rate of progression of mild and moderate aortic stenosis in patients aged 80 years and older. Methods In all, 41 patients with mild and moderate aortic stenosis were included and divided into two groups by age: 19 patients aged 80 years and older (mean 84 ± 4 years), and 21 patients younger than 80 years (mean 66 ± 6 years). Results The rate of degression of aortic valve area was more rapid in the 80 years and older age group than that in the younger than 80 years age group (−0.05 ± 0.06 and −0.10 ± 0.08 cm2/y, P = .014). Univariate and multivariate analysis of the rate of degression of aortic valve area were performed, and age was the only independent predictor of the rate of degression of aortic valve area. Conclusion Progression of mild and moderate aortic stenosis in patients aged 80 years and older was more rapid than that in those aged younger than 80 years.

The objectives of this study were: (1) to evaluate the relationship between coronary arterial remodeling assessed by intravascular ultrasound (IVUS) and plaque morphology assessed by histological examination in patients without clinical evidence of coronary artery disease and (2) to compare plaque morphology between histological examination and optical coherence tomography (OCT).Coronary segments (n=98) were harvested from the heart of 34 patients who died without clinical evidence of coronary artery disease. The segments with remodeling were assessed by IVUS and compared with corresponding OCT and histological images.The fibrofatty plaque area was larger in lesions with expansive remodeling (ER) than in lesions with intermediate/constrictive remodeling (IR/CR) (p0.01). Incidence of lipid containing plaque with the thickness of the fibrous cap smaller than 200 microm tended to be higher in ER than in IR/CR (34% versus 13%, p=0.10). OCT assessment of lipid containing plaque with thinner fibrous cap was achieved with 92% sensitivity and 75% specificity.The fibrofatty plaque area was larger in lesions with ER than IR/CR even in patients without clinical evidence of coronary artery disease. The current capabilities of OCT are well suited for evaluation of lipid containing plaques with thinner fibrous cap.

The purpose of this study was to investigate the prognostic impact of functional mitral regurgitation (FMR) and tissue Doppler-derived index of left ventricular filling pressure, E/E', on long-term clinical outcome in a broad spectrum of ischemic heart disease.FMR has been shown to predict prognosis in patients with myocardial infarction.A total of 524 patients with ischemic heart disease were enrolled. Patients were categorized according to the presence (n = 58) or absence (n = 466) of severe FMR.Patients with severe FMR were significantly older. By echocardiography, ejection fraction was significantly lower (43.0% +/- 14.6% vs. 56.4% +/- 12.8%, P.01) and E/E' was significantly higher (21.3 +/- 9.0 vs. 14.6 +/- 6.4, P.01) in patients with FMR than without FMR. Event-free (death and congestive heart failure) survival was significantly lower in patients with FMR than in those without (log-rank P.0001). By multivariate logistic regression analysis, E/E' greater than 15 (relative risk [RR] 3.49; 95% confidence interval [CI] 2.08-5.88, P.0001), ejection fraction less than 50% (RR 3.33; 95% CI 1.96-5.64, P.0001), and severe FMR (RR 2.34; 95% CI 1.22-2.48, P = .01) were independent echocardiographic predictors of cardiac events. In further analysis of 116 patients matched by a propensity score, severe FMR remained associated with reduced event-free survival (log-rank P = .004).FMR is a strong predictor of cardiac events independently of left ventricular systolic and diastolic indices in patients with ischemic heart disease.

Geometric changes of tricuspid valve, particularly leaflets configuration, in functional tricuspid regurgitation (TR) remain to be defined. We sought to investigate geometric changes of tricuspid valve tenting in functional TR secondary to pulmonary hypertension by transthoracic real-time 3-dimensional echocardiography (3DE). Real-time 3DE was performed in 30 individuals (17 patients with TR and 13 control subjects). We used a novel software system with 3DE to reconstruct tricuspid geometry at midsystole. In patients with TR, tricuspid leaflets were tethered into right ventricle with apparent tenting showing a mountain-like bulging. Maximum tenting site was mostly located at the center of the tenting. Tenting volume was larger (4.2 +/- 2.4 vs 1.1 +/- 0.6 cm(3), P.001), and the maximum and mean tenting lengths were longer, than in control subjects. Annular area was also larger (11.3 +/- 2.3 vs 8.7 +/- 1.8 cm(2), P = .003) than in control subjects. Geometric changes in functional TR secondary to pulmonary hypertension were characterized by enlargement of tricuspid tenting volume and dilatation of annulus. This study suggested usefulness of the novel system with 3DE in evaluation of tricuspid valve geometry.

Identification of the fibrous cap is important because its thickness is a major determinant of plaque vulnerability in lipid-rich plaque. Thus, a high-resolution imaging technique may be a promising method for the identification of the fibrous cap within lipid-rich plaque. The purpose of this study was to investigate the feasibility of using optical coherence tomography (OCT) to measure the thickness of the fibrous cap within lipid-rich plaque.We examined 35 lipid-rich plaques from 102 coronary arterial segments of 38 human cadavers (22 men and 16 women; mean ages, 74 +/- 7 years). Optical coherence tomography and corresponding histological images were digitized for measurement of the thickness of fibrous cap, and the results between OCT and histological examination were compared. There was good correlation of the thickness of the fibrous cap between OCT and histological examination (y = 0.97x + 28.49; r = 0.90; P.001). A Bland-Altman test showed good agreement of the thickness of the fibrous cap between OCT and histological examination (mean difference, -24 +/- 44 microm).Optical coherence tomography provides an accurate representation of the thickness of the fibrous cap and may prove useful in assessing plaque vulnerability in lipid-rich plaque.