小林 欣夫

Intracoronary acetylcholine (ACh) provocation test is useful to diagnose vasospastic angina. Although outpatient coronary angiography has been widely performed in current clinical settings, the feasibility and safety of ACh provocation test in outpatient services are unclear. A total of 323 patients, who electively underwent ACh provocation test in hospitalization and outpatient services, were included. Coronary angiography was performed after insertion of a temporary pacing electrode in the right ventricle. The positive diagnosis of intracoronary ACh provocation test was defined as total or subtotal coronary artery narrowing accompanied by chest pain and/or ischemic electrocardiographic changes. Cardiac complications defined as composite of death, ventricular fibrillation or sustained ventricular tachycardia, myocardial infarction, cardiogenic shock, and cardiac tamponade, were evaluated. There were 201 patients (62%) in the hospitalization group and 122 patients (38%) in the outpatient group. The incidence of positive ACh provocation test was similar between the 2 groups (47 vs. 54%, p = 0.21). Coronary angiography in the outpatient group was performed through the radial artery, mostly (98%) with a 4 F sheath. Venous access site was not significantly different between the 2 groups, and the sheath size was 5 F in all cases. There were 2 cases (1.0%) of cardiac complications in the hospitalization group, whereas 1 case (0.8%), which led to unexpected hospitalization, occurred in the outpatient group. In conclusion, intracoronary ACh provocation test for the diagnosis of vasospastic angina in outpatient services was feasible and safe in selected patients.

Background: Cardiovascular surgery is one of the highest risk procedures in the field of surgery. Preoperative assessment of endothelial function has been reported as useful for predicting postoperative adverse events (AEs). The aim of this study was to investigate the relationship between endothelial function assessed by reactive hyperemia index (RHI) and AEs after cardiovascular surgery. Methods and Results: A prospective observational study of 197 patients who underwent cardiovascular surgery was conducted. RHI was measured before the surgery. The primary endpoint was a composite of postoperative death, reoperation, stroke, newly required dialysis, deep sternum infection, and prolonged ventilation within 30 days. The secondary endpoint was new-onset atrial fibrillation (AF) within 30 days. Following cardiovascular surgery, 19 patients (9.6%) had AEs. New-onset AF was documented in 42 (25.9%) of 162 patients without a prior history of AF. In the receiver-operating characteristic curve analysis, RHI significantly predicted AEs (area under the curve [AUC] 0.67, best cutoff value 1.64, P=0.03), whereas RHI did not predict new-onset AF (AUC 0.53, P=0.93). Patients with RHI ≤1.64 had more AEs than those with RHI &gt 1.64 (16.3% vs. 4.5%, P=0.005). Multiple logistic regression analysis showed the number of surgical procedures and RHI ≤1.64 as significant predictors of AEs. Conclusions: Preoperative endothelial dysfunction assessed by RHI was associated with postoperative AEs in patients with cardiovascular surgery.

Augmentation index (AIx) and pulse pressure (PP) amplification can be determined by the SphygmoCor XCEL device in an operator-independent manner. This study aimed to examine its validity against invasive measurements. Simultaneous recordings of central aortic pressure waveforms were performed with oscillometric and high-fidelity invasive methods in 35 patients who underwent coronary arteriography. Brachial blood pressure was also recorded using the two methods. AIx for the aortic pressure waveform was defined as the ratio of augmentation pressure to PP. PP amplification was defined as the ratio of brachial PP to aortic PP. The differences between the invasive and oscillometric measurements were-7.7±12.7% for AIx and 0.17±0.14 for PP amplification (mean±s.d.). Strong correlations between the invasive and oscillometric measurements were found in both indices (AIx: R=0.75 PP amplification: R=0.80 both P&lt 0.001). The Bland-Altman plot showed a proportional bias of PP amplification, but not of AIx (AIx: R=-0.21, P=0.23 PP amplification: R=-0.61 P&lt 0.001). In conclusion, estimated AIx may be reliable considering the high correlation between the invasive and noninvasive values and the lack of proportional bias against invasive assessment. However, a substantial underestimation and a large scatter of estimated AIx were also observed. Further studies using the device to investigate associations with target organ damage or prognoses are needed to clarify its clinical validity.

Objective: To investigate the relationship between 1-h post-load plasma glucose, measured during an oral glucose tolerance test, and arterial stiffness, determined by brachial–ankle pulse-wave velocity, in normotensive subjects with normal glucose tolerance. Methods: Study subjects were non-industrial workers aged 25–55 years (n = 8381) who underwent a regular health check-up every 5 years. We included only normotensive subjects with normal glucose tolerance based on the American Diabetes Association criteria. Subjects taking medication and having an abnormal ankle–brachial index (⩽1.0 or ⩾1.3) were excluded. The final sample comprised 4970 participants (mean age: 38.8 ± 9.4 years women: n = 2048). Results: 1-h post-load plasma glucose correlated with brachial–ankle pulse-wave velocity in men (β = 0.04, p = 0.01), but not women (β = –0.03, p = 0.13) in multivariate linear regression analysis. We found a significant interaction between 1-h post-load plasma glucose and age in men (p = 0.04) therefore, a subgroup analysis was performed in each 5-year age group. The correlation between 1-h post-load plasma glucose and brachial–ankle pulse-wave velocity was significant in the 55-year-old age group (β = 0.12, p = 0.01) and neared significant in 45-year-old (β = 0.08, p = 0.07) and 50-year-old (β = 0.09, p = 0.07) age groups. Conclusion: Elevated 1-h post-load plasma glucose levels were associated with arterial stiffness in normotensive, middle-aged men with normal glucose tolerance.

Background The aim of this study was to investigate microvascular function in patients with valvular heart disease (VHD), which causes chronic left ventricular volume and/or pressure overload, therefore change in coronary microvascular hemodynamics. Patients and methods We prospectively enrolled 30 patients with VHD considered for surgery (10 aortic stenosis, 12 aortic regurgitation, and eight mitral regurgitation) and 30 controls. Intracoronary physiological assessments were performed in the unobstructed left anterior descending artery using a pressure-temperature sensor guidewire at rest and hyperemia. Results The index of microcirculatory resistance (IMR) was similar between the two groups (16.2 ± 6.5 vs. 16.2± 8.5, P=0.997), whereas coronary flow reserve (CFR) was lower in the VHD group compared with the controls (3.2 ± 1.4 vs. 4.3± 1.7, P=0.005). Resting and hyperemic coronary distal pressure, and hyperemic mean transit time were similar between VHD and controls, whereas resting mean transit time was significantly shorter (0.70±0.29 vs. 0.89± 0.39, P=0.035) and baseline resting microvascular resistance was significantly lower in the VHD group compared with the controls (58.1± 25.4 vs. 78.1± 36.7, P=0.011). Patients with aortic stenosis showed numerically higher IMR values than aortic regurgitation, mitral regurgitation, and controls, although this was not statistically significant (20.4 ± 6.9, P=0.14). CFR was significantly correlated with log highsensitivity cardiac troponin T levels in patients with VHD (r=-0.523, P=0.004). Conclusion CFR was reduced in patients with VHD compared with controls, despite similar microvascular function as assessed by IMR. This appeared to be mainly because of an increased resting coronary flow accompanied by a decreased resting coronary microvascular resistance rather than microvascular disease.

Background: Atrial fibrillation (AF) is the most common arrhythmia in the ageing population in East Asia. Silent cerebral infarction (SCI) is defined as cerebral infarction in the absence of corresponding clinical symptoms, and is a highly prevalent and morbid condition in AF. SCI is increasingly being recognized as a risk factor for future stroke, which can lead to cognitive decline or dementia. The latter is an increasingly common health problem in East Asia. Methods and Results: We conducted a meta-analysis to compare the association of AF and SCI between East Asian and non-Asian patients. AF was associated with SCI in patients with no symptomatic stroke history (relative risk [RR], 2.24 95% CI: 1.26–3.99, I2=83% P=0.006) although the prevalence varied widely between studies (P for heterogeneity&lt 0.001). In non-Asian patients, the prevalence of SCI in AF is higher than that in controls (RR, 1.85 95% CI: 1.65–2.08, I2=17% P&lt 0.001). There was no significant racial difference between Asian and non-Asian studies (P=0.53). Conclusions: In East Asia, AF was significantly associated with SCI and no racial difference was seen between East Asian and non-Asian patients. The present findings offer clinicians new insights into the association between AF and SCI.

Peak longitudinal strain (PLS) of the left ventricular (LV) myocardium by transthoracic echocardiogram (TTE) is useful to detect LV myocardial damage. We hypothesized that myocardial fibrosis (MF) in the LV myocardium may influence PLS. Eighteen hypertrophic cardiomyopathy (HCM) patients (14 males 58 ± 17 years old) underwent 1.5 Tesla cardiac magnetic resonance (CMR) and TTE. Patients with previous myocardial infarction were excluded. We used TTE to assess whole-layer PLS in an American Heart Association-defined 17-segment LV model. Whole-layer PLS was calculated using Echo PAC, version 113 (GE Healthcare). MF was assessed by T1-weighted CMR of the LV endocardial layer, the LV epicardial layer, or both the LV endocardial and epicardial layers for each lesion. Of the 306 segments, MF was detected in the LV endocardial layer only (13 segments), in the LV epicardial layer only (9 segments), or in both LV endocardial and epicardial layers (59 segments). PLS values were significantly lower in segments with MF affecting only the LV endocardial layer (7% ± 4%) (P &lt 0.05) and where MF was observed in both the LV endocardial and epicardial layers (9% ± 5%) (P = 0.001) compared with segments without MF (13% ± 7%). No significant difference in PLS values was detected between the MF segments for the LV epicardial layer only (10% ± 6%) and those without MF (13% ± 7%) (P &gt 0.05). In HCM patients, fibrotic lesions in the LV endocardium have a greater adverse effect on PLS than those in the LV epicardium. Our results are significant for HCM patients with fibrotic lesions within the LV endocardium.

OBJECTIVE: Although severe obstructive sleep apnea (OSA) is an important risk factor for atherosclerosis-related diseases including coronary artery disease (CAD), there is no reliable biomarker of CAD risks in patients with OSA. This study aimed to test our hypothesis that circulating autoantibodies against neuroblastoma suppressor of tumorigenicity 1 (NBL1-Abs) are associated with the prevalence of CAD in patients with OSA. METHODS: Eighty-two adults diagnosed with OSA by polysomnography, 96 patients with a diagnosis of acute coronary syndrome (ACS) and 64 healthy volunteers (HVs) were consecutively enrolled. Serum samples were collected from patients with OSA at diagnostic polysomnography and from patients with ACS at disease onset. Serum NBL1-Ab level was measured by amplified luminescence proximity homogeneous assay and its association with clinical variables related to atherosclerosis was evaluated. RESULTS: NBL1-Ab level was significantly elevated in patients with both OSA and ACS compared with HVs. Subgroup analyses showed that NBL1-Ab level was markedly higher in patients with severe OSA and OSA patients with a history of CAD. Weak associations were observed between NBL1-Ab level and apnea-hypopnea index, age, mean SpO2 and arousal index, whereas significantly higher NBL1-Ab levels were observed in OSA patients with a history of CAD than in those without a history of CAD. Sensitivity analysis using a logistic regression model also demonstrated that increased NBL1-Ab levels were associated with the previous history of CAD in patients with OSA. CONCLUSIONS: Elevated NBL1-Ab levels may be associated with the prevalence of CAD in patients with OSA, which needs to be confirmed further.

The cutdown technique for the cephalic vein is a common access route for transvenous cardiac device leads (TVLs), and sometimes one cephalic vein can accomodate two TVLs. We examined a novel ligation technique to balance the hemostasis and lead maneuverability for this two-in-one insertion. A total of 22 patients scheduled for cardiac device implantations with two or more leads were enrolled. The ipsilateral cephalic vein was identified for inserting the TVLs with a cutdown. If two TVLs could be introduced into one cephalic vein, hemostasis was established by ligating the venous wall between the TVLs. We measured the amount of hemorrhaging per minute and the operators assessed the lead maneuverability before and after the ligation. We successfully implanted cardiac devices in 15 patients (68%) with this novel method, whereas only one TVL could be introduced via the cephalic vein in 7 patients. As for the successful patients, hemorrhaging from the gap was significantly reduced (5.6 ± 7.3 to 0.41 ± 0.36g/min, p = 0.016) after the novel ligation. The lead maneuverability was well maintained so there was no difficulty placing the leads into the cardiac chambers in all cases. No major complications were observed. In the present study, the novel ligation method provided significant hemostasis as well as a preserved maneuverability. It could be an optional choice for insertion of multiple TVLs.

Background: Myocardial bridge (MB) has been reported to induce cardiac complications including coronary vasospasm. Although MB has some anatomical and morphological variations, the association of these variations with vasospasmis unclear. The aim of this study was to investigate the relation between morphological severity of MB and vasospasm induced by acetylcholine (ACh) provocation test. Methods: A total of 392 patients without coronary stent in the left anterior descending artery (LAD) undergoing intracoronary ACh provocation test were included. Angiographic coronary artery vasospasm was defined as total or subtotal occlusion induced by ACh provocation. MB was identified on coronary angiography as a milking effect. Total bridged length and maximum percent systolic compression of MB in the LAD were analyzed quantitatively. Results: MBs in the LAD were identified in 140 patients (36%), mostly in the mid segment. Patients with MB in the LAD had greater number of provoked vasospasm in the LAD and positive ACh provocation test compared to those without. The bridged length positively correlated with percent systolic compression of MB (r=0.37, p < 0.001). In the receiver operating characteristic curve analysis, both bridged length and percent systolic compression of MB significantly predicted the provoked LAD spasm (AUC 0.74, p < 0.001, and AUC 0.68, p < 0.001). Multivariate regression analysis demonstrated these factors as independent predictors for provoked LAD spasm. Conclusion: MB, especially morphologically severe MB, may induce greater coronary vasospasm. (C) 2017 Elsevier B.V. All rights reserved.

Dipeptidyl peptidase-4 (DPP-4) inhibitors are hypoglycemic agents. DPP-4 inhibitor has cardioprotective effects after transverse aortic constriction (TAC), but role of DPP-4 on cardiac fibrosis after TAC is not well known. Our aim was to determine the effects of DPP-4 on cardiac fibrosis in murine TAC model. Wildtype mice and DPP-4 knockout mice were subjected to TAC. Wild-type mice were then treated with vehicle or DPP-4 inhibitor. DPP-4 activities in serum and heart tissue were significantly increased at 2 weeks after TAC, but they were significantly decreased by DPP-4 inhibitor treatment. The inhibition of DPP-4 did not affect left ventricular hypertrophy, but improved cardiac function and decreased myocardial and perivascular fibrosis after TAC. The inhibition of DPP-4 decreased the collagen type III/I ratio in myocardium. These results suggest that DPP-4 inhibition ameliorates the progression of heart failure after TAC by changing the quality and quantity of cardiac fibrosis. (c) 2017 The Authors. Production and hosting by Elsevier B.V.

Background: Prevalence of myocardial bridging of the left anterior descending coronary artery (LAD) in patients with takotsubo syndrome (ITS) has been demonstrated. However, the impact of myocardial bridging on in-hospital outcome has not been fully evaluated. Methods: A total of 144 consecutive patients with TTS were enrolled. Coronary angiography and left ventriculography were performed in all patients and absence of obstructive coronary disease explaining the left ventricular contraction abnormality was confirmed. Myocardial bridging was diagnosed when a dynamic compression in systole, so-called "milking effect", was observed in the LAD. We evaluated differences in the clinical characteristics and in-hospital outcome between patients with and without myocardial bridging. Furthermore, multiple logistic regression analysis was performed to predict in hospital death. Results: Myocardial bridging was observed in 33 patients (23%). In-hospital death was more frequent in patients with myocardial bridging (21% vs. 6%, p = 0.02), which was due mainly to a higher non-cardiac death in those patients (15% vs. 5%, p = 0.049). Multiple logistic regression analysis demonstrated myocardial bridging (odds ratio = 12.0, 95% CI = 2.52-78.5, p < 0.01) as one of the independent predictors of in-hospital death. Conclusion: Myocardial bridging is an independent predictor of in-hospital death in patients with TTS. (C) 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

【緒言】完全房室ブロックを呈するリウマチ性心炎は稀であり、限局的な心筋炎所見を呈したリウマチ性心炎は報告がない。心臓MRIにて炎症部位を同定しえた症例を経験したので報告する。【症例】10歳女児。先行する感冒症状に続き失神発作が出現し入院となった。心電図波形は完全房室ブロックであり、心臓超音波検査で心室中隔に局所的な壁運動低下部位を認めた。A群β溶血連鎖球菌抗原迅速キット陽性、ASO296IU/mLであり、完全房室ブロックを併発したリウマチ性心炎と診断した。一時ペーシング、大量ガンマグロブリン静注、ステロイド、ACE阻害剤、およびアンピシリン投与を行った。入院翌日には洞調律となり、同29日目に軽快退院した。同10日目の心臓MRIで心室中隔基部に限局的なT2高信号を示す領域を認めた。発症から8ヵ月後の心臓MRIでは異常所見は消失しており、遅延造影でも同様に異常は見られなかった。【考察】心室中隔基部はHis束の走行部位であり、同部位の限局的な炎症により完全房室ブロック主体のリウマチ性心炎を発症したと考えた。同部位に発生した心臓腫瘍でも同様に完全房室ブロックを起こした症例が報告されており、炎症の部位によってはリウマチ性心炎でも完全房室ブロックの所見を呈することがあると考えられる。リウマチ性心炎の炎症部位の同定には心臓MRIが有用であった。(著者抄録)

The difference in the intraluminal intensity of blood speckle (IBS) on integrated backscatter-intravascular ultrasound (IB-IVUS) across a coronary artery stenosis (i.e., Delta IBS) has previously shown a negative correlation with fractional flow reserve, reflecting an impaired coronary blood flow. Periprocedural myocardial injury (PMI) after coronary stenting has also been associated with coronary circulatory dysfunction. The aim of this study was to investigate the relation between Delta IBS after coronary stenting and PMI. A total of 180 patients who underwent elective coronary stenting under IVUS guidance for a single lesion were included. Intraluminal IBS was measured using IB-IVUS in cross sections at the ostium of the target vessel and at the distal reference of the stent. Delta IBS was calculated as (distal IBS value) (ostium IBS value). PMI was defined as an elevation of troponin I >5 times the 99th percentile upper reference limit (>0.45 ng/ml) within 24 hours after the procedure. The mean Delta IBS after coronary stenting was 6.52 +/- 5.71. There was a significantly greater use of the rotational atherectomy, the number of stents, the total stent length, and RIBS in patients with PMI than those without. In the receiver operating characteristic curve analysis, AIM significantly predicted PMI (area under the curve 0.64, best cut-off value 7.88, p = 0.001). Multiple logistic regression analysis determined that the total stent length, the use of rotational atherectomy, and Delta IBS were independent predictors of PMI. In conclusion, greater Delta IBS assessed by IB-IVUS was significantly associated with PMI after coronary stenting in patients with a stable coronary artery disease. (C) 2017 Elsevier Inc. All rights reserved.

Dipeptidyl peptidase-4 (DPP-4) inhibitors are relatively new class of anti-diabetic drugs. Some protective effects of DPP-4 on cardiovascular disease have been described independently from glucose-lowering effect. However, the detailed mechanisms by which DPP-4 inhibitors exert on endothelial cells remain elusive. The purpose of this research was to determine the effects of DPP-4 inhibitor on endothelial barrier function. Human umbilical vein endothelial cells (HUVECs) were cultured and exposed to hypoxia in the presence or absence of Diprotin A, a DPP-4 inhibitor. Immunocytochemistry of vascular endothelial (VE-) cadherin showed that jagged VE-cadherin staining pattern induced by hypoxia was restored by treatment with Diprotin A. The increased level of cleaved beta-catenin in response to hypoxia was significantly attenuated by Diprotin A, suggesting that DPP-4 inhibition protects endothelial adherens junctions from hypoxia. Subsequently, we found that Diprotin A inhibited hypoxia-induced translocation of NF-kappa B from cytoplasm to nucleus through decreasing TNF-alpha expression level. Furthermore, the tube formation assay showed that Diprotin A significantly restored hypoxia-induced decrease in number of tubes by HUVECs. These results suggest that DPP-4 inhibitior protects HUVECs from hypoxia-induced barrier impairment. (C) 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of Japanese Pharmacological Society.

Intracoronary acetylcholine (ACh) provocation test is useful to diagnose vasospastic angina. However, paroxysmal atrial fibrillation (AF) often occurs during intracoronary ACh provocation test, leading to disabling symptoms. The aim of this study was to investigate the incidence and predictors of paroxysmal AF during the test. A total of 377 patients without persistent AF who underwent intracoronary ACh provocation test were included. Paroxysmal AF during ACh provocation test was defined as documented AF on electrocardiogram during the procedure. There were 31 patients (8%) with paroxysmal AF during the test. Of these, 11 (35%) required antiarrhythmic drugs, but none received electrical cardioversion. All of them recovered sinus rhythm within 48 h. At procedure, paroxysmal AF occurred mostly during provocation for the right coronary artery (RCA) rather than for the left coronary artery (LCA) (90 vs. 10%). Multivariate logistic regression analysis demonstrated that a history of paroxysmal AF (OR 4.38 CI 1.42-13.51, p = 0.01) and body mass index (OR 0.88 CI 0.78-0.99, p = 0.03) were independent predictors for occurrence of paroxysmal AF during intracoronary ACh provocation test. In conclusions, paroxysmal AF mostly occurs during ACh provocation test for the RCA, especially in patients with a history of paroxysmal AF and lower body mass index. It may be better to initially administer intracoronary ACh in the LCA when the provocation test is performed.

Purpose Ventricular outflow tract arrhythmias (VOTAs) can be successfully treated by catheter ablation. However, it is sometimes difficult to differentiate the origin of VOTAs between the right ventricular outflow tract (RVOT) and the other sites, leading to a long fluoroscopy time and unnecessary radiofrequency applications. This study aimed to clarify distinguishable characteristics of the propagation pattern obtained from non-contact mapping (NCM) for VOTA ablation. Methods Consecutive 45 patients with VOTAs who underwent catheter ablation using the NCM system were included in this study. We analyzed an isopotential map on three-dimensional geometry of the RVOT obtained from the virtual unipolar electrograms (VUEs) and assessed mapping data of the isopotential area with an initial negative VUE of -1 mV. Results Successful ablation was achieved from the endocardial RVOT in 34 patients (RVOT group) and the non-RVOT in 11 (non-RVOT group). Major and minor axis diameters of the isopotential area did not significantly differ between the two groups. However, a ratio of major/minor axis diameter was greater in the RVOT group (1.9 +/- 0.1 versus 1.3 +/- 0.1; P < 0.001). In addition, the propagation velocity defined as an increase of the isopotential area per millisecond was significantly slower in the RVOT group (2.2 +/- 0.4 versus 4.2 +/- 0.7 mm(2)/ms; P = 0.02). Conclusions The isopotential area of VOTAs originating from the RVOT, as compared to the other sites, spread more elliptically and slowly. The propagation pattern obtained from NCM can provide useful information and efficient strategy for VOTA ablation.

Background: Direct oral anticoagulants (DOACs) have been developed as alternatives to conventional therapy with warfarin for the treatment of acute venous thromboembolism (VTE) events. The safety and efficacy of DOACs in Japanese patients with acute VTE has been investigated in small trials or subgroups from global randomized controlled trials (RCTs). Methods and Results: We conducted a systematic review and meta-analysis of RCTs, to compare the safety and efficacy of DOACs to those of conventional therapy in Japanese patients with acute VTE. Published research was systematically searched for RCTs that compared DOAC to conventional therapy in Japanese patients with acute VTE. Random-effects models were used to pool safety and efficacy data across RCTs. Three studies, including 386 patients, were identified. Patients randomized to DOAC had a decreased risk for all bleeding [risk ratio (RR) 0.69, 95% confidential interval (CI) 0.50-0.95], without any significant differences in recurrent VTE (RR 0.84, 95% CI 0.29-2.43) and recurrent VTE/all-cause death (RR 0.60, 95% CI 0.23-1.56). Conclusion: DOACs offer clinical benefit over conventional therapy in Japanese patients with acute VTE, showing a significant difference in their bleeding profile. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Background: The impact of chronic kidney disease (CKD) on the antiplatelet effect of clopidogrel and low dose (3.75 mg) prasugrel in Japanese patients is largely unknown. Methods: A total of 53 consecutive Japanese patients with stable coronary artery disease who received aspirin and clopidogrel were enrolled, and categorized by estimated glomerular filtration rate (eGFR): CKD group (n = 15, eGFR < 60 int/min/1.73 m(2)) and non-CKD group (n = 38, eGFR >= 60 ml/min/1.73 m2). Clopidogrel was switched to 3.75 mg prasugrel. Platelet reactivity measurement using the VerifyNow P2Y12 assay (Accumetrics, San Diego, CA, USA) was performed at baseline (on clopidogrel) and day 14 (on prasugrel). Results: The VerifyNow P2Y12 reaction units (PRU) during clopidogrel therapy was significantly higher in the CKD group than that in the non-CKD group (185.2 +/- 51.1 PRU vs. 224.3 +/- 57.0 PRU, p = 0.02), whereas, the PRU with the prasugrel therapy in the CKD group and non-CKD group were not significantly different (149.9 +/- 51.1 PRU vs. 165.3 +/- 61.8 PRU, p = 0.36). The PRU was significantly lower with the prasugrel therapy compared to that with the clopidogrel therapy both in the CKD group and in the non-CKD group. Conclusions: Antiplatelet effect of clopidogrel but not prasugrel is attenuated in patients with CKD. Prasugrel achieves a consistently lower platelet reactivity compared with clopidogrel regardless of the presence of mild to moderate CKD. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Deployment of polytetrafluoroethylene (PTFE)-covered stent is a useful technique to seal coronary perforation. However, the high profile and low flexibility compromise its deliverability. To facilitate stent delivery, a guide extension catheter (GuideLiner™ catheter) through a 6 Fr guiding catheter has been used. This case report describes a successful deployment of a PTFE-covered stent using a 6 Fr GuideLiner catheter to seal coronary perforation.

We report a case of structural valve deterioration, which occurred 7 years after aortic valve replacement in a 78-year-old male with cardiac sarcoidosis. His echocardiography showed low transprosthetic valve gradient and depressed left ventricular function. A dobutamine stress echocardiography was performed to identify his pathophysiology, and it revealed that his depressed left ventricular function was not due to cardiac sarcoidosis but to structural valve deterioration. Reoperation for structural valve deterioration was performed, and his left ventricular function recovered.

冠動脈疾患を対象とする心臓CTの臨床的有用性について述べた。心電図同期撮像法の開発や検出器の多列化を中心としたCTの技術的革新により、近年は造影CTで冠動脈狭窄の診断が可能となった。CTによる冠動脈疾患評価は狭窄度評価のみならず、FFR-CTや心筋灌流CTなどによる冠動脈機能評価の面でもさらなる臨床応用が進むと思われる。また、画像再構成法の進歩による検査時の被曝低減や撮像時間短縮による造影剤減量も進み、今後心臓CTはさらに低侵襲で身近な検査になることが予想される。本稿では以下の項目で概説した。1)心臓CTによる冠動脈疾患診断の現状。2)心臓CTによる冠動脈機能評価の展望。3)心臓CTによる症例予後予測の有用性。4)遅延造影CTによる心筋梗塞(線維化)評価。5)三次元CT心筋ストレインの開発。

Our aim was to assess the discrepancy in the blood pressure amplification (BPA) value defined as the aortic-to-brachial increase in systolic BP (SBP) between invasive and noninvasive brachial cuff-based methods. In 45 patients undergoing cardiac catheterization, BP in the brachial artery and ascending aorta were measured with an invasive catheter and a brachial cuff-based oscillometric device. To calculate aortic SBP, brachial waveforms were calibrated by the brachial systolic and diastolic BP (DBP) (C1 calibration) or by the brachial mean BP and DBP (C2 calibration). C1 calibration underestimated aortic SBP (-17.7 mm Hg (95% confidence interval: -21.9 to -13.5)), whereas C2 calibration generated an approximately accurate aortic SBP (1.8 mm Hg (-2.4 to 5.9)). Regarding brachial SBP, noninvasively measured values were markedly underestimated (22.2 mm Hg (-26.4 to -18.0)), resulting in a slightly low BPA value in C1 calibration (11.9 +/- 6.3 mm Hg) and a paradoxical negative BPA value in C2 calibration (-7.6 +/- 6.7 mm Hg). Multiple linear regression analysis showed that the cuff-catheter difference of BPA was positively correlated with the cuff-catheter difference of brachial SBP in both calibrations (C1 calibration: beta=0.51; C2 calibration: beta=0.50; both P < 0.01). Although noninvasively measured BPA was associated with invasively measured BPA only in C1 calibration (r=0.33, P=0.03), when using invasively measured brachial SBP instead of a cuff-based measurement, the BPA was well associated with invasively measured BPA in both calibrations (C1 calibration: r=0.57; C2 calibration: r=0.52; both P < 0.001). In conclusion, there was a trade-off in accuracy between brachial cuff-based noninvasive aortic SBP and BPA because of the inherent inaccuracies in the cuff-based method. This finding should be fully considered in establishing standardized reference values for aortic BP.

Objectives The difference in intraluminal intensity of blood speckle (IBS) on integrated backscatter intravascular ultrasound (IVUS) across the coronary stenosis was reportedly correlated with fractional flow reserve (FFR) in the left descending coronary artery. The aim of this study was to investigate the novel physiological assessment using IVUS in all coronary arteries. Patients and methods Fifty-four patients with 57 coronary lesions underwent both FFR and IVUS. Intraluminal IBS was analyzed using integrated backscatter IVUS in crosssections at the ostium and the distal site of the target vessel Delta IBS was calculated as: (distal IBS)-(ostium IBS). Results Both.IBS (r=-0.50, P< 0.01) and minimum lumen area (MLA) (r= 0.55, P< 0.01) showed significant correlations with FFR. There were significant correlations between FFR and.IBS in the right and left descending coronary arteries (r=-0.60, P= 0.02, and r=-0.58, P< 0.01), but not in the left circumflex (r= 0.30, P= 0.44). In receiver operating characteristic curve analyses,Delta IBS predicted FFR less than or equal to 0.80 (area under the curve= 0.82, P< 0.01, best cutoff value= 6.78), as with MLA (area under the curve= 0.83, P< 0.01, best cutoffvalue=2.38). FFR progressively decreased in association with Delta IBS greater than or equal to 6.78 and MLA less than or equal to 2.38, and was the lowest when these were combined. Conclusion Delta IBS was correlated with FFR in right and left descending coronary arteries. IVUS may assess coronary artery stenosis anatomically and physiologically. (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

Purpose: Right ventricular myocardial (RVM) fibrosis may be a significant indicator of prognosis in pulmonary hypertension (PH). To detect the presence of RVM fibrosis in PH subjects, we employed ECG gated 320-slice CT. Methods: 62 confirmed PH subjects (16 males; 55 +/- 16 years; 45 chronic thromboembolic PH (CTEPH) who underwent conventional non-surgical medical therapy; and 17 pulmonary arterial hypertension (PAH)) underwent ECG-gated 320-slice CT. On CT, RV fibrosis was defined as contrast defect in the early phase and conversely abnormal enhancement in the late phase. Results: RVM fibrosis was observed in 14 subjects (23%) on CT (CTEPH 22%; PAH 29%; P = 0.91). CT attenuation of RVM in the late phasewas significantly greater in subjectswith RVM fibrosis than in thosewithout (P= 0.025). ROC curves of CT attenuation of RVM in the early and late phase, and ratio of CT attenuation of RVM in the early phase/late phase showed AUCs of 0.55, 0.70, and 0.65, respectively. The best cutoff points of 79.5 HU (sensitivity of 50% and specificity of 69% for CT attenuation of RVM in the early phase, P= 0.59), 99.5 HU (sensitivity of 50% and specificity of 88% for CT attenuation of RVM in the late phase, P = 0.025), and 1.416 (sensitivity of 29% and specificity of 94% for ratio of CT attenuation of RVM in the early phase/late phase, P = 0.092) were used to distinguish subjects +/- RVM fibrosis. Conclusion: Quantitative-measurement of CT attenuation of RVMin the late phasemay be able to detect presence of RVM fibrosis in PH subjects. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Purpose: To evaluate the diagnostic accuracy of computed tomography (CT) for the detection of myocardial fibrosis, we compared the frequency of abnormal late enhancement (LE) in left ventricular myocardium(LVM) on CT with that on gadolinium-enhanced cardiac magnetic resonance (CMR) in patients with various myocardial diseases. Methods: Fifty-six patients with suspected various myocardial diseases (19 with hypertrophic cardiomyopathy, 3 with cardiac amyloidosis, 3 with post myocarditis, 2 with dilated cardiomyopathy, 2 with cardiac sarcoidosis, 2 with cardiac tumor, 2 with previous myocardial infarction, 2 with hypertensive heart disease) underwent 1.5-T CMR and cardiac CT within 2 months without clinical accidents. Results: LE on LVM was detected in 31 and 31 patients on CT and CMR, respectively, and in 192 and 197 LVM segments on CT and CMR, respectively, among a total of 952 LVM segments. The sensitivity, specificity, positive and negative predictive values, and consistency for detection of LE on CT in comparison with CMR were 90, 89, 90, 89 and 89%, respectively, on patient-based analysis, and 67, 92, 68, 91 and 87%, respectively, on segment-based analysis. Inter-observer agreement for detection of LE on CT was 0.71 (kappa coefficient), and it was significantly lower than that on CMR (0.82) on segment-based analysis (P < 0.05). Conclusions: Compared with CMR, diagnostic accuracy of CT for the evaluation of LE in LVM in patients with myocardial diseases was relatively higher on patient-based analysis, but was limited on segment-based analysis, and the inter-observer agreement on CT was significantly lower than that on CMR. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background: Weaimed to optimize the acquisition of the left atrial (LA) and pulmonary vein (PV) ultrasound contours formore accurate integration of intracardiac echocardiography (ICE) and computed tomography (CT) using the CARTO (R) 3 system during atrial fibrillation (AF) ablation. Methods: Eighty-five AF patients underwent integration of ICE and CT using (1) the LA roof and posterior wall contours acquired from the right atrium (RA), (2) all LA/PV contours from the RA (Whole-RA-integration), (3) the LA roof/posterior wall contours from the RA and right ventricular outflow tract (RVOT) (Posterior-RA/RV-integration), and (4) all LA/PV contours from the RA and RVOT (Whole-RA/RV-integration). The integration accuracy was compared using the (1) surface registration error, (2) distances between the three-dimensional CT and eight specific sites on the anterior, posterior, superior, and inferior aspects of the right and left circumferential PV isolation lines, and (3) registration score: a score of 0 or 1 was assigned for whether or not each specific site was visually aligned with the CT, and summed for each method (0 best, 8 worst). Results: Posterior-RA/RV-integration revealed a significantly lower surface registration error (1.30 +/- 0.15 mm) than Whole-RA-and Whole-RA/RV-integration (p < 0.001). The mean distances of the eight specific sites and the registration score for Posterior-RA/RV-integration (median 1.26 mm and 2, respectively) were significantly smaller than those for the other integration approaches (p < 0.001). Conclusions: Image integration with the LA roof and posterior wall contours acquired from the RA and RVOT may provide greater accuracy for catheter navigation with three-dimensional CT during AF ablation. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background: A newtransthoracic echocardiography (TTE) technique allows multi-layer measurement of left ventricular (LV), endocardial, epicardial, and whole layer myocardial strain. We evaluated interobserver and intraobserver TTE reproducibility for 2D LV global longitudinal (GLS) and circumferential strain (GCS) estimates using data from severe aortic stenosis (AS) subjects with preserved LV ejection fraction (EF). Methods: Twenty severe AS subjects (11 male; mean age, 75 +/- 7 years; LV EF >50%) underwent TTE (Vivid E9, GE Healthcare). Quantitative strain measurements of whole, endocardial, and epicardial layers were performed. GLS was defined as all 17 averaged LV segments, according to the American Heart Association classification. GCS was measured at the levels of the mitral valve, papillary muscle, and apex. Results: Interobserver correlation coefficients in whole, endocardial, and epicardial layers for GLS estimates were 0.81, 0.83, and 0.80, respectively, whereas those for GCS estimates were 0.38, 0.56, and 0.19, respectively, for the mitral valve, 0.44, 0.54, and 0.36, respectively, for the papillary muscle, and 0.55, 0.29, and 0.59, respectively, for the apex. Intraobserver correlation coefficients in whole, endocardial, and epicardial layers for GLS estimates were 0.97, 0.97, and 0.94, respectively, whereas those for GCS estimates were 0.86, 0.81, and 0.50, respectively, for the mitral valve, 0.56, 0.72, and 0.28, respectively, for the papillary muscle, and 0.70, 0.69, and 0.62, respectively, for the apex. Conclusion: In severe AS subjectswith preserved LVEF, inter-and intra-observer TTE reproducibility in whole, endocardial, and epicardial layers were more consistent for 2D LV GLS than for 2D LVGCS. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Purpose: To evaluate CT utility for detection of cardiac or lung abnormalities in the diagnosis of organic cardiac disease in subjects with second- or third-degree atrioventricular block (AVB) excepting Wenckebach type. Materials and methods: A total of 50 consecutive patients (25 male; 64 +/- 15 years) with de novo third- or second-degree AVB underwent both TTE and a combination of cardiac and chest 320 slice CT (Aquilion one, Toshiba Medical) and were retrospectively analyzed. The presence of focal left ventricular (LV) wall thinning and thickening was evaluated on both TTE and cardiac CT. We evaluated the presence of significant coronary artery stenosis, focal late enhancement (LE) in LV myocardium, significant-sized (>10 mm) lymph nodes in hialus or mediastinum and/or typical lung nodules for sarcoidosis on CT. Results: Abnormalities for 26%, 30%, and 36% of patients were demonstrated on TTE, cardiac CT, and a combination of cardiac and chest CT, respectively. 12% and 18% patients who did not exhibit cardiac abnormalities on TTE, revealed abnormalities on cardiac CT, or a combination of cardiac and chest CT, respectively. 36% patients had organic cardiac diseases. Sensitivities for detection of organic cardiac disease were significantly greater when cardiac and chest CT were combined than TTE alone (P < 0.01). Conclusions: Approximately one third of patients with third- or second- degree AVB had organic cardiac diseases. For detection of cardiac and chest abnormality and correct diagnosis of organic cardiac disease in patients with third- or second-degree AVB, TTE is not sufficient on its own. CT or a combination of TTE and CT are required. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Purpose: We performed 2D speckle tracking transthoracic-echocardiography (TTE) to compare the ability to predict occurrence of major adverse cardiac events (MACE) between global longitudinal strain (GLS) and circumferential strain (GCS) in left ventricular (LV) myocardium in hypertrophic cardiomyopathy (HCM) patients without obstructed coronary arteries. Methods: We measured 2D LV GLS and GCS retrospectively by TTE within 13 months of performance of cardiac CT in 41 consecutive symptomatic HCM patients (27 males; 60 +/- 13 years) without obstructed coronary arteries on CT. Patients were followed up for a median period of 30 months. Results: MACE occurred in 7 (17%) patients. The Cox proportional hazard model for univariate analysis revealed that 2D LV GLS (hazard ratio (HR) 1.89, P = 0.019) was a significant predictor of MACE but GCS (HR 1.07, P = 0.118) was not. The Cox model for multivariate analysis revealed that 2D LV GLS (hazard ratio 2.144, P = 0.013) was a significant predictor for MACE. In receiver operating characteristic (ROC) curves at a best cut-off of -9.65% (2D LV GLS) and -29.35% (2D LV GCS), the sensitivity and specificity for MACE occurrence were 100% and 64.7% (2D LV GLS) and 100% and 47.1% (2D LV GCS), respectively. Kaplan Meier analysis revealed significant differences in MACE occurrence during the follow-up period between <= - 9.65 and >9.65% of 2D LV GLS (P= 0.004) and <= - 29.35 and > - 29.35% of 2D LV GCS (P = 0.017). Conclusions: Both 2D LV GLS and GCS (2D LV GLS > GCS) on TTE can predict poor prognosis in HCM patients without obstructed coronary arteries. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

The entirely subcutaneous implantable cardioverter-defibrillator (ICD) system was developed to provide a life-saving defibrillation therapy that does not affect the heart and vasculature. The subcutaneous ICD is preferred over the transvenous ICD for patients with a history of recurrent infection presenting major life-threatening rhythms. In this case report, we describe the first successful intermuscular implantation of a completely subcutaneous ICD in a Japanese patient with pectus excavatum. There were no associated complications with the device implantation or lead positioning. Further, the defibrillation threshold testing did not pose any problem with the abnormal anatomy of the patient.