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Although left ventricular (LV) cardiac power output (CPO) is a powerful prognostic indicator in heart failure (HF), the significance of right ventricular (RV) CPO is unknown. In contrast, RV pulsatile load is a key prognostic marker in HF. We investigated the impact of RV-CPO and pulsatile load on cardiac outcome and the prognostic performance of the combined systemic and pulmonary circulation parameters in HF.Right heart catheterization and echocardiography were performed in 231 HF patients (62 ± 16 years, LV ejection fraction 42 ± 18 %). Invasive and noninvasive CPOs were calculated from mean systemic or pulmonary arterial pressure and cardiac output. LV-CPO was then normalized to LV mass (LV-P/M). Pulmonary arterial capacitance and the ratio of acceleration time to ejection time (AcT/ET) of RV outflow were used as parameters of RV pulsatile load. The primary endpoints, defined as a composite of cardiac death, HF hospitalization, ventricular arrythmia, and LVAD implantation after the examination, were recorded.Noninvasive CPOs were moderately correlated with invasive ones (LV: ρ = 0.787, RV: ρ = 0.568, and p 0.001 for both). During a median follow-up period of 441 days, 57 cardiovascular events occurred. Lower LV-P/M and higher RV pulsatile load were associated with cardiovascular events; however, RV-CPO was not associated with the outcome. Echocardiographic LV-P/M and AcT/ET showed significant incremental prognostic value over the clinical parameters.RV pulsatile load assessed by AcT/ET may be a predictor of clinical events in HF patients. The combination of echocardiographic LV-P/M and AcT/ET could be a novel noninvasive prognostic indicator in HF patients.

This study investigated the novel non-invasive left atrial (LA) stiffness parameter using pulmonary venous (PV) flow measurements and the clinical usefulness of the novel LA stiffness parameter.We retrospectively analyzed 237 patients who underwent right heart catheterization and echocardiography less than one week apart. From the pulmonary artery wedge pressure waveform, the difference between x-descent and v-wave (ΔP) was measured. Using the echocardiographic biplane method of disks, the difference between LA maximum volume and that just before atrial contraction (ΔVAmong the PV flow parameters, D/R was significantly correlated with ΔP (r = 0.62), and the correlation coefficient exceeded that between S/D and ΔP (r = - 0.39) or S/R and ΔP (r = 0.14). The [D/R]/ΔVThe [D/R]/ΔV

Aims Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF. Methods and results We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan–Meier curves showed that VMT ≥2 (n = 54) was associated with worse outcomes than the VMT ≤1 group (n = 256) (P Conclusions In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF.

We aimed to investigate left atrial (LA) myocardial dynamics during reservoir phase using three-dimensional speckle-tracking echocardiography (3DSTE) focusing on its longitudinal-circumferential relationship in patients with left ventricular (LV) hypertrophy and clarifying the difference in LA myocardial reservoir dynamics between hypertrophic cardiomyopathy (HCM) and hypertension with LV hypertrophy (HT-LVH). We studied 4 age-matched groups consisting of 27 patients with HCM, 16 with HT-LVH, 22 hypertensive patients without LV hypertrophy (HT), and 18 normal controls. Using 3DSTE, we measured LA global longitudinal strain (LA-LSR), global circumferential strain (LA-CSR), and global area strain (LA-AS(R)) during the reservoir phase, as well as LV global longitudinal strain (LV-LS), global circumferential strain (LV-CS), and global area strain (LV-AS). LA-LSR was significantly lower in the HCM and HT-LVH groups than in the controls, but there was no significant difference between the HCM and HT-LVH groups. LA-CSR and LA-AS(R) were significantly lower in the HCM group than in the other three groups, among which no significant difference was detected. In all subjects, LA-LSR was significantly correlated with LV-LS but not with LV-CS. LA-CSR was correlated with neither LV-LS nor LV-CS. In conclusion, both longitudinal and circumferential LA myocardial expansion during reservoir phase were reduced in HCM, while only the longitudinal one was reduced in HT-LVH. Reduction of LA circumferential expansion may reflect a more serious and intrinsic impairment of LA myocardial distensibility in HCM. Measuring LA-CSR and LA-AS(R) using 3DSTE would contribute to a more accurate understanding of LA reservoir function abnormality in HCM.

Background Although global longitudinal strain (GLS) is recognized as a sensitive marker of intrinsic left ventricular (LV) dysfunction, its afterload dependency has also been pointed. We hypothesized that GLS during handgrip exercise could be more sensitive marker of intrinsic myocardial dysfunction. Methods Handgrip exercise-stress echocardiography was performed in 90 cardiovascular disease patients with preserved LV ejection fraction. LV diastolic function was graded according to the guidelines. Diastolic wall stress (DWS) and ratio of left atrial (LA) volume index to late-diastolic mitral annular velocity (LAVI/a¢) were measured at rest as LV stiffness. As well, LA strains were measured to assess LA function. GLS was expressed as absolute value and significant changes in GLS by handgrip exercise was defined as changes over prespecified mean absolute test-retest variability (2.65%). Results While mean value of GLS did not change by the exercise, substantial patients showed significant changes in GLS: decreased (group I, n=28), unchanged (group II, n=34), and increased (group III, n=28). Unexpectedly, patients in group I did not show any clinical and echocardiographic characteristics, while those in group III were characterized by elevated natriuretic peptide levels, blunted heart rate response to handgrip exercise, and advanced LV diastolic dysfunction. Multivariable analyses revealed that DWS, left atrial booster strain, and grade II or more diastolic dysfunction determined the increase in GLS even after adjustment for elevated natriuretic peptides and the changes in heart rate by the exercise. Conclusion Paradoxical increase in GLS by handgrip exercise could be associated with advanced LV diastolic dysfunction in cardiovascular patients with preserved LV ejection fraction.

Background Accurate detection of significant pulmonary regurgitation (PR) is critical in management of patients after right ventricular (RV) outflow reconstruction in Tetralogy of Fallot (TOF) patients, because of its influence on adverse outcomes. Although pressure half time (PHT) of PR velocity is one of the widely used echocardiographic markers of the severity, shortened PHT is suggested to be seen in conditions with increased RV stiffness with mild PR. However, little has been reported about the exact characteristics of patients showing discrepancy between PHT and PR volume in this population. Methods Echocardiography and cardiac magnetic resonance imaging (MRI) were performed in 74 TOF patients after right ventricular outflow tract (RVOT) reconstruction [32 ± 10 years old]. PHT was measured from the continuous Doppler PR flow velocity profile and PHT

Determinants of exercise intolerance in a phenotype of heart failure with preserved ejection fraction (HFpEF) with normal left ventricular (LV) structure have not been fully elucidated.Cardiopulmonary exercise testing and exercise-stress echocardiography were performed in 44 HFpEF patients without LV hypertrophy. Exercise capacity was determined by peak oxygen consumption (peak VODuring exercise, CO, LV-s', RV-s', e', and SPAP were significantly increased (p 0.05 for all), whereas E/e' remained unchanged and TAPSE/SPAP was significantly reduced (p 0.001). SPAP was higher and TAPSE/SPAP was lower at peak exercise in patients showing lower-half peak VOIn HFpEF patients without LV hypertrophy, altered RV-PA coupling by exercise could be associated with exercise intolerance, which might not be caused by elevated LV filling pressure.

Aims Although the left ventricular (LV) dysfunction in pre-capillary pulmonary hypertension (PH) has been recently recognized, the mechanism of LV dysfunction in this entity is not completely understood. We thus aimed to elucidate the determinants of intraventricular pressure difference (IVPD), a measure of LV suction, in pre-capillary PH. Methods and results Right heart catheterization and echocardiography were performed in 86 consecutive patients with pre-capillary PH (57 ± 18 years, 85% female). IVPD was determined using colour M-mode Doppler to integrate the Euler equation. In overall, IVPD was reduced compared to previously reported value in normal subjects. In univariable analyses, QRS duration (P = 0.028), LV ejection fraction (P = 0.006), right ventricular (RV) end-diastolic area (P < 0.001), tricuspid annular plane systolic excursion (P = 0.004), and LV early-diastolic eccentricity index (P = 0.009) were associated with IVPD. In the multivariable analyses, RV end-diastolic area and LV eccentricity index independently determined the IVPD. Conclusion Aberrant ventricular interdependence caused by RV enlargement could impair the LV suction. This study first applied echocardiographic IVPD, a reliable marker of LV diastolic suction, to investigate the mechanism of LV diastolic dysfunction in pre-capillary PH.

A 69-year-old man with HCC was treated. Abdominal US, CT and angiography revealed three small nodules in S5, S6 and S8 segment of the liver. US pattern and CT density of the nodules were different each other.According to this findings, these nodules were thought to be multicentric growth of HCC. Using microwave tissue coagulator, limited atypical subsegmentectomy to each nodule was performed. Histological examination of resected specimens showed atypical adenomatous hyperplasia (AAH) in S8 segment, and coexistencce of AAH and middle or low grade HCC in each S5, S6 segment. On this histological findings, atypical subsegmentomy applied to this patient was suspected to be a reasonable operative method and radical operation in the result.

胃内腔に穿通し消化管出血を来した, 非常にまれな肝外発育型肝細胞癌の1例を経験したので報告する. 患者は66歳の男性で, 吐下血を主訴に近医を受診した. 上部消化管X線検査および内視鏡検査では胃穹窿部から体部後壁にかけ巨大な隆起性病変として, CTでは最大径13cmの腫瘤陰影が肝外側区域下面に接して認められた. 胃粘膜下腫瘍からの出血と診断され手術目的で当科入院となった. 入院時, 貧血著明で緊急手術を施行した. 開腹すると腫瘍は肝外側区域と胃体部後壁の間にあり, 腫瘍の一部は肝外側区域下面に浸潤しているようにみえた. 胃全摘, 脾摘に加え肝外側区域切除を行った. 組織学的検査の結果, 腫瘍は肝外側区域から肝外発育し, 胃内腔に穿通したEdmondson III型の肝細胞癌であった.

We have recently encountered a case of multiple eosinophilic granulomas in the fornix of the stomach. A 51-year-old woman was admitted to our hospital with a chief complaint of epigastralgia. Radiologic and endoscopic examinations showed irregular, excavated and protruded lesions in the fornix. Endoscopic biopsy showed benign findings (Group-I). With a suspicion of gastic malignant lymphoma or reactive lymphoreticular hyperplasia (RLH), total gastrectomy was performed. The resected specimen showed five protruding lesions of various sizes (maximum 1.6×1.3cm, minimum 0.6×0.6cm) with an ulcer at the top of each. Histologic diagnosis was eosinophilic granuloma of the stomach. One hundred and thirty-three cases of eosinophilic granuloma of the stomach have been reported in the Japanese literature. We discussed the age distribution, sex difference, symptoms, location, size, shape, layer of occurrence, preoperative diagnosis, and treatment of this lesion in the light of these reports.

There have been very few reports of small bowel obstruction due to bands or adhesions caused by inflammation of an epiploic appendage. A 75-year-old man suffered from small bowel obstruction due to a band from an inflamed epiploic appendage adherent to the caecum. The inflamed epiploic appendage was removed and the dilated ileal segment was released from obstruction.

From January 1977 through December 1982, 297 patients underwent enteral feeding. Among them, postoperative gastric cancer patients accounted for 66%. The feeding was started on the fourth or fifth postoperative day and stopped two to three weeks later in patients whose postoperative courses were uneventful. Complications of the feeding appeared in about 70% of the patients, in whom some nutritional parameters, the serum levels of total protein and albumin deteriorated slightly. Diarrhea and/or soft or muddy stools were the most common complication, octarring in 61.4% of the subjects. Regulation of the feeding speed was thought to be one of the most important measures to avoid this abnormal bowel movement. Since renal failure was present in 2.6% of the patients as a preoperative coexistent disease, a low-residue diet was specially devised, and its clinical usefulness was confirmed in patients with renal failure.