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BACKGROUND Diabetic cardiomyopathy (DMCMP) is characterized by myocardial dysfunction regardless of coronary artery disease in diabetic patients. The features of LV dysfunction in rat model of type 1 DM induced by streptozocin, are variable and controversial. Thus, we tested the usefulness of tissue Doppler imaging in the early detection of ventricular dysfunction in a rat model of DMCMP. METHODS Diabetes was induced by intra-peritoneal injection of streptozocin (70 mg/kg) in 8 weeks of Sprague-Dawley rat. Diagnosis of diabetes was defined as venous glucose level over 350 mg/dL 48 hrs after streptozocin injection. Echocardiography was done at baseline and 10 weeks after diabetes induction both in diabetes group (n=15) and normal control (n=10). After echocardiography at 10 weeks, invasive hemodynamic measurement using miniaturized conductance catheter was done in both groups. RESULTS Ten weeks after diabetes induction, heart and lung mass indexes of diabetes were larger than those of normal control (3.2+/-0.3 vs. 2.4+/-0.2 mg/g, p

Background: Persistence of regional diastolic dysfunction after ischemic insult remains debatable. With speckle tracking echocardiography (STE), we sought to (1) prove the persistence of regional diastolic dysfunction, (2) assess the feasibility of applying persistent regional diastolic dysfunction to differentiating ischemic and nonischemic chest pain, and finally (3) examine statin effects on postischemic regional diastolic dysfunction. Methods: Nineteen patients with variant angina (VA) and 12 normal subjects were enrolled. Comprehensive echocardiographic examinations were performed before and 1 day after coronary angiography (CAG) with ergonovine provocation. Radial systolic (rSRsys) and diastolic (rSRdia) strain rates were obtained and averaged using standard segmentation models corresponding to the three major coronary territories assigned. Results: No significant changes in rSRsys and rSRdia values were observed for controls and in rSRsys for VA. However, rSRdia for VA demonstrated a weak, but significant, decrease from −2.25 ± 0.71/sec to −2.04 ± 0.71/sec (P = 0.003) 1 day after CAG. However, because of the wide overlap between rSRdia values in normal and ischemic segments for VA patients, predictability of remote ischemia based solely on the rSRdia was limited. Subgroup analysis according to statin prescription showed that statin administration contributed to the elimination of rSRdia reduction (−2.28 ± 0.84/sec on pre-CAG vs. −2.29 ± 0.77/sec on post-CAG, P = 0.72 for patients without statin premedication; −2.23 ± 0.64/sec for pre-CAG vs. −1.88 ± 0.65/sec for post-CAG, P = 0.002 for those without). Expectedly, rSRsys values showed no significant changes in all situations. Conclusions: The presence and sustained nature of regional diastolic dysfunction can be demonstrated with STE. Statin minimized the persistence of regional diastolic dysfunction after an acute ischemia. Although the clinical usefulness of rSRdia by STE appears to be limited, its clinical utility requires further consideration, given the brevity of the ischemia provoked during CAG with ergonovine and the protracted regional diastolic dysfunction. (Echocardiography 2010;27:244-252)

Recent clinical trials have challenged the clinical applicability of mechanical dyssynchrony in predicting cardiac resynchronisation therapy response.To evaluate whether mechanical dyssynchrony has an additional benefit over QRS duration in predicting cardiac events in patients with systolic heart failure.A total 167 patients admitted to hospital with heart failure (age 65+/-12, ejection fraction35%) were followed up prospectively. Using tissue Doppler imaging (TDI), the time to peak systolic velocity during the ejection phase was measured in the basal septal and lateral segments. A temporal difference between the septal to lateral wall (Ts-l) ofor =65 ms was defined as a mechanical dyssynchrony.After 33 months of follow-up, 70 patients (41.9%) had cardiac events, including 42 (25.1%) with cardiac death. The event-free survival time decreased as Ts-l or QRS duration increased. Patients with QRSor =120 ms had increased risks of cardiac events by multivariate Cox proportional hazard analysis (HR=1.88, 95% CI 1.07 to 3.29, p = 0.028). The presence of mechanical dyssynchrony also predicted an increased risk of cardiac events (HR=2.37, 95% CI 1.39 to 4.04, p = 0.002). Those with both electrical and mechanical dyssynchrony had a HR of 3.98 (95% CI 2.02 to 7.86, p0.001) when compared with those with normal QRS duration and absence of mechanical dyssynchrony. The addition of mechanical dyssynchrony significantly improved the prognostic power of a model containing echocardiographic parameters and QRS duration.TDI-derived mechanical dyssynchrony is an important prognosticator and independently associated with QRS duration in predicting adverse events in patients with systolic heart failure.

Background Behcet's disease (BD) is a systemic vasculitis that can be a possible cause of aortic regurgitation (AR). When aortic valve replacement is performed in patients with BD, unless preoperative immunosuppressive therapy and special operative techniques are used, the postoperative course is usually complicated by valve dehiscence, necessitating another operation. The preoperative diagnosis of BD is challenging because of its protean manifestations, but an early diagnosis is associated with a more favorable prognosis. Methods Between 1990 and 2008, 15 patients with final diagnoses of BD underwent aortic valve replacement. Medical records and echocardiographic findings were retrospectively analyzed. Results Of the 15 patients, only 2 were diagnosed as having BD prior to first operation. Twelve underwent repeat open-heart surgery because of valve dehiscence, and 6 of these 12 patients eventually died. In 5 patients with available echocardiographic findings of native valve morphology, echocardiography demonstrated characteristic aneurysmal changes and redundant coronary cusp motion in 4 patients. Vegetation-like mobile lesions and echo-free spaces mimicking abscess pockets led to misdiagnoses of infective endocarditis in 7 patients at least once during their clinical courses. Furthermore, complete atrioventricular block requiring permanent pacemaker insertion developed in 5 patients, especially those with echo-free spaces in the periannular area. Conclusions Dismal prognoses are almost inevitable unless etiologic diagnoses are made prior to surgery in patients with BD and AR. It is important to diagnose BD preoperatively, and the diagnostic importance of echocardiographic findings should be kept in mind when evaluating patients with AR.

Myocardium is a rare site for metastasis. We present here the case of myocardial metastasis from cholangiocarcinoma.

Development of left ventricular (LV) remodeling after acute myocardial infarction (AMI) is a serious medical complication. We investigated the correlation of LV dyssynchrony after AMI with LV remodeling using magnetic resonance-myocardial tagging (MR-MT) derived dyssynchrony index (circumferential uniformity ratio estimate [CURE]). Forty-three patients diagnosed with ST-elevation AMI were analyzed. After treatment with primary percutaneous intervention, cardiac magnetic resonance imaging was performed to obtain a cine image, a delayed enhancement image, and an MR-MT image. CURE as a dyssynchrony index was calculated from the MR-MT image using HARP software (CURE 0 to 1 = dyssynchrony to synchrony). After 6 months, follow-up cardiac magnetic resonance imaging was performed to assess degree of LV remodeling. Sixteen patients (37%) had an increased LV end-systolic volume (ESV)15% compared with baseline. The baseline LV dyssynchrony index, CURE, was significantly associated with ESV at 6 months (r = -0.49, p0.001) and weakly correlated with change in ESV (percentage) compared with baseline values (r = -0.26, p = 0.08). Multivariate analysis showed that CURE was associated only with change in ESV (beta -0.39, p = 0.03). Subgroup analysis for patients with nonviable myocardium (infarct thickness75%, n = 31) showed that this correlation was stronger (beta -0.52, p = 0.006), suggesting that CURE could predict progression of LV remodeling in patients with AMI and nonviable myocardium. LV dyssynchrony immediately after AMI is an important determinant of LV remodeling. In conclusion, the MR-MT dyssynchrony index, CURE, might be useful for prediction of LV remodeling in patients with AMI.

Background and Objectives: The purpose of this study was to investigate 1) the beneficial effect of bosentan treatment (125 mg twice daily) on exercise capacity and echocardiographic variables and 2) the profiles and frequency of adverse events in Korean patients with World Health Organization (WHO) class III or IV pulmonary artery hypertension (PAH). Subjects and Methods: Twelve patients who received bosentan treatment were investigated in an open label manner. One patient was excluded in the final analyses due to a prohibited concomitant medication. A 6-minute walk test and echocardiography were performed at baseline and after 12 weeks of treatment. Results: The administration of bosentan for 12 weeks resulted in a significant improvement in exercise capacity (measured with the 6-minute walking distance), WHO functional capacity, and in echocardiographic variables. Bosentan treatment was associated with a decrease in the maximal tricuspid regurgitation jet velocity {from 4.7 m/sec (95% confidence interval, 3.89-5.45) at baseline to 4.4 m/sec (95% confidence interval, 3.615.1) at 12 weeks, p=0.03} and systolic pulmonary arterial pressure {from 105 mmHg (95% confidence interval, 74.4-135.6) at baseline to 93 mmHg (95% confidence interval, 66.3-120.1) at 12 weeks, p=0.04}. Treatment with bosentan at a dose of 125 mg twice a day was not associated with life-threatening side effects, although a higher incidence of elevated liver enzymes compared to previous studies was noted. Conclusion: Bosentan at a dose of 125 mg twice daily is considered a clinically optimal, safe dose and can be used as a valuable treatment option in Korean PAH patients with WHO functional capacity III or IV, though close monitoring of liver function is required. (Korean Circ J 2009;39:105-110)

Diastolic and systolic dyssynchrony are common in patients with heart failure. However, the presence of dyssynchrony in asymptomatic patients with hypertension who are susceptible to the development of heart failure is not well understood. The aims of this study were (1) to evaluate the prevalence of systolic and diastolic dyssynchrony and (2) to identify the main determinants of left ventricular (LV) dyssynchrony in asymptomatic patients with hypertension.One hundred ten patients with hypertension consecutively enrolled were compared with 55 age-matched and gender-matched normal control subjects. Comprehensive echocardiography was performed, including conventional and Doppler tissue imaging parameters. LV end-systolic wall stress was calculated using a hemodynamic and echocardiographic M-mode data set. For the assessment of LV dyssynchrony, both the standard deviation of the time from QRS onset to peak systolic velocity and the maximal difference of the time from QRS onset to peak systolic velocity from 6 basal segments at the apical views were used and were compared between the two groups.Both systolic and diastolic dyssynchrony indexes were significantly higher in patients with hypertension than in the normal controls (P.001), with no significant correlation between the systolic and diastolic dyssynchrony indexes. The proportions of patients with hypertension who had LV systolic and diastolic dyssynchrony were 24% and 21%, respectively. Multivariate analysis showed that the E/E' ratio (P.001) was independently associated with LV systolic dyssynchrony, whereas LV mass index (P = .001) and E/E' (P.001) were major determinants of LV diastolic dyssynchrony.LV systolic and diastolic dyssynchrony are not uncommon in asymptomatic patients with hypertension and are significantly associated with LV filling pressure. The determinants of LV systolic dyssynchrony are not the same as those of diastolic dyssynchrony, implying that different mechanisms are involved in the development of LV systolic and diastolic dyssynchrony in asymptomatic patients with hypertension.

Background Few data exist on the changes in left ventricular (LV) short- and long-axis function and their usefulness as markers of LV contractile function in patients with chronic, severe mitral regurgitation (MR). Methods We studied 59 patients who had severe MR with an ejection fraction ≥50% and 34 healthy controls. Speckle tracking imaging was performed to measure peak systolic radial (SR R ), circumferential (SR C ), and longitudinal strain rates (SR L ). In all patients, the peak rate of LV pressure rise (peak dP/dt) was measured using a micromanometer-tipped catheter. The patients were subdivided into patients with preserved (group 1, peak dP/dt ≥1,300 mm Hg/s [n = 30]) and depressed (group 2 [n = 29]) contractile function. Results SR L was significantly depressed in groups 1 and 2 when compared with the control group, but there was no difference between groups 1 and 2. In contrast, SR R and SR C were depressed only in group 2, whereas there were no differences between the control group and group 1. SR R and SR C correlated well with peak dP/dt ( r = 0.71, P r = −0.63, P L did not. These findings suggest that LV long-axis function becomes depressed earlier than short-axis function in the chronic remodeling process. Conclusions Left ventricular short-axis function is a useful marker of LV contractility in patients with chronic, severe MR. Left ventricular long-axis function becomes depressed earlier in the chronic remodeling process. Therefore, evaluation of short-axis as well as long-axis function might be important for better assessment of LV contractile function in these patients.

We herein report a rare case of subaortic stenosis in association with a previous tetralogy of Fallot (TOF) surgical repair, which was not taken into account as a differential diagnosis. Echocardiography plays a pivotal role in identification of this rare combination. Therefore, echocardiography should be performed periodically during follow-up of patients with surgically corrected TOF. Given the clinical complications that can result from subaortic stenosis (i.e., aortic regurgitation and infective endocarditis), early and aggressive management of this rare combination should be performed.

Background Afterload is expected to increase with pneumatic compression of the lower extremities. There are left ventricular (LV) wall stress, which is the most important factor determining myocardial oxygen demand, will also increase, leading to an increase in the sensitivity of dobutamine stress echocardiography (DSE) or a shortened time to a positive response. Methods and Results In 40 patients who underwent DSE and were anticipating undergoing coronary angiography (CAG), the imaging was repeated with pneumatic compression (100 mmHg) of the lower extremities (DSEcomp) prior to CAG. The sensitivity and specificity of DSE and DSEcomp were determined based on the CAG findings. All patients tolerated pneumatic compression of the lower extremities during the tests. LV end-systolic volume (p=0.042) and end-systolic wall stress (p=0.036) were significantly greater with DSEcomp than with DSE. In 3 patients with false-negative results for DSE, DSEcomp gave a positive response, demonstrating a significant increase in sensitivity from 75% to 94% (p=0.045). Only 1 patient with a true negative result for DSE was interpreted as showing a positive response for DSEcomp, resulting in a decrease in specificity from 88% to 83% (p=NS). In 10 of 12 patients with true positive results for both DSE and DSEcomp, positive responses were seen at least 1 stage earlier with DSEcomp than with DSE. Conclusions Pneumatic compression of the lower extremities increases the sensitivity of DSE and shortens the time to a positive response. (Circ J 2008; 72: 251 - 255)

Background Hemodynamic and functional evaluation with Doppler and tissue Doppler study as a part of comprehensive echocardiography is essential but normal reference values have never been reported from Korean normal population especially according to age and sex. Methods Using Normal echOcaRdiographic Measurements in a KoreAn popuLation study subjects, we obtained normal reference values for Doppler and tissue Doppler echocardiography including tricuspid annular velocities according to current guidelines and compared values according to gender and age groups. Results Mitral early diastolic (E) and late diastolic (A) velocity as well as E/A ratio were significantly higher in women compared to those in men. Conversely, mitral peak systolic and late diastolic annular velocity in both septal and lateral mitral annulus were significantly lower in women compared to those in men. However, there were no significant differences in both septal and lateral mitral early diastolic annular (e') velocity between men and women. In both men and women, mitral E velocity and its deceleration time as well as both E/A and E/e' ratio considerably increased with age. There were no significant differences in tricuspid inflow velocities and tricuspid lateral annular velocities between men and women except e' velocity, which was significantly higher in women compared to that in men. However, changes in both tricuspid inflow and lateral annular velocities according to age were similar to those in mitral velocities. Conclusion Since there were significant differences in Doppler and tissue Doppler echocardiographic variables between men and women and changes according to age were even more considerable in both gender groups, normal Doppler echocardiographic values should be differentially applied based on age and sex.

Background We sought to assess echocardiographic predictors of left ventricular (LV) adverse remodeling after successfully reperfused acute ST elevation myocardial infarction (STEMI). LV remodeling is commonly found in STEMI patients and it may suggest adverse outcome in acute myocardial infarction. We sought to identify whether 2D strain and torsion be independent parameters for prediction of LV adverse remodeling. Methods We investigated 208 patients with low-risk STEMI patients who had follow up echocardiography at 6 or more months. After clinical assessments, all patients received revascularization according to current guideline. LV remodeling was defined as > 20% increase in end-diastolic volume (EDV) at follow up. Results During the follow-up (11.9 ± 5.3 months), 53 patients (25.5%) showed LV remodeling. In univariate analysis, EDV, end-systolic volume, deceleration time (DT), CK-MB, and global longitudinal strain (GLS) were associated with LV remodeling. In multivariate analysis, EDV [hazard ratio (HR): 0.922, 95% confidence interval (CI): 0.897–0.948, p< 0.001], GLS (HR: 0.842, 95% CI: 0.728–0.974, p = 0.020), DT (HR: 0.989, 95% CI: 0.980–0.998, p = 0.023) and CK-MB (HR: 1.003, 95% CI: 1.000–1.005, p = 0.033) independently predicted LV remodeling. However, global circumferential strain, net twist, and twist or untwist rate were not associated with remodeling. Conclusion Of various parameters of speckle strain, only GLS predicted adverse remodeling in STEMI patients.

Positive longitudinal pre-ejectional velocity (+PEVL) was recently reported to be a reliable index of myocardial recovery early after successful revascularization in myocardial infarction (MI); that is, it recognizes the transmural extent of viable myocardium. The applicability of PEVL in the real-world clinical setting for identifying the transmural extent of viable myocardium in reperfused recent MI was assessed.Using tissue Doppler imaging, the resting basal and mid myocardial PEVLs were determined within 3 days after revascularization in 41 consecutive patients with recent MI. Infarct thickness was semi-quantified using delayed gadolinium-enhanced magnetic resonance imaging (MRI) at baseline and at 6-month follow up to differentiate transmural from nontransmural MI. The proportion of segments showing the presence of +PEVL was not significantly changed as infarct thickness increased (p=0.2), with 66.2% having +PEVL even in segments involving75% transmural infarction. Moreover, +PEVL was found in a large fraction of segments with akinesia (70.4%). Specificity and negative predictive value of +PEVL for assessing infarct nontransmurality were disappointingly low (32.0% and 26.9%, respectively). All of these results were not altered when the 6-month follow-up MRI was done.+PEVL cannot be regarded as a reliable marker for predicting the transmural extent of viable myocardium in recent MI.

Aim: We investigated the incidence and predictors of tricuspid regurgitation (TR) development long after left-sided valve surgery in patients without significant preoperative TR. Methods: Of 615 patients who underwent surgery for left-sided valve disease between 1992 and 1995, 335 patients without preoperative TR who completed at least 5 years of clinical and echocardiographic follow-up were enrolled. Late significant TR development was assessed by echocardiography with a mean follow-up duration of 11.6 ± 2.1 years. Results: Significant late TR was found in 90 patients (26.9%). Patients with late TR showed; an advanced age, a higher prevalence of atrial fibrillation and prior valve surgery, and a greater left atrial dimension. In addition, late TR was more frequent in patients with mitral valve surgery. Systolic pulmonary artery pressure and mean right atrial pressure were not different between the groups. Multivariate analysis showed that the preoperative atrial fibrillation (OR 5.37; 95% CI. 2.71–10.65; p Conclusion: The development of significant TR long after left-sided valve surgery is not uncommon and is associated with a poor prognosis. The preoperative atrial fibrillation is an independent predictor of the late TR. Main Clinical and Echocardiographic Characteristics According to the Presence of Significant Late TR

Background Assessment of the left ventricular (LV) contractile function is critical for deciding optimal timing of surgery in patients with chronic severe mitral regurgitation (MR). We investigated the LV long-axis and short-axis function in MR. Methods We studied 30 patients (16 men, age: 51 ± 14 years) who had 3+ or 4+ MR with LV ejection fraction (EF) greater than 50%. Comprehensive 2D and Doppler echocardiography was performed. Peak systolic radial (SR R ), circumferential (SR C ), and longitudinal strain rate (SR L ) were measured using speckle tracking imaging. In all patients, peak dP/dt was measured using micromanometer-tipped catheter. Results Mean LVEF was 63.1% and regurgitation fraction was 61.8%. LV end-systolic volume was 78.3 ml. Peak dP/dt ranged from 1019 to 2049 mmHg/sec with the mean value of 1583 mmHg/sec. 16 patients (53.3%) showed latent systolic dysfunction defined by peak dP/dt less than 1300 mmHg/s. SR R and SR C correlated well with peak dP/dt (Fig. A , r=0.74, p< 0.01, r=− 0.54, pL did not correlate with peak dP/dt (r=− 0.58, p=0.76). SR R > 1.94 S −1 showed a sensitivity of 86 % and a specificity of 75 % for predicting latent LV systolic function (Fig. B , AUC=0.87, CI=0.732– 0.991). SR R also correlated with LV end-diastolic and end-systolic sphericity index (r=− 0.54, p Conclusion SR R and SR C , not SR L , correlated well with peak LV dP/dt. These results imply the importance of short-axis function in the presence of chronic severe MR, probably due to the geometrical change in response to chronic volume overload.

Background Growing use of the left ventricular(LV) systolic(LVSIsys) and diastolic synchronicity indexes(LVSIdia) in selecting potential responders to cardiac resynchronization therapy(CRT) has created a need for normative reference values. This study was performed to determine reference ranges for tissue Doppler imaging-derived LVSIsys and LVSIdia, and to assess their relationships to age and conventional parameters reflecting LV systolic and diastolic functions. Methods and Results We recruited 160 completely healthy volunteers (45±13yrs, 104 men) free of any systemic or cardiovascular disease. Maximal difference and SD of time to peak systolic and early diastolic velocities for LVSIsys and LVSIdia were measured using 6- and 12-segment models. Table and Figure represent normal ranges. Aging was not found to significantly change LVSIsys, whereas LVSIdia progressively and consistently increased with age. Significant correlations were observed between LVSIdia and parameters representing LV diastolic function, i.e. early mitral inflow velocity and its deceleration time, and early mitral annulus velocity. A physiologic rise in LV mass/Ht 2.7 showed a weak, but significant correlation with LVSIdia( r = 0.15 to 0.22), but not with LVSIsys. On multivariate analysis, age-dependent increase in LVSIdia was confirmed. Conclusions Age-specific reference ranges for LVSIsys and LVSIdia are presented here. LVSIsys remain stable throughout age groups, whereas LVSIdia progressively increases with age. These data given here will be useful for defining abnormal LV synchronous contraction and relaxation, and help better select patients likely to respond favorably to CRT.

Background Afterload is expected to increase with pneumatic compression of the lower extremities. Therefore, left ventricular (LV) wall stress which is the most important factor determining myocardial oxygen demand will also increase, leading to an increase in sensitivity of dobutamine stress echocardiography (DSE) or shortened time to positive response.The purpose of this study was to evaluate the effect of pneumatic compression of lower extremities on the diagnostic accuracy of DSE. Methods In 40 patients who underwent DSE and were anticipating coronary angiography, DSE was repeated with the pneumatic compression (100mmHg) of lower extremities (DSEcomp) prior to coronary angiography. Sensitivity and specificity of DSE and DSEcomp were determined based on the coronary angiographic finding. Results All patients tolerated pneumatic compression of the lower extremities during the tests. LV end-systolic volume (p=0.042) and end-systolic wall stress (p=0.036) were significantly greater in the DSEcomp than DSE. In 3 patients with false negative results in DSE, DSEcomp showed positive responses, demonstrating a significant increase in sensitivity from 75% to 94% (p=0.045). Only 1 patient with true negative result in DSE was interpreted as showing positive response in DSEcomp, resulting in a decrease in specificity from 88% to 83% (p=NS). In 11 of 13 patients with true positive results both in DSE and DSEcomp, positive responses were seen at least 1 stage earlier in DSEcomp compared to DSE. Conclusions Pneumatic compression of lower extremities increases the sensitivity of DSE and shortens the time to positive response.

In this paper, we describe the development of multi-touch tabletop display system and the classification of hand gesture commands for interacting with our system. And also, we analyze the suitability for interactive tabletop in light of the respective input and output degrees of freedom, as well as the precision and completeness provided by each. Our system is based on FTIR (frustrated total internal reflection) principle and hand gestures for necessary instructions are predefined using position sensing and tracking of multi-touch points and the number of fingertips. The system consists of two beam-projectors, diffuser film, infrared cameras and large acrylic screen that attached infrared LED. In recognition process, gesture commands are analyzed by comparing with predefined gesture instructions according to the number of contacted fingertips, Euclidean distance and angles between two bright spots. In this paper, vision based tabletop display system that we proposed provides much advantages understanding human and computer interaction. Also the efficiency of proposed method can be proved through controlling Google-earth.

Background Recently, multidetector computed tomography (MDCT) has been proposed as an accurate diagnostic tool to evaluate for coronary artery disease. However, the role of MDCT as part of the initial diagnostic for evaluating acute chest pain is less well established. Methods We prospectively enrolled patients presenting with acute chest pain to the emergency department (ED) and risk stratified them based on the pretest probability for an acute coronary syndrome (ACS): (1) very low, (2) low, (3) intermediate, (4) high, and (5) very high or definite. After exclusion of very low and very high risk patients, 268 patients were randomized to either immediate 64-slice cardiac MDCT or a conventional diagnostic strategy. Number of admissions, ED and hospital length of stay (LOS), and major adverse cardiac events over 30 days of follow-up were compared between the strategies based on the pretest probability for ACS. Results The number of patients ultimately diagnosed with an ACS did not differ between the 2 strategies. Emergency department LOS and total admissions were not different between strategies. Patients in the MDCT-based strategy had a decreased hospital LOS ( P = .049) and fewer admissions deemed unnecessary ( P = .007). Reductions in unnecessary admissions were more prominent in intermediate-risk patients ( P = .015). None of the patients discharged from the ED in the MDCT-based strategy experienced major adverse cardiac events at follow-up. Conclusion Use of an MDCT-based strategy in the ED as part of the initial diagnostic approach for patients presenting with acute chest pain is safe and efficiently reduces avoidable admissions in patients with an intermediate pretest probability for ACS.

Background On the basis of the close association of left atrial compliance with pulmonary hypertension in patients with mitral stenosis, we hypothesized that: (1) Doppler-derived net atrioventricular compliance (C n ) can be used for predicting the occurrence of mitral valve (MV) replacement or percutaneous mitral commissurotomy (PMC); and (2) determinants of exercise capacity are variable depending on C n . Methods We consecutively enrolled 26 patients (22 women; mean age, 47.0 ± 6.1 years; range, 35-59 years) with pure moderate or severe mitral stenosis, in whom comprehensive echocardiography was performed at rest. C n was derived from the equation that has been previously validated (ie, C n = 1270 × [MV area by 2-dimensional planimetry/mitral E-wave downslope]. Measurements of stroke volume and systolic pulmonary artery pressure were repeated immediately after symptom-limited treadmill exercise test within 60 seconds. Results On the basis of earlier reports, C n less than 4 mL/mm Hg was selected to define abnormally small C n . During a mean duration of 24-month follow-up, C n of less than 4 mL/mm Hg could reliably predict the occurrence of either MV replacement or PMC, which was confirmed by multivariate logistic regression analysis. In patients with C n less than 4 mL/mm Hg, exercise duration was found to be closely correlated primarily with resting systolic pulmonary artery pressure ( r = −0.73, P = .03), whereas in patients with C n greater than or equal to 4 mL/mm Hg, postexercise stroke volume was the only determinant of exercise capacity ( r = 0.49, P = .04). When combining C n less than 4 mL/mm Hg with MV area less than 1.0 cm 2 as a cut-off value for predicting MV replacement or PMC, the sensitivity improved from 63.6% to 81.8% ( P = .05). Conclusions Left atrial compliance estimated by C n with Doppler echocardiography allows us to effectively predict the future occurrence of MV replacement or PMC, with a special usefulness in patients with moderate mitral stenosis. In addition, determinants of exercise capacity were variable depending on the degree of C n .

OBJECTIVES This study sought to investigate the incidence and identify the predictors of significant tricuspid regurgitation (TR) development long after left-sided valve surgery. METHODS Of 615 patients who underwent surgery for left-sided valve disease between 1992 and 1995, 335 patients without significant TR who completed at least 5 years of clinical and echocardiographic follow-up were enrolled. Late significant TR development was assessed by echocardiography with a mean follow-up duration of 11.6 +/- 2.1 years. RESULTS Significant late TR was found in 90 patients (26.9%). Patients with late TR showed an advanced age (47.6 +/- 13.4 vs 44.3 +/- 13.2 years, P = .04), a higher prevalence of preoperative atrial fibrillation (83.3 vs 46.5%, P < .001), a greater left atrial dimension (56.9 +/- 13.2 vs 52.4 +/- 11.5 mm, P = .006), and a higher prevalence of prior valve surgery (40.0 vs 25.3%, P = .01). In addition, late TR occurred more frequently in patients who had undergone mitral valve surgery than in those who did not (93.3 vs 72.2%, P < .001). However, multivariate analysis showed that the presence of preoperative atrial fibrillation (odds ratio 5.37; 95% CI 2.71-10.65; P < .001) was the only independent factor of late TR development. Patients who developed late TR had a lower event-free survival rate than those who did not (P = .03). CONCLUSIONS The development of significant TR long after left-sided valve surgery is not uncommon with an estimated incidence of 27% and is closely associated with a poor prognosis. The presence of preoperative atrial fibrillation was identified as the only independent predictor of the development of late TR.

Chronic atrial fibrillation (AF) is common in patients with mitral stenosis (MS). Because AF induces electrical and mechanical remodeling of the left atrium, left atrial (LA) compliance is likely to be changed in its presence. This study was performed to investigate the influence of AF on LA compliance in patients with moderate to severe MS. Data were analyzed for 356 patients (282 women; mean age 40 +/- 11 years; range 17 to approximately 71) who were registered in the percutaneous mitral commissurotomy database. Mean LA pressure was lower (21 +/- 7 vs 26 +/- 8 mm Hg; p0.001), but LA volume was higher in the AF than sinus-rhythm group (126 +/- 62 vs 74 +/- 27 ml; p0.001), indicating higher LA compliance, which was further confirmed by lower LA v wave at catheterization in the AF group (27 +/- 9 for AF vs 32 +/- 10 mm Hg for sinus rhythm; p0.001). In conclusion, the presence of AF has a significant influence on LA compliance in patients with moderate to severe MS.

Increased left ventricular (LV) mass is associated with adverse cardiovascular outcomes, and its accurate assessment is important. The aim of this study was to analyze the degree of difference among various methods of LV mass calculation based on transthoracic echocardiographic (TTE) measurements and cardiovascular magnetic resonance (CMR) measurements, especially in patients with aortic stenosis with varying degrees of LV hypertrophy (LVH). The mechanism underlying this disagreement was also investigated.Ninety-nine patients with moderate to severe aortic stenosis and 33 control subjects matched for age, sex, body weight, and height were enrolled in this prospective observational cohort study. All patients underwent TTE and CMR imaging. LV mass index (LVMI) was calculated using three formulas on the basis of TTE measurements (the Penn-cube, American Society of Echocardiography [ASE], and Teichholz methods) and compared with measurements obtained using CMR, the reference method.Although all methods calculated using TTE measurements showed good correlations with CMR measurements, LVMI measured using the Penn-cube and ASE methods tended to be larger than LVMI measured using CMR (difference in LVMI by the Penn-cube and ASE methods, 59.3 ± 29.7 and 30.6 ± 22.3 g/m², respectively). This tendency decreased with the Teichholz method (difference in LVMI by the Teichholz method, 22.9 ± 19.1 g/m²). The degree of LVMI overestimation was significantly different among the three methods (P.001 by one-way analysis of variance), which was more significant in patients with LVH, especially with the Penn-cube method (differences between CMR and TTE measurements in patients with aortic stenosis and LVH, 66.3 ± 34.8 vs 31.2 ± 26.6 vs 15.5 ± 20.9 g/m² for the Penn-cube, ASE, and Teichholz methods, respectively; P.001 with post hoc Tukey analysis). There was a good correlation between LVMI and LV diameter-to-length ratio (r = 0.468, P.001), which suggested that the left ventricle takes on a more globular shape with the increase of LVMI, resulting in a significant deviation from the basic assumptions on which the Penn-cube and ASE methods were built.Current methods of calculating LVMI from echocardiographic measurements carry a tendency to measure LVMI larger than methods based on CMR measurements, which was more significant in patients with LVH. The change of the left ventricle's shape with LVH may be a plausible explanation for this, and a correction method may be needed when calculating LVMI from echocardiographic measurements, especially in patients with LVH and smaller body size.

Impaired nitric oxide-mediated pulmonary vascular tone is commonly found in heart failure with reduced ejection fraction (HFrEF), and is associated with derangement of left ventricular (LV) hemodynamics and decreased exercise capacity, which may be reversed by PDE5 inhibitor. This study investigated the effects of a new, long-acting PDE5 inhibitor on LV hemodynamics and exercise capacity in HFrEF.Patients with chronic HFrEF on optimal medical therapy for30 days before enrollment were randomly assigned to placebo or udenafil at a dose of 50mg 2x/day for the first 4 weeks followed by 100mg 2x/day for the next 8 weeks. All patients underwent cardiopulmonary exercise echocardiography before and after the 12-week treatment.Improvement of subjective functional capacity was more frequently reported in the udenafil group (P = 0.002). Also, a higher increase in peak VO2 (Δpeak VO2, 21.6% (6.9 ~ 106.4%) vs 1.9% (-15.7 ~ 21.0%) in the placebo group, P = 0.04) and a larger decrease in ventilatory efficiency were observed in the udenafil group (Δ-6.4 ± 9.7 vs Δ1.9 ± 12.1 in the placebo group, P = 0.03). Regarding LV systolic function, the extent of increment in LV ejection fraction was significantly greater in the udenafil group (6.6 ± 6.4% vs 2.3 ± 4.8% in the placebo group, P = 0.02). In the udenafil group, an echocardiographic surrogate of LV filling pressure was more prominently decreased (P = 0.006) along with a significant reverse remodeling of left atrial volume index (57 ± 25mL at baseline to 44 ± 23 at 12th week, P = 0.04) and a progressive fall in B-type natriuretic peptide level (589 ± 679pg/mL at baseline to 220 ± 225pg/mL at 12th week, P0.001), indicating LV diastolic function improvement. Udenafil was well tolerated without excess of adverse events compared to placebo.Udenafil improves LV systolic/diastolic functions and exercise capacity in conjunction with established conventional pharmacotherapy, without significant adverse events in HFrEF.

Prevention of tachycardia is an important therapeutic strategy in patients with relaxation abnormality.Eleven patients with stable relaxation abnormality (group 1) and 8 healthy individuals (group 2) were enrolled. Left ventricular (LV) mean diastolic pressure, LV dimensions, stroke volume (SV), and LV ejection, filling, and isovolumic times between right atrial pacing rates of 80 and 120/min were compared.Both groups 1 and 2 showed significant decreases in LV mean diastolic pressure when heart rate (HR) increased. At a HR of 80/min, no significant difference was noted between groups 1 and 2 in SV (51.4 +/- 13.0 vs 45.2 +/- 9.0 mL, P = .35). However, a decrement in SV between a HR of 80 and 120/min was significantly greater for group 1. Therefore, group 1 showed a significantly lower SV (30.2 +/- 7.1 vs 40.1 +/- 6.9 mL, P.05) at a HR of 120/min. In terms of time intervals between HRs of 80 and 120/min, group 1 showed a significantly greater reduction in LV ejection time (84.5 +/- 20.1 vs 30.0 +/- 34.6 milliseconds, P.005) and a smaller reduction in LV filling time (106.4 +/- 38.5 vs 166.3 +/- 30.7 milliseconds, P.005) than group 2.Results of our study suggest that an inadequate SV response to tachycardia may play an important role in the production of dyspnea associated with tachycardia in these patients.

Background— The efficacy of intracoronary infusion of granulocyte colony-stimulating factor (G-CSF) mobilized peripheral blood stem cells (PBSCs) has not been compared between patients with acute (AMI) versus old myocardial infarction (OMI). In addition, the potential risk of restenosis associated with G-CSF–based stem cell therapy has not been evaluated in the setting of drug eluting stent (DES) implantation. Methods and Results— We randomly allocated 96 patients with myocardial infarction who underwent coronary revascularization with DES for the culprit lesion into 4 groups. Eighty-two patients completed 6-month follow-up; AMI cell infusion (n=25), AMI control (n=25), OMI cell infusion (n=16), and OMI control group (n=16). In cell infusion groups, PBSCs were mobilized by G-CSF for 3 days and delivered to infarcted myocardium via intracoronary infusion. The AMI cell infusion group showed a significant additive improvement in left ventricular ejection fraction (LVEF) and remodeling compared with controls (change of LVEF: +5.1±9.1% versus −0.2±8.6%, P P Conclusions— Intracoronary infusion of mobilized PBSCs with G-CSF improves LVEF and remodeling in patients with AMI but is less definite in patients with OMI. G-CSF–based stem cell therapy with DES implantation is both feasible and safe, eliminating any potential for restenosis.

Speckle tracking echocardiography (STE) has a unique feature of angle independence and, thus, may provide a powerful means of assessing left ventricular (LV) torsion (LVtor). The aims of this study were to assess: (1) the feasibility of 2-dimensional STE in the measurement of LVtor; and (2) the relationship of LVtor with age and conventional echocardiographic parameters.We consecutively recruited 160 healthy volunteers. After obtaining conventional echocardiographic parameters, apical and basal short-axis rotations were assessed with STE. LVtor was defined as the net difference between rotation angles in the two short-axis planes normalized for LV longitudinal length.Reliable LVtor measurement was possible only in 56 volunteers (35%). This low feasibility was largely a result of the failure to obtain reliable basal rotation values. In 56 volunteers who were finally enrolled in this study, a significant correlation was found between LV ejection fraction and LVtor (r = 0.56, P.001) and this correlation was attributed to apical (r = 0.47, P.001) but not basal (P = .14) rotation. There was no significant change in LVtor with aging. However, initial counterclockwise motion (r = -0.51, P = .001) and its interval (r = -0.44, P = .001) in the basal rotation gradually decreased with aging, and correlated with early transmitral inflow velocity (r = 0.44 and 0.49, respectively) and its deceleration time (r = -0.43 and -0.48, respectively) (all P.001). In contrast, such correlations were not found for initial clockwise motion and its interval in the apical rotation.Currently, STE has limited feasibility in the measurement of LVtor. There was no significant age-related change in LVtor. In LV rotations, basal rotation was affected by the age-related changes in the LV early diastolic filling, whereas apical rotation was mainly related to LV systolic performance.

Background— Atrial fibrillation (AF) has been reported to be a predisposing factor for the progression of TR in patients with previous mitral or combined mitral/aortic valve surgery. We hypothesized that the maze operation (MAZE) can prevent the progression of tricuspid regurgitation (TR) in these patients. Methods and Results— We analyzed 170 patients (age, 45.5±10.9 years) who had undergone mitral or combined mitral/aortic valve surgery. On the basis of preoperative rhythm, patients were divided into 3 groups; GrI was composed of 44 patients with sinus rhythm, GrII of 48 who had undergone MAZE, and GrIII of 78 with AF who had not undergone MAZE. Echocardiographic examinations were performed before, immediately after, and 92.2±17.2 (range, 50 to 131) months after surgery. Preoperative and immediate postoperative clinical and echocardiographic parameters were similar among the groups. Insignificant TR at the immediate postoperative examination worsened with time in 7.3% of GrI (3 of 41), 12.8% of GrII (6 of 47), and 38.8% of GrIII (26 of 67) patients at the final examination ( P =0.63 for GrI versus GrII, P =0.001 for GrI versus GrIII, P =0.005 for GrII versus GrIII). The incidence of significant TR at the final echocardiographic examination was higher in GrIII (39.7%) compared with GrI (9.1%) and GrII (14.6%) ( P =0.001 for GrI versus GrIII, P =0.005 for GrII versus GrIII), whereas GrI and GrII did not show any difference ( P =0.63). By multivariate analysis, the only factor identified to prevent TR progression was the group factor (GrI and GrII versus GrIII, P =0.002 and P =0.005, respectively). In a subgroup analysis of GrII according to the presence or absence of atrial mechanical activity, the absence of atrial mechanical activity was identified as an independent parameter for the progression of TR ( P =0.001). Conclusions— AF predisposes patients undergoing mitral valve surgery to the progression of TR, which can be prevented by MAZE. This additional benefit of MAZE is largely dependent on the restoration and maintenance of atrial mechanical function.

Background In contrast to in-depth studies on the chronic hazardous effects of smoking, the immediate effects of smoking on left ventricular function have not been evaluated in detail. Objectives We aimed to assess the hypothesis that smoking a cigarette might have more deleterious immediate impacts on left ventricular function in patients with diabetes mellitus than in healthy volunteers. Methods In all, 20 patients with type 2 diabetes mellitus and 25 healthy volunteers were consecutively enrolled. Mitral inflow parameters (peak early and late diastolic velocities, and deceleration time of early diastolic mitral inflow) and mitral annulus velocity parameters (systolic, late, and early diastolic velocity [E']) were obtained together with heart rate and blood pressure before and 5, 15, 30, 45, 60, and 75 minutes after smoking a cigarette. Results Transient elevations in heart rate and blood pressure were observed after smoking in both groups. In terms of mitral inflow parameters, transient trends toward abnormal relaxation were noted in both groups. For mitral annulus velocity parameters, in contrast to a temporary decrease in E' in healthy volunteers, reduction in E' persisted throughout the study for patients with diabetes. No significant change in peak early diastolic velocity/E' ratio was observed in healthy volunteers; however, a significant increase in peak early diastolic velocity/E' ratio lasted throughout the study period for patients with diabetes. Systolic velocity had no significant change during the study in either group. Conclusions Even one cigarette can induce more protracted and more severe left ventricular diastolic dysfunction in patients with type 2 diabetes mellitus than in healthy volunteers. Our results have clinically relevant implications in the current era of increasing recognition of the diabetes epidemic and of the associated cardiovascular risks.

Background: Mitral regurgitation (MR) is known as one of the most frequent causes of heart failure and sudden death. In spite of increasing prevalence of MR, there have been no available data on cardiac determinants of exercise capacity in patients with chronic MR. Hypothesis: This study aimed to investigate cardiac determinants of exercise capacity in patients with chronic MR. Methods: We consecutively enrolled 32 patients (11 men, mean age: 44 ± 14 years) who had greater than moderate MR with normal left ventricular (LV) systolic function (LV ejection fraction > 50%). Conventional echocardiographic indices and parameters measured by Doppler tissue imaging at septal side of mitral annulus were obtained before exercise. Mitral regurgitation fraction, forward stroke volume, pulmonary venous flow velocities, and systolic pulmonary artery pressure (sPAP) were also obtained with standard methods. Results: Left ventricular ejection fraction was 61 ± 6% and MR fraction was 48 ± 13%. All patients finished a symptom‐limited treadmill exercise test with a peak heart rate of > 85% of predicted maximum heart rate. Mean exercise time was 9.95 ± 2.17 min, corresponding to 11 ± 2 metabolic equivalents. Among pre‐exercise echocardiographic variables, only early diastolic mitral annulus velocity (E') and pulmonary venous reversal flow velocity (PVa) showed a significant correlation with exercise time (r = 0.44, p = 0.011, and r = −0.40, p = 0.040, respectively), which persisted after multivariate analysis (p = 0.011 and 0.038, respectively). Other parameters such as systolic mitral annulus velocity, resting and post‐exercise sPAP, forward stroke volume, LV size, LV ejection fraction, left atrial size, and regurgitant fraction showed no significant correlation. Conclusions: Left ventricular diastolic function is an important determinant of exercise capacity in patients with chronic MR. Both E' and PVa, accepted surrogate estimates for LV diastolic function, may be useful for identifying patients with chronic MR and with poor exercise capacity.

Background Mitral annulus calcification (MAC) or aortic valve sclerocalcification (AVSC) is common with aging and associated with coronary artery disease (CAD) in Caucasians. This study was performed to determine whether MAC or AVSC is also associated with, and has a power to predict, CAD in Koreans as in Caucasians. Methods Three hundred and eight patients with chest pain, who had undergone coronary angiography and transthoracic echocardiography, were enrolled (189 moles; mean 60.5 ′ 9.8 years). Results The prevalence of MAC and AVSC was significantly more common in CAD (+) compared with CAD (-) group (83.9%:55.2%, 87.9%:57,5%, respectively, both p

BACKGROUND: Measurement of the cardiac chamber is essential, and current guidelines recommend measuring and reporting values for both sides of the cardiac chamber during echocardiographic evaluation. Normal echocardiographic reference values have been suggested previously, but detailed information about right-sided chambers and values according to gender was not included. METHODS: This is a prospective multicenter (23 centers) study evaluating normal Korean adult subjects using comprehensive echocardiography. We included normal adult subjects (age; 20-79 years old) who had no significant cardiac disorders or illnesses, such as hypertension or diabetes, which could affect cardiac structure and function. We measured the cardiac chamber including both right and left ventricles as well as atria according to current echocardiography guidelines and compared values according to gender and age groups. RESULTS: A total of 1003 subjects were evaluated and the mean age was 48 ± 16 years. Left ventricular (LV) dimensions increased, but LV volume decreased in older subjects. Right ventricular (RV) area decreased in women and older subjects, and the RV long-axis dimension showed a similar trend. Left atrial (LA) volume increased in men but there were no differences in LA volume index between men and women. The dimension of great arteries increased in men and older subjects. CONCLUSION: Since there were considerable differences between men and women and in the different age groups, and the trends differed significantly between different echo variables, normal echocardiographic cutoff values should be differentially applied based on age and gender.

This study was conducted to determine clinical parameters predicting future major adverse cardiovascular events (MACEs) in patients without significant stenosis on coronary computed tomographic angiography (CCTA). A total of 625 patients with suspected coronary artery disease (CAD) who underwent CCTA that revealed insignificant (< 50%) CAD was reviewed in three cardiac centers. The MACEs including cardiac death, non-fatal myocardial infarction (MI), unstable angina and late (> 90 days after CCTA) revascularization were assessed. During the mean follow-up period of 819 ± 529 days (median 837 days), there were 28 cases of MACEs (4.5%). In multivariable Cox regression analysis, independent predictors for MACEs were male sex (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.01-5.69; P = 0.046) and low estimated creatinine clearance (eCCr) (< 60 mL/min/1.73 m2) (HR, 3.07; 95% CI, 1.22-7.74; P = 0.017). Low eCCr was the only independent predictor for hard events including cardiac death and MI (HR, 17.6, 95% CI, 1.44-215.7; P = 0.025). In conclusion, renal function is an independent predictor for cardiovascular events among patients without significant CAD by CCTA. Careful monitoring and preventive strategy are warranted in patients with impaired renal function even without significant CAD. Graphical Abstract

We introduce a noble fault-tolerant distributed real-time operating system, SROS (Scalable Real-time Operating System), that is successfully implemented and working in an ATM switching system for B-ISDN. SROS is based on a micro-kernel for the purpose of achieving portability, scalability and reusability. In addition, to reduce system development period and to preserve call service continuity during system/application software upgrade, SROS adopts a dynamic code binding (DCB) method that enables system/application software upgrade without system halt or service disconnection. We also propose a cool development environment suitable for an embedded, distributed real-time system. This environment, together with SROS mechanisms, greatly cuts down the system development time.

Recently, it has become possible to measure coronary flow reserve (CFR) non-invasively with transthoracic echocardiography (TTE). Twenty-one hypertrophic cardiomyopathy (HCMP) patients with asymmetric septal hypertrophy who had either not started medication or had stopped medication for at least 24 h were enrolled, along with 29 normal subjects. Mean diastolic coronary flow velocity (CFmv) and time velocity integral of diastolic coronary flow velocity (CFtvi) were measured at the distal left anterior descending artery with a 7 MHz transducer at the baseline and after dipyridamole infusion at a dose of 0.56 mg/kg. CFR was defined as the ratio of CFmv after dipyridamole over CFmv before dipyridamole. The baseline values for CFmv and CFtvi were significantly higher (0.40+/-0.09 vs. 0.31+/-0.06 m/s, p

Recently, transcatheter aortic valve replacement (TAVR) has emerged as an alternative for the treatment of severe symptomatic aortic stenosis patients. Although experience with TAVR is increasing exponentially, few cases of post-TAVR endocarditis are reported. We present a case of 76-year-old man with infective endocarditis after TAVR who was definitely diagnosed by echocardiography.

Although Brucella endocarditis is a rare complication of human brucellosis, it is the main cause of the mortality in this disease. Traditionally, the therapeutic approach to endocarditis caused by Brucella species requires a combination of antimicrobial therapy and valve replacement surgery. In the literature, only a few cases of mitral prosthetic valve endocarditis caused by Brucella species have been successfully treated without reoperation. We present a case of a 42-year-old man with a prosthetic mitral valve infected by Brucella abortus who was cured solely by medical treatment. (Korean Circ J 2014;44(6):441-443)

Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.

A 47-year-old man was referred to our hospital from an outside facility with a left ventricular mass. He had experienced chest discomfort and palpitations for a period of 1 month. His medical history was unremarkable except that he had been treated for pulmonary tuberculosis in his youth. During physical examination, the patient was alert and well oriented. His blood pressure was 127/77 mm Hg, pulse 75 bpm, respiration rate 20 breaths per minute and temperature 36.6 8C. Chest auscultation revealed bilateral clear lung sounds, regular heart rate and rhythm, without abnormal sounds. His electrocardiogram demonstrated a normal sinus rhythm. However, by transthoracic and transesophageal echocardiography, a mobile, round and cystic

methods: A total of 1,286 patients who underwent both CCTA and SPECT within 90 days, between November 2004 and November 2010, were retrospectively reviewed in 2 cardiac centers. Diagnostic performance of CCTA and SPECT were compared using invasive coronary angiography (ICA) as a reference standard. The cardiac events including cardiac death, non-fatal myocardial infarction, unstable angina and late (> 90 days after the exam) revascularization were assessed.

Thiamine (vitamin B1) serves as an important cofactor in body metabolism and energy production. It is related with the biosynthesis of neurotransmitters and the production of substances used in defense against oxidant stress. Thus, a lack of thiamine affects several organ systems, in particular the cardiovascular and nervous system. The cardiac insufficiency caused by thiamine deficiency is known as cardiac beriberi, with this condition resulting from unbalanced nutrition and chronic excessive alcohol intake. Given that the disease is now very rare in developed nations such as Korea, it is frequently missed by cardiologists, with potentially fatal consequences. Herein, we present a case study in order to draw attention to cardiac beriberi. We believe that this case will be helpful for young cardiologists, reminding them of the importance of this forgotten but memorable disease.

Background Over the last few years, the use of phosphodiesterase type 5 (PDE5) inhibitors has been expanded to management of various cardiovascular disorders beyond pulmonary arterial hypertension. This study is designed to investigate the ability of udenafil, a newly developed long-acting PDE5 inhibitor, to improve functional capacity and hemodynamic status in a cohort of chronic systolic heart failure (SHF) patients. Methods/design Stable, chronic SHF patients will be randomly assigned to placebo (26 patients) or udenafil at a dose of 50 mg twice per day (26 patients) for the first 4 weeks followed by 100 mg twice daily for the next 8 weeks. Eligibility criteria will be age ≥18 years, clinical diagnosis of chronic SHF with current New York Heart Association class II to IV symptoms, left ventricular ejection fraction ≤ 40%, and experience of at least one of following during the 12 months prior to study entry: hospitalization for decompensated heart failure, acute treatment with intravenous loop diuretics or hemofiltration, or pulmonary artery systolic pressure ≥40mmHg on transthoracic echocardiography. Pharmacological therapy for SHF will be optimized in all patients at least 30 days before study entry. The primary outcome will be the change of maximal oxygen uptake, assessed by cardiopulmonary exercise testing. Secondary outcomes will include changes in ventilatory efficiency (minute ventilation/carbon dioxide production slope), left ventricular systolic and diastolic parameters, pulmonary artery systolic pressure, plasma concentration of brain natriuretic peptide, occurrence of mortality or hospitalization for heart failure, and the occurrence of any adverse event. Clinical trial registration Unique identifier: NCT01646515

In spite of the frequent involvement of many cardiac diseases, it is difficult to evaluate the left ventricular apex in detail with transthoracic echocardiography, a first-line imaging modality in cardiovascular diseases, because the apex is very closely located at the echocardiographic probe. Cardiac magnetic resonance enables us to evaluate the cardiac apex without any limitation to the image acquisition. We here present a case regarding a broad-based apical diverticulum, which was initially confused with apical aneurysm.