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Atrial fibrillation (AF) is a common disease that changes cardiac morphology, especially in the left atrium (LA). It is now known that certain categories of functional mitral regurgitation (MR) are associated with AF; however, the influence of AF on right cardiac morphology is not fully understood. Our aim in this study was to investigate the association between AF and right cardiac morphology. This was a retrospective cohort study of 86 patients with persistent AF without other cardiac disease who underwent catheter ablation (CA). Seventy-one patients had sustained sinus rhythm (SR) (SR Group) and 15 patients had sustained AF (AF Group) during the study period. We compared the changes in the right cardiac dimensions and tricuspid regurgitation (TR) between the groups 12 months after CA. Patients' baseline echocardiographic assessments revealed that the LA volume index was significantly smaller in the SR group than in the AF group (46.8 ± 11.9 ml/m2 vs 59.3 ± 12.8 ml/m2, respectively; p < 0.01). Comparing baseline data with the 12-month follow-up data, in the SR group, right atrial area (RAA, cm2), tricuspid annular diameter (mm), and tricuspid regurgitant jet area (cm2) were significantly decreased compared with the AF group (19.5 ± 4.5–15.5 ± 3.6 vs 20.7 ± 3.6–19.7 ± 2.3; 30.5 ± 4.9–26.4 ± 3.9 vs 28.7 ± 4.0–28.8 ± 3.1; and 1.4 [interquartile range (IQR) 0.7–2.6]–0.6 [IQR 0.2–1.2] vs 1.2 [IQR 1.1–1.5]–0.9 [IQR 0.4–1.3], respectively). On multivariate analysis, change in RAA correlated with the reduction in tricuspid regurgitant jet area (R = 0.51, p < 0.001). In conclusion, successful CA for persistent AF led to right heart reverse remodeling, and our findings suggested that persistent AF was associated with RAA dilatation and TR. [ABSTRACT FROM AUTHOR]

Although epicardial adipose tissue (EAT) and abdominal visceral adipose tissue (VAT) can contribute to left ventricular diastolic dysfunction (LVDD), the impact of these distribution has not been fully understood. A total of 235 patients who underwent cardiac computed tomography angiography and Doppler echocardiography was included in this study. We evaluated the association of indexed EAT volume and VAT area with septal and lateral early diastolic mitral annular velocity (e′). The VAT area index was significantly associated with septal and lateral e′ velocity after adjusted for conventional cardiovascular risk factors and obstructive coronary artery disease (β-estimate; − 0.015 and − 0.019, both p = 0.01). The natural logarithmic EAT volume index (ln EAT volume index) also showed a significant association with septal and lateral e′ (β-estimate; − 1.72 and − 0.99, both p < 0.01). The significant association of ln EAT volume index with septal and lateral e′ was observed even after adjusting for VAT area index (β-estimate; − 0.79 and − 1.52, both p < 0.03). In the subgroup analysis, there were significant association of ln EAT volume index with both septal and lateral e′ in the lower VAT group (β-estimate; − 1.40 and − 1.53, both p < 0.03) and with lateral e′ in the higher VAT group (β-estimate − 1.64, p = 0.006). In contrast, ln EAT volume index was not associated with septal e′ in the higher VAT group (p = 0.98). EAT accumulation was significantly associated with LVDD independently of obstructive coronary artery disease and abdominal VAT. The impact of EAT on LVDD may vary depending on the amount of abdominal VAT. [ABSTRACT FROM AUTHOR]

Background: Persistent AF makes left side heart expansion especially left atrium, but the effect on the right side heart is unknown. The influence to right cardiac morphology with recovering from persistent AF by catheter ablation is almost uncertain even though some guidelines suggest characterize the category of tricuspid regurgitation (TR) due to persistent AF. Objectives: The aim of this study is to seek whether the recover from persistent atrial fibrillation (AF) would provide the contraction in volume of right heart and TR. Methods and Results: A total of 101 patients (60.4 ± 9.3 years, 83 male) with persistent AF continued more than one year were performed first catheter ablation in our institution for 5 years. Of those, 71 patients kept sinus rhythm (SR) at 3 month and one year after ablation (SR Group), 15 patients had AF rhythm at both times of follow up (Recurrence Group). Before catheter procedure, only left atrial (LA) size (LA volume index; 46.8 ± 11.9 vs. 59.3 ± 12.8 ml/m2, p<0.01) had significant difference in echocardiac parameters between two groups. In follow up, right atrium (RA) area (19.5 ± 4.5 vs. 15.5 ± 3.5 cm2, p<0.01), tricuspid annular diameter (28.7 ± 4.0 vs. 27.2 ± 3.8 mm, p<0.01) and TR area [1.4 (IQR 0.7 - 2.6) vs. 0.6 (IQR 0.2 - 1.2) cm2, p<0.01] decreased three month after catheter ablation and these were maintained at one-year follow up in SR Group. No parameters changed in Recurrence Group. Conclusions: In patients with persistent AF, restoration to SR makes RA area and tricuspid annular diameter decrease. Persistent AF can be the reason of right side heart enlargement and it is reversible change. [ABSTRACT FROM AUTHOR]

Tricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling. A total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration. PersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (β 0.37 [95% CI: 0.77–1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01). AF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes. • Previous studies have suggested that increasing tricuspid regurgitation (TR) severity is associated with worse survival and atrial fibrillation (AF) persisting itself is associated with adverse cardiovascular outcomes; hence it is important to prevent tricuspid valve (TV) remodeling and progression of atrial functional TR (AF-TR) to improve prognosis. • In this study, AF duration itself is one of independent determinants of TV annular dilatation only in patients with persistent AF, not in paroxysmal AF. • Significant TV annular dilatation (TV annular area index ≥840 mm2/m2) and predominant right atrial remodeling (right atrium area-to-right ventricle end-systolic area ratio > 2.1) has already initiated at AF duration of 20 months and 37 months, respectively. • Based on the relationship between AF duration and right heart remodeling to progress along the time sequence in this study, early rhythm control may be important in the management of AF patients to prevent right heart structure remodeling leading to the incidence of AF-TR. [ABSTRACT FROM AUTHOR]

Background: Estimation of left ventricular filling pressure (LVFP) is the essential part of the echocardiographic workup for exercise intolerance. The ratio of the mitral early filling velocity to the left ventricular global longitudinal strain (E/LVGLS) has emerged as a novel index of LVFP. This study aimed to investigate the relationship between E/LVGLS and exercise capacity. Methods and results: We retrospectively reviewed 90 patients with exertional dyspnea who underwent echocardiography and cardiopulmonary exercise test. Patients were classified into three groups according to their percent‐predicted maximal oxygen consumption (ppVo2) (G ≧ 75, ppVo2 > 75%, n = 20; G 50‐75, ppVo2 75‐50%, n = 57; G < 50, ppVo2 < 50%, n = 13). Measurements were (a) the relationship between ppVo2 and E/LVGLS and (b) the efficiency of integrated diastolic assessment using E/LVGLS, left ventricular volume, mitral annular early diastolic velocity (E′), and tricuspid regurgitation to identify the patient with impaired exercise capacity. Univariate linear regression analysis demonstrated that E/LVGLS had significant correlation with ppVo2 (ρ = 0.52, P < 0.001). The area under the ROC of E/LVGLS for ppVo2 < 50% was 0.86 (95%CI 0.75‐0.97). The DeLong test showed that E/LVGLS was efficient to detect ppVo2 < 50% than E/E′ (P = 0.007). When used in the integrated assessment of LVFP as the alternative for E/E′, E/LVGLS improved risk classification for impaired exercise capacity. Conclusion: E/LVGLS may be a more efficient index than E/E′ to identify exercise impairment as a single index and as a part of the integrated diastolic assessment. [ABSTRACT FROM AUTHOR]

Background Nearly half of patients with heart failure have normal left ventricular ejection fraction ( LVEF), but their prognosis is no better than those with reduced LVEF. Although peak oxygen consumption ( VO2) is an independent predictor of mortality in heart failure, it is unclear how cardiac function during exercise contributes to peak VO2. Therefore, we explored the useful parameters measured by exercise stress echocardiography to predict peak VO2 in patients with heart failure with preserved LVEF ( HFp EF). Methods and Results We assessed 80 patients being investigated for effort intolerance or dyspnea and finally analyzed 50 patients who satisfied the HFp EF criteria. Mean peak VO2 was 16.4±2.8 mL/kg/min. Twenty-three patients (46.0%) achieved a peak VO2 <16.0 mL/kg/min (Weber class C or D). There was a significant relationship between mitral systolic velocity (S′) and cardiac output ( CO) at rest ( R=.55, P<.0001) and peak exercise ( R=.64, P<.0001). The absolute increase in S′ from rest to peak exercise also correlated with the absolute increase in CO ( R=.32, P=.02). Multivariate logistic regression analysis showed that S′ at peak exercise independently predicted peak VO2. Receiver-operator characteristic curve analysis identified that an S′ at peak exercise of ≤8.13 cm/s predicted a peak VO2 <16.0 mL/kg/min (sensitivity 95.7%, specificity 44.4%, area under curve 0.70, 95% confidence interval 0.55-0.84, P=.004). Conclusions Mitral systolic velocity at peak exercise accurately reflects peak VO2 and may facilitate stratification of risk in patients with HFp EF. [ABSTRACT FROM AUTHOR]

Abstract: Background: Pathologically, the lesions responsible for acute coronary syndrome (ACS) are ruptures of vulnerable plaques (and occasionally fibrous-cap erosions or calcified nodules) with a superimposed thrombosis. We aimed to clarify the clinical presentations related to the morphologies of coronary lesions of ACS using intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Methods and results: Seventy-five culprit lesions of ACS patients were clearly assessed with IVUS and OCT. Patients were classified into two groups based on the presence or absence of a rupture of a culprit plaque as identified by OCT. Clinical characteristics and lesion morphologies were compared between the two groups. Waist circumference was significantly greater (p<0.02) and prevalence of the metabolic syndrome (MS) higher (p=0.0011) in the rupture group. The prevalence of prodromal angina was higher in patients without plaque ruptures (p<0.0001). Using multivariate analysis, the MS and prodromal angina were independent predictors of rupture of a culprit coronary plaque (odds ratio (OR): 27.30, p<0.003 and OR: 0.04, p=0.0004, respectively). Among the components of the MS, the prevalence of abdominal obesity was a significant independent predictor of rupture of a culprit plaque (OR: 4.24, p<0.02). Conclusions: There are two presentations related to the coronary lesion morphologies of ACS: we should understand these aspects of ACS. [Copyright &y& Elsevier]

Background--Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results--This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P=0.01), the intra-arrest PCI was higher (88% versus 70%; P=0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25-51] versus 54 minutes [34-74 minutes]; P=0.002). Conclusions--Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed. [ABSTRACT FROM AUTHOR]

Background: Currently the surgical decision-making of tricuspid annuloplasty for tricuspid regurgitation (TR) depends on the measurements of tricuspid annular diameter (TAD) obtained in the apical 4-chamber view on 2-dimensional transthoracic echocardiography (2DTTE). However, whether shape and orientation of the dilated annulus would affect the accuracy of 2DTTE-TAD is unknown. Methods: A total of 185 patients with moderate to severe TR with various underlying causes and 22 controls underwent 2DTTE and 3DTEE assessment of the tricuspid valve (TV). The 3DTEE-TAD defined as the maximum diameter and tricuspid annular (TA) eccentricity index defined as the minimum diameter/maximum diameter ratio, were obtained on mid-diastole frame. As an index of TA orientation, the angle between the 3D TEE-TAD and the interatrial septum parallel to the vertical axis (α°) was measured (Figure 1). Results: Compared with normal TV, TR subgroups had a larger α° irrespective of its etiology (all P <0.05 after multiple comparison) with most frequency of patients with posteriorly orientated TA in atrial fibrillation-TR (normal control, 49±10°; primary TR, 81±36°; left-sided heart disease-TR, 66±28°; atrial fibrillation-TR, 103±35°; Figure 2). An excellent correlation was found between 3DTEE-TAD and 2DTTE-TAD (r=0.88, P <0.001); but 2DTTE-TAD was significantly smaller than 3DTEE-TAD (36.6±5.3 vs 40.6±5.6 mm; P <0.001; bias, 4.0±2.7 mm; limits of agreement, –1.3 to 9.3 mm). After multivariate adjustment, a larger 3DTEE-TAD (P <0.001) and larger absolute value of 90–α° (P <0.001) were independent determinants of the bias between 3DTEE-TAD and 2DTTE-TAD. Notably, a strong curved correlation between TA orientation and the bias was observed (r=0.57, P <0.001; Figure 2). Conclusion: This 3DTEE study demonstrates various TA orientation and its impact on the measurement of 2DTTE-TAD in patients with TR, highlighting the need for reappraising methodology for the measurement of TAD. [ABSTRACT FROM AUTHOR]

Background: Exercise-induced mitral regurgitation (MR) is an important prognosticator regardless of MR etiology. However, different mechanisms of exercise-induced MR according to MR subgroups remain unknown. Measured using three-dimensional (3D) transesophageal echocardiography (TEE), 3D vena contracta area (3D-VCA) has shown to be an accurate parameter to quantify MR. The aims of this study were (1) to investigate the increase between resting 3D-VCA and 3D-VCA after hand-grip exercise (Δ3D-VCA), (2) to compare the Δ3D-VCA between degenerative and functional MR. Methods: Fifty-seven symptomatic patients with moderate to severe MR (degenerative MR, n=30; functional MR, n=27) were prospectively enrolled between May 2017 and May 2018. Using 3D TEE, MV geometry (annular diameters, annular height, averaged tenting height, 3D-VCA) and hemodynamic status were measured immediately before and after 5-minute hand-grip exercise (Figure 1). Results: There was no significant difference in 3D-VCA at rest (38.7±17.2 mm2 in degenerative MR vs. 34.4±14.3 mm2 in functional MR, P =0.32). After hand-grip exercise, the 3D-VCA increased significantly in both MR subgroups, but a larger Δ3D-VCA was observed in functional MR (16.0±9.8 mm2 vs. 5.9±4.7 mm2, P <0.001; Figure 2). In functional MR, a significant augmentation in averaged tenting height was observed after hand-grip exercise (P <0.001). Univariable linear regression analysis revealed the association of Δ3D-VCA with averaged tenting height in functional MR and with blood pressure in degenerative MR (both P <0.01). Conclusions: Hand-grip exercise alters MV geometry and causes an exacerbation of MR. The effects of changes in MV geometry and their association with increased MR severity differs between degenerative and functional MR. [ABSTRACT FROM AUTHOR]