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BACKGROUND There is little evidence regarding the effect of outpatient cardiac rehabilitation (CR) on exercise capacity or the long-term prognosis in patients after coronary artery bypass graft surgery (CABG). This study aimed to determine whether participation in outpatient CR improves exercise capacity and long-term prognosis in post-CABG Japanese patients in a multicenter cohort.Methods and Results:We enrolled 346 post-CABG patients who underwent cardiopulmonary exercise testing during early (2-3 weeks) and late (3-6 months) time points after surgery. They formed the Active (n=240) and Non-Active (n=106) CR participation groups and were followed for 3.5 years. Primary endpoint was a major adverse cardiac event (MACE): all-cause death or rehospitalization for acute myocardial infarction/unstable angina/worsening heart failure. Peak oxygen uptake at 3-5 months from baseline was significantly more increased in Active than in Non-Active patients (+26±24% vs. +19±20%, respectively; P

Objective It is recommended that middle-aged and elderly individuals reduce their salt intake because of the high prevalence of hypertension. The consumption of miso soup is associated with salt intake, and the reduced consumption of miso soup has been recommended. Recent studies have demonstrated that the consumption of miso soup can attenuate an autonomic imbalance in animal models. However, it is unclear whether these results are applicable to humans. This study examined the cross-sectional association between the frequency of miso soup consumption and the blood pressure and heart rate of human subjects. Methods A total of 527 subjects of 50 to 81 years of age who participated in our hospital health examination were enrolled in the present study and divided into four groups based on the frequency of their miso soup consumption ([bowl(s) of miso soup/week] Group 1

A 21-year-old man with Wolff–Parkinson–White syndrome and aneurysmal septal dyskinesis underwent radiofrequency catheter ablation of the accessory pathways. Before radiofrequency catheter ablation, the activation wavefront arose from the aneurysmal septum, whereas the propagation of the left ventricle was normalised after radiofrequency catheter ablation. These findings demonstrate the importance of the electro-mechanical interaction in patients with Wolff–Parkinson–White syndrome and ventricular dysfunction.

Sleep-disordered breathing (SDB) is common in patients with heart failure and carries an independent risk for poor long-term prognosis. We aimed to study the effects of supervised, aerobic exercise training for 6 months on SDB in patients with chronic heart failure.We enrolled 18 patients having both systolic dysfunction (left ventricular ejection fraction45%) and SDB (apnea-hypopnea index [AHI]10). The exercise group comprised 10 patients who participated in our cardiac rehabilitation program for 6 months, and the remaining 8 patients served as control. AHI (median [interquartile range]) was unchanged in the control group patients at 6-month intervals (30.4 [19.9-36.3] versus 36.6 [8.6-39.4], NS). In contrast, AHI was significantly decreased in the exercise group from 24.9 [19.2-37.1] to 8.8 [5.3-10.1] (P.01). In the exercise group, the numbers of central sleep apnea per night was significantly decreased (152 [124-244] versus 50 [24-67], P.01) after exercise training, but those of obstructive apnea/hypopnea were unchanged (42 [7-94] versus 18 [7-54], NS). In addition, exercise training significantly increased peak oxygen consumption and decreased minute ventilation to carbon dioxide production slope (both P.01).Six-month, aerobic exercise training increased exercise capacity and improved central sleep apnea in patients with chronic heart failure from systolic dysfunction.

Objectives. The purpose of this study was to determine whether the assessment of mitral annulus displacement (MAD) using Doppler-tissue image (DTI) could provide a useful marker of heart failure severity.[Methods] In seventy-five subjects with heart diseases, we measured MAD by tissue-tracking method with DTI. MAD was evaluated in both septal and lateral corners of the mitral annulus in the apical 4-chamber view, and the degree of MAD in postsystolic phase was estimated as a ratio of displacement at aortic valve closure and peak point (P/A ratio). We divided subjects into three groups (group A: subjects with preserved MAD, group B: subjects with reduced MAD without increasing P/A ratio, group C: subjects with reduced MAD with increasing P/A ratio) and compared NYHA functional class and left ventricular ejection fraction (LVEF).Results. NYHA functional class and LVEF were significantly different among the three groups (NYHA functional class; group A: 1.2±0.4, group B: 2.3±0.9, group C: 3.1±0.8, LVEF; group A: 58±12 %, group B: 42±15 %, group C: 25±8 %). These results indicated that MAD which represents mainly LV longitudinal function is decreased in the first place, and then, post-systolic displacement is exaggerated according to the severity of heart failure.Conclusions. The classification of the degree and timing of peak MAD (P/A ratio) is well correlated with NYHA functional class and LVEF and becomes one of the useful indexes of heart failure severity.

Introduction: Although the prognostic efficacy of out-patient cardiac rehabilitation (OPCR) in patients with coronary artery disease (CAD) has been established in Western countries, it has not been studied in Japan, where both incidence and mortality of CAD are known to be much lower than in Western counties. Methods: To determine the prognostic efficacy of OPCR in Japan, a prospective, controlled, multicenter study of OPCR (J-REHAB) was conducted in 15 hospitals in Japan. A total of 1047 patients hospitalized with cardiac events were prospectively assigned to either OPCR group (n=848) or Non-OPCR group (n=199) according to patient’s preference at the time of hospital discharge. Patients in OPCR group were scheduled to participate in a comprehensive OPCR program for 3 months and Non-OPCR group received usual care. Event-free survivals for cardiac and all-cause death/rehospitalization were assessed according to the initial group assignment and the “prespecified” actual OPCR performance (attendance >=4 times/month and total exercise time >=150 min/week). Results: Patients were followed-up for 416days on average and the follow-up rate was 99.4%. At baseline, patients were 64±11years of age, 85% was male, 58% acute myocardial infarction, with preserved EF (53±13%). By Kaplan-Meier analysis, OPCR group had significantly better event-free survival for cardiac death/rehospitalization (p Conclusions: The first Japanese prospective multicenter J-REHAB study has demonstrated that active participation in OPCR is associated with better event-free survival in CAD patients, independent of baseline clinical characteristics.

Objectives: Biventricular pacing (BVP) therapy has recently emerged as an effective treatment for patients with moderate to severe congestive heart failure (CHF) and ventricular asynchrony all over the world. However, this therapy is not yet available in Japan. We evaluated the effects of BVP in patients with severe CHF due to dilated cardiomyopathy (DCM). Subjects: Four patients with medically refractory severe CHF due to DCM in New York Heart Association functional class III or IV heart failure underwent BVP therapy. We combined the implantation of the left ventricular (LV) epicardial lead via small thoracotomy following right atrial and ventricular intravenous leads under general anesthesia. We evaluated to determine whether improvements of ventricular function, ventricular size, mitral regurgitation, functional status, frequency of hospitalization, and quality of life were associated with BVP therapy. Results: BVP improved LV systolic function, decreased LV size and mitral regurgitation, and shortened prolonged QRS interval. The patients’ symptoms, exercise tolerance, frequency of hospitalization, and quality of life were also dramatically improved by BVP. Furthermore, combination of BVP and oral administration of amiodarone significantly prevented recurrence of ventricular tachycardia and paroxysmal atrial fibrillation, and maintained sinus rhythm for a long period. Conclusions: In view of these findings, BVP therapy may contribute to the development of new therapeutic method for patients with severe CHF due to DCM.

Supervised cardiac rehabilitation provided at dedicated centres ameliorates exercise intolerance in patients with chronic heart failure.To correlate the amount of physical activity outside the hospital with improved exercise tolerance in patients with limited access to centre-based programs.Forty patients (median age 69 years) with stable heart failure due to systolic left ventricular dysfunction participated in cardiac rehabilitation once per week for five months. Using a validated single-axial accelerometer, the number of steps and physical activity-related energy expenditures on nonrehabilitation days were determined.Median (interquartile range) peak oxygen consumption was increased from 14.4 mL/kg/min (range 12.9 mL/kg/min to 17.8 mL/kg/min) to 16.4 mL/kg/min (range 13.9 mL/kg/min to 19.1 mL/kg/min); P0.0001, in association with a decreased slope of the minute ventilation to carbon dioxide production plot (34.2 [range 31.3 to 38.1] versus 32.7 [range 30.3 to 36.5]; P0.0001). Changes in peak oxygen consumption were correlated with the daily number of steps (P0.01) and physical activity-related energy expenditures (P0.05). Furthermore, these changes were significantly correlated with total exercise time per day and time spent for light (≤3 metabolic equivalents) exercise, but not with time spent for moderate/vigorous (3 metabolic equivalents) exercise.The number of steps and energy expenditures outside the hospital were correlated with improved exercise capacity. An accelerometer may be useful for guiding home-based cardiac rehabilitation.

This study investigated whether the measurement of mitral annulus displacement by the tissue-tracking method with Doppler-tissue images can provide more accurate information on the severity of heart failure compared to conventional methods, such as left ventricular ejection fraction (LVEF).Impaired left ventricular function is an important predictor of poor prognosis. Although LVEF has been used to assess left ventricular function, such indicators do not necessarily correlate well to clinical variables such as New York Heart Association (NYHA) functional class or plasma brain natriuretic peptide (BNP) concentration.In 90 subjects with or without various heart diseases, mitral annulus displacement was measured by the tissue-tracking method with Doppler-tissue images and the correlations evaluated with NYHA functional class, plasma BNP concentration, left ventricular mass index and Tei index.Mitral annulus displacement by the tissue-tracking method with Doppler-tissue images was well correlated with NYHA functional class and plasma BNP concentration. LVEF was also correlated with these clinical variables, but significantly more weakly. Furthermore, mitral annulus displacement by the tissue-tracking method with Doppler-tissue images was correlated with left ventricular mass index and Tei index, which indicate left ventricular systolic and diastolic function.The present study suggests that mitral annulus displacement measured by our technique is a useful and reliable method for assessing the severity of heart failure.

A 47-year-old man was referred to us for an evaluation of chest pain. Upon arrival, he had a blood pressure of 156/80 mm Hg and a heart rate of 87 bpm. The physical examination was unremarkable. An ECG was normal, and a cardiac echocardiogram showed normal left ventricular wall motion, no valvular …

We encountered a case of wide QRS tachycardia with chronic atrial fibrillation in Wolff-Parkinson-White syndrome. Unique features were late onset of syncope attacks associated with this tachycardia at an advanced age of 72 years old without previous documentation of Wolff-Parkinson-White syndrome on electrocardiogram. He had a high likelihood of sudden cardiac death. Catheter ablation using CARTO system easily led to a successful ablation of the accessory pathway. The mechanism of late onset of the wide QRS tachycardia was attributed to possible changes of electrophysiologic properties including the atrio-ventricular node and/or the accessory pathway, and the unique location of the accessory pathway.

We report a 90-year-old man, who presented 17 months after his pacemaker implantation with erythema and blistering at site of pacemaker insertion. He was initially treated with non-steroidal anti-inflammatory drugs and anti-allergic agents. After 2 weeks, erythema and blistering at site of pacemaker insertion was cured. However, he had recurrence of erythema and blistering at site of pacemaker insertion after 2 month. To make matters worse, blister had broken with inflammatory granulation tissue and pus, methicillin-sensitive staphylococcus aureus were detected by bacteriological culture. After pacemaker generator and leads removal and administration of antibiotics, new pacemaker generator and leads were implanted another side of chest under greater pectoral muscle. Eosinophilic infiltration was shown in the section of the skin at blister histologically. The histological finding suggest that preexsisting pakemeker-mediated dermatitis cause pacemaker infection.

ObjectivesThe present study evaluated clinical benefits of radiofrequency catheter ablation (RFA) for premature ventricular complexes from right ventricular outflow tract (RVOT-PVC) in patients without structural heart disease.BackgroundIt is unknown whether PVC causes left ventricular (LV) dilation, which is a well-recognized precursor of LV dysfunction and heart failure, and whether eliminating PVC by RFA produces clinical benefits in patients with RVOT-PVC.MethodsFrequency of PVC per total heart beats by 24-h Holter monitoring, left ventricular ejection fraction (LVEF), left ventricular end-diastolic internal dimension (LVDd), mitral regurgitation (MR) by echocardiogram, cardiothoracic ratio (CTR) by chest radiogram, and New York Heart Association (NYHA) functional class of 40 patients with RVOT-PVC without structural heart disease were evaluated before and 6 to 12 months after RFA.ResultsBefore RFA, a subgroup of patients with frequent (>20%) PVC demonstrated significantly enlarged LVDd and CTR, reduced LVEF, increased MR, and deteriorated NYHA functional class as compared to the subgroup with rare (20%) RVOT-PVC may be a possible cause of LV dysfunction and/or heart failure, and RFA produces clinical benefits in these patients.

We report herein a case with multiple coronary arterioventricular fistulas, in which exercise-induced myocardial ischemia was demonstrated by stress thallium scintigraphy, illustrating the coronary “steal” phenomenon. A 52-year-old Japanese man complained of exertional chest pain for 1 year. The chest pain was relieved by rest but not by sublingual nitroglycerin or oral isosorbide dinitrate. His past medical history and family history were not contributory. Physical examination revealed blood pressure or 100/60 mm Hg and regular heart rate of 80lmin. There was no heart murmur. The chest x-ray examination showed slight cardiac dilation with cardiothoracic ratio of 52 % . The ECG showed T wave inversion in leads II, III, aVr, and V,.,. He complained of chest pain at peak treadmill exercise, along with pseudonormalization of T waves in leads II, III, aVr, and V,.,. Thallium-201 emission computed myocardial tomography at rest showed a mild perfusion defect of the inferoposterior to lateral wall of the left ventricle (LV) and posterior half of the septum, where severe perfusion defect was induced by peak ergometer exercise, with chest pain and pseudonormalization of T waves in leads II, III, aVr, and V,, (Fig. 1). Cardiac catheterization showed normal right and left heart pressures and no evidence of an intracardiac shunt. Left ventriculography revealed normal cavity size and no wall motion abnormality. Selective coronary arteriography showed no stenotic lesions and multiple fistulas from all three major coronary arteries (Fig. 2). The coronary venous drainage was normal. Propranolol therapy was started at oral doses of 90 mg/day and the frequency of exertional angina decreased. Although coronary artery fistula is an unusual congenital anomaly, clinical experiences have accumulated along with the evidence of selective coronary arteriography. However, the majority of coronary artery fistulas drain into the right heart chamber from a single coronary artery. Multiple coronary artery fistulas communicating with the LV involving all three major coronary arteries are extremely rare, and only five cases have been reported in the world literature.‘-5