Remodeling myocytes show a typical switch between the embryonic and classical features of apoptosis and/or hypertrophy representing a signal of death (ie, apoptosis) and a signal of life (ie, hypertrophy). The adult myocyte, however, is a terminal cell; usually it is unable to reproduce and death is not genetically programmed (apoptosis), but occurs by necrosis. The reinstatement of apoptosis and development of hypertrophy during remodeling could be part of the switch forward to the embryonic phenotype with reinstatement of the early embryonic genetic program. Hypertrophy and apoptosis are "sons" of the same "mother": the local, tissue neuroendocrine-neurohumoral response to a mechanical stretch of the myocytes consequent to the geometric changes imposed on the viable myocytes by the necrotic ones. As expected, the life and death cycle is very closely regulated by several autocrine systems, one of which is linked to the interleukin-6 family via a regulatory protein named GP-130. Activation of the GP-130 slows down the death signals, thus favoring hypertrophy and reducing fibrosis. (Circ J 2009; 73: 1973-1982)

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Endothelial cells (ECs) lining blood vessel walls respond to shear stress, a fluid mechanical force generated by flowing blood, and the EC responses play an important role in the homeostasis of the circulatory system. Abnormal EC responses to shear stress impair various vascular functions and lead to vascular diseases, including hypertension, thrombosis, and atherosclerosis. Bioengineering approaches in which cultured ECs are subjected to shear stress in fluid-dynamically designed flow-loading devices have been widely used to analyze EC responses at the cellular and molecular levels. Remarkable progress has been made, and the results have shown that ECs alter their morphology, function, and gene expression in response to shear stress. Shear stress affects immature cells, as well as mature ECs, and promotes differentiation of bone-marrow-derived endothelial progenitor cells and embryonic stem cells into ECs. Much research has been done on shear stress sensing and signal transduction, and their molecular mechanisms are gradually coming to be understood. However, much remains uncertain, and many candidates have been proposed for shear stress sensors. More extensive studies of vascular mechanobiology should increase our understanding of the molecular basis of the blood-flow-mediated control of vascular functions. (Circ J 2009; 73: 1983-1992)

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Oxidatively modified low-density lipoprotein (oxLDL) is implicated in the pathogenesis of atherosclerosis. Endothelial dysfunction is the initial change in the vascular wall that induces morphological changes for atheroma-formation. Lectin-like oxidized LDL receptor-1 (LOX-1) was identified as the receptor for oxLDL that was thought to be a major cause of endothelial dysfunction. LOX-1 has been demonstrated to contribute not only to endothelial dysfunction, but also to atherosclerotic-plaque formation, myocardial infarction and intimal thickening after balloon injury. Recent findings on the genetics of LOX-1 and the methodology to detect it and its ligands would further facilitate the examination of the receptor's pathophysiological contribution in atherosclerosis. Furthermore, LOX-1-related tools might open new gateways from diagnosis to therapeutics for cardiovascular diseases. (Circ J 2009; 73: 1993-1999)

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Although considerable advances have been made in the diagnosis and management of acute myocardial infarction (AMI), the disorder is still a major cause of morbidity and mortality worldwide and continues to pose significant therapeutic challenges. The use of biomarkers to aid the diagnosis of AMI is now increasing and has enabled better understanding of the pathophysiology of the disorder and identification of patients who require urgent reperfusion therapy. Early percutaneous coronary intervention (PCI) appears to be beneficial when performed in a timely manner with a door-to-balloon time <90 min. The goal of PCI is now shifting from simple revascularization of occluded coronary arteries to optimum reperfusion at the microvascular level. Effective strategies and pharmacological agents need to be developed for better cardiac protection during AMI. Most deaths resulting from AMI occur within 1 h of its onset, and half of them occur before hospital admission. Thus, an effective pre-hospital lifeline system should be an important priority, achieved through the chain of survival, including the immediate implementation of definitive resuscitative efforts and rapidly transporting the patients to the hospital. (Circ J 2009; 73: 2000-2008)

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Background: Intravenous amiodarone (AMD) has been used for the treatment of ventricular tachycardia/fibrillation (VT/VF) in emergency care medicine. However, AMD acts slowly and is occasionally accompanied by hypotension and bradycardia. The antiarrhythmic effect of intravenous nifekalant (NIF) was assessed in patients with VT/VF complicating acute coronary syndrome (ACS) according to our study protocol. Methods and Results: Among a series of 1,143 ACS patients, 41 patients who suffered sustained VT/VF were enrolled; 19 failed to respond to a preceding lidocaine (LID) injection. NIF was given first as an intravenous bolus injection (0.2 mg/kg) and then as a continuous intravenous infusion at a relatively low dose level (0.2 mg · kg^-1 · h^-1). Sustained VT/VF was successfully inhibited by NIF in 34 patients (83%). In subgroup analysis, NIF achieved VT/VF inhibition in 79% of patients who received preceding LID and in 86% of patients who received direct NIF. There were no significant changes in systolic blood pressure or heart rate following NIF therapy. A corrected QT interval was significantly prolonged (P<0.01), whereas torsade de pointes developed in only 1 patient (2%). Conclusions: An intravenous bolus injection and subsequent continuous infusion of NIF at a relatively low dosage were effective in treating severe ventricular tachyarrhythmias complicating ACS, reducing the potential risk of proarrhythmia. (Circ J 2009; 73: 2021-2028)

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Background: Multisite atrial pacing (MAP) was introduced to improve atrial electrical synchrony and prevent recurrence of atrial fibrillation (AF). Methods and Results: In the present study there were 57 patients with sinus node disease, AF recurrence and prolonged P-wave on ECG with 2 MAP modalities. In all patients 1 lead was implanted in the coronary sinus (CS) ostium area. In the right atrial appendage (RAA)+CS group (28 patients) the other atrial lead was in the RAA, and in the BB+CS group (29 patients) in the Bachmann's bundle (BB) region. Tissue Doppler was used to register the electromechanical delay (EMD) in the atrial walls and estimate the atrial contraction synchrony. Cardiac output and myocardial performance index did not differ during the 2 MAP modalities. During BB+CS, in comparison with RAA+CS pacing, the peak of the mitral atrial wave occurred earlier (P<0.01), the usual right-left atrial contraction sequence was reversed more frequently (P<0.004), all atrial EMDs except for the lateral left atrium (LA) were shorter (P<0.05), and LA synchrony was greater (P<0.001). Conclusions: In patients treated with MAP, implanting 1 of the atrial leads in the BB area instead of the RAA has no influence on global cardiac hemodynamics, but does result in earlier LA contraction, and reversal of the typical right-left atrial contraction sequence, as well as providing greater LA contraction synchrony. (Circ J 2009; 73: 2029-2035)

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Background: Stent fracture is a cause of in-stent restenosis (ISR) after sirolimus-eluting stent (SES) implantation, so this study investigated the incidence, predictors and prognosis of stent fracture. Methods and Results: The 273 consecutive patients (364 lesions) after SES implantation and who had 6-9 month' scheduled follow-up coronary angiography (CAG) were divided into groups with and without stent fracture. Δangle was defined as the difference in the angle in the target lesion between diastole and systole before the procedure. The incidence of stent fracture was 4.9% (18 of 364 lesions). Δangle in the target lesion was larger in the fracture group (28.3 ±11.5° vs 12.3 ±9.0°, P<0.0001). Independent predictors of stent fracture were Δangle and total stent length. The rates of binary restenosis and target lesion revascularization (TLR) were higher in the fracture group (33% vs 4.0%, P=0.0002 and 28% vs 3.5%, P=0.0007, respectively). There were no major adverse cardiac events (MACE) in the fracture group during a mean 24-month follow-up after follow-up CAG. Conclusions: Predictors of stent fracture were Δangle and total stent length. Although stent fracture was associated with ISR and TLR, it was not associated with MACE during long-term follow-up. (Circ J 2009; 73: 2036-2041)

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Background: The efficacy of drug-eluting stents after rotational atherectomy (ROTA) has not been clarified. Methods and Results: The 704 consecutive patients who underwent percutaneous coronary intervention (PCI) with a sirolimus-eluting stent (SES) (79 with and 625 without ROTA) were enrolled. The 2-year clinical outcome of these patients was compared with that of a group of 1,123 consecutive patients treated with bare-metal stents (BMS) (144 with and 979 without ROTA). At 2 years after index PCI, the use of SES after ROTA was associated with a lower crude incidence of major adverse cardiac events (MACE) than were BMS after ROTA (30.1% vs 43.1%, P=0.024). The difference was mainly derived from the reduction in target lesion revascularization (TLR) (25.0% vs 39.1%, P=0.022). After adjusting for confounders, ROTA-SES was associated with a reduction in MACE and TLR, with a similar hazard ratio to the non-ROTA group only with SES implantation. In a subgroup of dialysis patients, the incidence of TLR after ROTA with SES and BMS was similarly high. Conclusions: The use of SES after ROTA is an appropriate method for selected hard lesions, but has a limited effect in dialysis patients, even after lesion preparation with ROTA. (Circ J 2009; 73: 2042-2049)

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Background: The aim of the present study was to test the hypothesis that the transradial arterial approach (TRA) is not inferior to the transfemoral arterial approach (TFA) for ≤Killip 3 acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI). Methods and Results: This study enrolled 506 AMI patients undergoing primary PCI using the TRA (group 1) between March 2002 and May 2007, and 810 AMI patients undergoing primary PCI using TFA (group 2) between May 1993 and February 2002. The results demonstrated that puncture to first balloon-inflation time was similar in both groups; however, the procedure time was shorter in group 1 than in group 2 (P<0.0001). Additionally, the incidences of stenting, tirofiban therapy and final normal coronary blood flow of the infarct-related artery were higher, whereas the frequency of intra-aortic balloon pump support was lower in group 1 than in group 2 (all P<0.02). Although the 30-day mortality rate did not differ between the 2 groups (P=0.341), the rate of combined major vascular and bleeding complications was higher in group 2 than in group 1 (P<0.0001). Conclusions: Initial selection of TRA is not inferior to initial selection of TFA for AMI patients undergoing primary PCI. However, in the present study, the incidence of combined vascular and bleeding complications was lower with the TRA than with the TFA approach. (Circ J 2009; 73: 2050-2055)

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Background: The purpose of this study was to investigate the preoperative risk factors of performing off-pump coronary artery bypass grafting (OPCAB) in patients on chronic dialysis. Methods and Results: The 41 consecutive patients on chronic dialysis who underwent OPCAB from February 2000 to April 2006 at the National Cardiovascular Center were studied retrospectively. Of them, 29 had diabetic nephropathy (DN group) and the remaining 12 did not (NDN group). There were significant differences in the duration of dialysis before surgery (9.1 ±7.5 years in NDN vs 4.2 ±5.5 years in DN, P=0.028) and low cardiac function (left ventricular ejection fraction <30%), which was recognized only in the DN group (7/29, P=0.048). The early mortality rate was 6.9% (2/29) in the DN group and 16.7% (2/12) in the NDN group (P=0.349). The actuarial survival rates in the DN group were 85% at 1 year, 45% at 3 years, and 30% at 5 years, whereas in the NDN group they were 71%, 49%, and 49%, respectively (P=0.789). Arteriosclerosis obliterans (ASO) and age (>65 years) were independent risk factors of late death. Conclusions: For patients on chronic dialysis ASO and aging were predicted risk factors for OPCAB, whereas diabetic nephropathy was not. (Circ J 2009; 73: 2056-2060)

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Background: Papillary muscle (PM) suspension concomitant with mitral annuloplasty and PM approximation (PMA) has been developed for functional mitral regurgitation (MR). In the present study, the early effect of PM suspension (PMS) on the postoperative mitral geometry and diastolic mitral tethering was investigated. Methods and Results: Subjects were 22 patients with left ventricular dysfunction and functional MR who underwent mitral annuloplasty and PMA with or without suspension from 2004 to 2008. The purpose of PMS is to maintain the mitral complex geometry and prevent future mitral tethering caused by left ventricular remodeling. The mean age was 64 ±10 (range 39-85) years. The submitral apparatus geometry was measured by echocardiography. PM and mitral inflow angles in the anterior-directional suspension group were significantly larger than those in the posterior-directional suspension group (57 ±7° vs 46 ±9°, P=0.017 and 78 ±9° vs 60 ±6°, P<0.001, respectively), which were comparable to the normal control. In the posterior-directional suspension group, the transmitral pressure gradient was higher and restrictive mitral filling pattern remained postoperatively in 2 cases of the group. Conclusions: Anterior-directional suspension is preferable to the posterior one in terms of diastolic mitral filling. (Circ J 2009; 73: 2061-2067)

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Background: There are few studies that compare measures of diagnostic accuracy for selected waist cutoff points and the criteria of abdominal obesity given by the International Diabetes Federation (IDF) and the National Cholesterol Education Program (NCEP). Methods and Results: The present study utilized data from the Third Korean National Health and Nutrition Examination Survey. Analyses for receiver-operating characteristic (ROC) curve were performed with data for 4,677 men and women aged 20-80 years who reported being free of a physician-diagnosed cardiovascular disease or cancer. On the basis of measures of diagnostic accuracy, including minimum distance to ROC curve and Youden index, waist circumference of 84-86 cm for men and of 78-80 cm for women were found to be optimal cutoff points. The study also demonstrated that the use of smaller waist circumference for diagnosis of the metabolic syndrome decreases discrepancies between the prevalence of the IDF-defined metabolic syndrome and that of the NCEP-defined metabolic syndrome. Conclusions: Waist circumference of 90 cm, the cutoff point given by the IDF for Asian men, may not be an appropriate value for Korean men, while its cutoff point for Asian women is appropriate for Korean women. (Circ J 2009; 73: 2068-2075)

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Background: To prevent a future shortage of cardiologists, it is important for female cardiologists to continue working. Gender differences in the professional and private lives of cardiologists, as well as the barriers to work for female cardiologists, were surveyed. Methods and Results: In August 2007, a questionnaire was mailed to all 195 faculty members/fellows and 155 alumni of the Department of Cardiovascular Medicine at Nippon Medical School. More female cardiologists were dissatisfied with their job than male cardiologists (34% vs 17%, P<0.005). Women reported greater career limitation by family responsibilities and housework. Men and women both reported that long working hours was the most problematic issue, but significantly more women reported this than men (76% vs 94%, P<0.05). Female cardiologists were more concerned about occupational radiation exposure (88% vs 59%, P<0.01) and wanted opportunities for retraining after childcare leave (100% vs 76%, P<0.01). Conclusions: The following measures should be taken: (1)establishment of more family-friendly working conditions in hospitals, (2)provision of various work positions that allow more flexibility and predictability for women, (3)establishment of a retraining system, and (4)development of work and research opportunities that are attractive to women. The Japanese Circulation Society is expected to establish a retraining system at certified institutions. (Circ J 2009; 73: 2076-2083)

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Background: Atrial fibrillation (AF) is a common arrhythmia in patients with heart failure (HF), but its prognostic importance is controversial. The effect of AF on long-term outcomes, including mortality and rehospitalization, among unselected HF patients hospitalized with HF in routine clinical practice in Japan was assessed in the present study. Methods and Results: The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) prospectively studied the characteristics and treatment strategies of a broad sample of patients hospitalized with worsening HF and the outcomes were followed with an average of 2.4 years of follow-up. The study cohort (n=2,659) was grouped according to the presence (n=937; 35.2%) or absence (n=1,722; 64.8%) of AF at baseline. After multivariable adjustment, patients with and without AF had a comparable risk for all-cause death (adjusted hazard ratio (HR) 0.931, 95% confidence interval (CI) 0.690-1.258, P=0.643), cardiac death (adjusted HR 0.949, 95%CI 0.655-1.377, P=0.784), rehospitalization because of the worsening HF (adjusted HR 1.028, 95%CI 0.816-1.295, P=0.816), and all-cause death or rehospitalization (adjusted HR 1.039, 95%CI 0.842-1.281, P=0.722). Conclusions: Among patients hospitalized for HF in Japan, AF was common, but was not an independent risk for long-term adverse outcomes, including death or rehospitalization, in routine clinical practice. (Circ J 2009; 73: 2084-2090)

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Background: Hypertension is associated with remodeling and mechanical alterations of resistance arteries. Numerous studies have investigated the mechanical and morphometric properties of small arteries obtained from hypertensive animals and humans. However, the functional properties of resistance arteries from normotensive and hypertensive subjects have only been examined under normotensive conditions. The objective of the present study was to evaluate the dilation responses of small mesenteric arteries (SMA) from spontaneously hypertensive rats (SHR) at various levels of intraluminal pressure. Methods and Results: SMA segments from Wistar Kyoto (WKY) rats and SHR were pressurized using pressure myography. Endothelium-dependent and -independent dilation responses of the SMA were examined under 3 different intravascular pressures (50, 80 and 120 mmHg). Endothelium-dependent dilation was evaluated by measuring vasodilator responses to increasing doses of acetylcholine or increases in intraluminal flow rate. Endothelium-independent vasodilator function was examined by using sodium nitroprusside. The results indicate that both endothelium-dependent and -independent dilation responses of SMA from WKY progressively decrease with increased intravascular pressure. In contrast, all dilatation responses of the SMA from SHR were enhanced at higher intraluminal pressures. Conclusions: These findings of differential sensitivity to luminal pressure should be considered during in vitro examination of vessels from normotensive and hypertensive subjects. (Circ J 2009; 73: 2091-2097)

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Background: Although a reduction in myocardial blood volume (MBV), an in vivo index of the myocardial microvasculature, measured by myocardial contrast echocardiography in patients with hypertension (HT), can be demonstrated, it is still unknown whether a decreased MBV can be improved by antihypertensive treatment. Methods and Results: Eleven HT patients (mean age 58 years, 7 men) with left ventricular hypertrophy (LVH) and 10 age- and sex-matched normal controls were studied. Harmonic power Doppler images were acquired at end-diastole of every 6^th beat and MBV was calculated as 10^X/10×100%, where X (dB) is myocardial contrast intensity minus the contrast intensity of the adjacent intracavity blood pool. Baseline blood pressure (BP) and left ventricular mass index (LVMI) in the HT patients were higher and MBV was lower than in the controls (2.52 ±0.37% vs 3.31 ±0.61%, P<0.01). MBV did not correlate with mean BP, but was inversely correlated with LVMI (r=0.61, P<0.01). After treatment with valsartan for 6 months, LVMI significantly decreased and MBV increased (2.72 ±0.26%, P<0.05 vs baseline) in the patients with HT. There was a significant inverse correlation between the changes in MBV and those of LVMI (r=0.62, P<0.05), but not between MBV and mean BP. Conclusions: Valsartan, an angiotensin II receptor blocker, corrected the decreased MBV in association with regression of LVH in patients with HT. (Circ J 2009; 73: 2098-2103)

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Background: Few studies dealing with the efficacy of statin therapy among patients with metabolic syndrome (MS) and coronary artery disease (CAD) have been conducted. In particular, there have been no studies of the efficacy of statins among Asian MS patients with treated CAD. Methods and Results: Data from 1,138 consecutive patients who underwent complete revascularization (coronary intervention or bypass surgery) were collected. Of these, 529 patients who satisfied the criteria for MS using the American Heart Association/National Heart, Lung and Blood Institute statement (body mass index ≥25 was used instead of waist circumference) were assessed. All-cause and cardiovascular mortality of patients given statins and those not given statins at least 2 weeks before the complete revascularization were compared. To adjust for the variables that would have been related to the decision to give statins, the propensity score was calculated, and multivariate Cox regression was carried out. Statins were given to 146 patients. During follow-up (9.1 ±2.5 years), 104 patients died. On multivariate analysis, statin use was significantly associated with reduced all-cause (hazard ratio (HR) 0.56, 0.31-0.99; P=0.049) and cardiovascular (HR 0.53, 0.30-0.96; P=0.042) mortality. Conclusions: In patients with MS and CAD, statins given at least 2 weeks before the complete revascularization, was associated with a reduced risk of all-cause and cardiovascular mortality. (Circ J 2009; 73: 2104-2109)

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Background: It has been suggested that intensive lipid-lowering therapy using statins significantly decreases atheromatous plaque volume. The effect of rosuvastatin on plaque volume in patients with stable coronary artery disease (CAD), including those receiving prior lipid-lowering therapy, was examined in the present study. Methods and Results: A 76-week open-label trial was performed at 37 centers in Japan. Eligible patients began treatment with rosuvastatin 2.5 mg/day, which could be increased at 4-week intervals to ≤20 mg/day. A total of 214 patients underwent intravascular ultrasound (IVUS) at baseline; 126 patients had analyzable IVUS images at the end of the study. The change in the serum low-density lipoprotein-cholesterol level from baseline to end of follow-up was -38.6 ±16.9%, whereas that of high-density lipoprotein-cholesterol was +19.8 ±22.9% (both P<0.0001). Percent change of plaque volume, the primary endpoint, was -5.1 ±14.1% (P<0.0001). Conclusions: Rosuvastatin exerted significant regression of coronary plaque volume in Japanese patients with stable CAD, including those who had previously used other lipid-lowering drugs. Rosuvastatin might be useful in the setting of secondary prevention in patients with stable CAD. (Circ J 2009; 73: 2110-2117)

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Background: The Pro12Ala polymorphism (rs1801282), a nonsynonymous substitution of peroxisome proliferator-activated receptor-γ (PPARG), has been robustly associated with type 2 diabetes. However, its role in metabolic syndrome (MetS) remains poorly understood. The associations among rs1801282, MetS and surrogate measures of insulin resistance (IR) were investigated in the present study. Methods and Results: A cross-sectional population-based survey of 572 unrelated healthy male Argentinian blood donors with normal findings on medical examination and not taking any medication was conducted. MetS was assessed using the National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) criteria, and the HOMA-IR, and QUICKI were calculated. Genotyping of rs1801282 was performed using RFLP-PCR. The prevalence of MetS was 26.2%. The Pro/Ala genotype (and the Ala12 allele) was associated with a high risk for MetS (odds ratio (OR) 1.67 [95% confidence interval (CI) 1.03-2.72], P=0.0394). This was highlighted among nonsmokers (OR 2.20 [95%CI 1.25-3.88], P=0.0059). ANCOVA confirmed an interaction between smoking status and this association (P=0.031). Ala12 carriers had a higher waist circumference than noncarriers (P=0.0065). Among nonsmokers, surrogates of IR, such as HOMA-IR, were significantly higher in Ala12 carriers than in noncarriers (P<0.05). Conclusions: Healthy men, in particular nonsmokers, carrying the Ala12 allele of PPARG rs1801282 polymorphism, have a high risk for MetS and IR. (Circ J 2009; 73: 2118-2124)

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Background: Mice lacking manganese-superoxide dismutase (Mn-SOD) activity exhibit the typical pathology of dilated cardiomyopathy (DCM). In the present study, presymptomatic and symptomatic mutant mice were treated with the SOD/catalase mimetic, EUK-8. Methods and Results: Presymptomatic heart/muscle-specific Mn-SOD-deficient mice (H/M-Sod2^-/-) were treated with EUK-8 (30 mg · kg^-1 · day^-1) for 4 weeks, and then cardiac function and the reactive oxygen species (ROS) production in their heart mitochondria were assessed. EUK-8 treatment suppressed the progression of cardiac dysfunction and diminished ROS production and oxidative damage. Furthermore, EUK-8 treatment effectively reversed the cardiac dilatation and dysfunction observed in symptomatic H/M-Sod2^-/- mice. Interestingly, EUK-8 treatment repaired a molecular defect in connexin43. Conclusions: EUK-8 treatment can prevent and cure murine DCM, so SOD/catalase mimetic treatment is proposed as a potential therapy for DCM. (Circ J 2009; 73: 2125-2134)

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Background: Refractory arrhythmias caused by right ventricular (RV) volume overload resulting from pulmonary regurgitation are the main concern in adult patients after repair of tetralogy of Fallot (TOF). Early pulmonary valve replacement (PVR) may prevent irreversible RV dysfunction and refractory arrhythmias, so the present study evaluated the PVR outcomes in adult patients with a severely dilated RV (d-RV) and refractory arrhythmias after TOF repair. Methods and Results: Three TOF patients with a d-RV and tachyarrhythmias underwent PVR between the ages of 28 and 38 years. All had a d-RV (RV end-diastolic volume index (RVEDVI) >200 ml/m²) with a polymorphic nonsustained ventricular tachycardia (NSVT). Atrial tachycardia (AT) was identified in 2 patients and they underwent radiofrequency catheter ablation. The arrhythmias in all 3 were refractory to antiarrhythmic drugs. One year after PVR, the RVEDVI, left ventricular ejection fraction, right atrial pressure, cardiac index, cardiothoracic ratio, brain natriuretic peptide levels, and peak VO₂ improved in all, but without normalization. During the 2.6-3.8 year follow-up, all experienced tachyarrhythmias (NSVT or AT), which were controlled with medication. Conclusions: PVR may be beneficial for refractory arrhythmias, even in TOF patients with a d-RV, but it is difficult to completely normalize the hemodynamics and resolve the arrhythmogenicity. (Circ J 2009; 73: 2135-2142)

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Background: Although in clinical practice endovascular therapy (EVT) with a nitinol stent for femoro-popliteal artery (FPA) lesions has been widely applied for TASC II A/B lesions, primary patency beyond 2 years remains unknown, as do the factors associated with restenosis. Methods and Results: A prospectively maintained database that included 189 limbs treated with nitinol stents for de novo TASC II A/B FPA lesions was retrospectively analyzed. The outcomes were overall primary and secondary patency during the follow-up period and predictors associated with restenosis. Primary patency overall with nitinol stents was 84%, 82%, 80%, 80% and secondary patency was 96%, 93%, 90%, 90% at 12, 24, 36, 48 months, respectively. Primary patency was not statistically different between the 2 types of nitinol stents (Luminexx vs S.M.A.R.T. Control. stent, P=0.37) during follow-up period. From the multivariate analysis, administration of cilostazol was the strongest independent factor associated with restenosis (P=0.0012). Conclusions: Nitinol stent implantation for TASC II A/B FPA lesions is suitable and durable in sustaining freedom from restenosis through 4 years of follow-up. (Circ J 2009; 73: 2143-2147)

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Background: Recent studies suggest that treatment of heart failure (HF) could improve cardiac function and sleep apnea syndrome (SAS), but it is unknown how cardiac surgery may affect SAS in HF patients. Relationships between HF with valvular heart diseases and 2 types of SAS (obstructive sleep apnea (OSA) and central sleep apnea (CSA)) were examined. The effects of valve repair surgery on OSA and CSA was also investigated. Methods and Results: Polysomnography, echocardiography and right cardiac catheterization were used to study 150 severe HF patients with mitral valvular and/or aortic valvular diseases. Significant associations between SAS and age, gender, body mass index, or hypertension were observed. The value of the CSA-apnea index (AI) was significantly correlated with pulmonary capillary wedge pressure (PCWP) and mean pulmonary artery pressure (PAP). These associations were not identified for OSA-AI. Valve repair surgery was used to treat 74 patients with severe SAS. The treatment led to a significant improvement in PCWP and mean PAP, and CSA-AI, but not in OSA-AI. Conclusions: These findings suggest close associations between CSA and cardiac function in HF patients with valvular heart diseases. Furthermore, improvement of cardiac function with valvular surgery reduces the severity of CSA in HF patients with valvular heart diseases. (Circ J 2009; 73: 2148-2153)

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Background: The serum levels of soluble elastin increase in patients with aortic dissection, but its distribution and characteristics are unclear. Methods and Results: The 173 aortic specimens were categorized into 4 groups under microscopy (non-atherosclerotic aorta, n=13; fiber-rich plaque, n=77; lipid-rich plaque, n=66; ruptured plaque, n=17). Soluble elastin was abundant within the intima of both the non-atherosclerotic aorta and fiber-rich plaque, rather than in the media, and was decreased within the intima of lipid-rich and ruptured plaques. Soluble elastin levels decreased with progress of atherosclerosis (6.0 ±0.3 μg/mg protein in non-atherosclerotic aorta; 5.8 ±0.2 μg/mg protein in fiber-rich plaque; 4.9 ±0.2 μg/mg protein in lipid-rich plaque; 2.8 ±0.4 μg/mg protein in ruptured plaque, P<0.05). As well, both matrix metalloprotease-9 activity and elastin mRNA expression showed inverse distribution against soluble elastin (r=0.437, P<0.0001; r=0.186, P<0.05, respectively). Multivariable analysis revealed a decrease in the level of soluble elastin in ruptured plaque (2.8 ±0.4 μg/mg protein in ruptured plaque, n=18; 5.5 ±0.2 μg/mg protein in non-ruptured plaque, n=155, P<0.01). Furthermore, western blot showed soluble elastin consists of heterogeneous molecular pattern proteins. Conclusions: Both the synthesis and degradation of elastin may be enhanced in active atherosclerotic lesions. (Circ J 2009; 73: 2154-2162)

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Noncompaction of the ventricular myocardium is a recently recognized genetic cardiomyopathy. The left ventricle is the most affected site, but right ventricular involvement has been reported in some cases. Diagnosis is made with 2-dimensional echocardiography or cardiac magnetic resonance imaging. The major clinical manifestations are heart failure, arrhythmias and embolic events. A 20-year old man had left and right ventricular noncompaction complicated by severe pulmonary hypertension, which is one of the first cases of biventricular noncompaction associated with severe pulmonary hypertension. Pulmonary hypertension may be a consequence of increased pulmonary venous pressures caused by systolic and diastolic heart dysfunction secondary to noncompaction. (Circ J 2009; 73: 2163-2165)

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Allograft coronary artery disease (CAD) is the main limiting factor of the long-term survival in cardiac transplant recipients. It is present in approximately 50% of patients at 5 years post-transplant. Allograft CAD might result in congestive heart failure, ventricular arrhythmias and sudden cardiac death. Acute coronary syndrome is a rare presentation of allograft CAD, because symptoms are usually atypical or absent as a result of cardiac denervation. However, it should be reminded that reinnervation of the transplanted heart might occur, and angina pectoris could be felt as a sign of an acute coronary syndrome. We present a 27-year-old female cardiac transplant patient with an acute myocardial infarction, who was successfully treated with percutaneous transluminal coronary angioplasty. (Circ J 2009; 73: 2166-2168)

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Isolated non-compaction of the ventricular myocardium (INCVM) is a relatively newly defined clinicopathologic entity. INCVM is clinically accompanied by depressed ventricular function, arrhythmias, and systemic embolization. We report two cases of INCVM with long QT syndrome (LQTS). In both cases the QT interval was over 0.55 s with episodes of torsades de pointes, and prominent ventricular trabeculations and deep intertrabecular recesses were detected by 2-dimensional echocardiography. Both cases had the KCNH2 mutation. To the best of our knowledge, this is the first report investigating INCVM with LQTS. (Circ J 2009; 73: 2169-2172)

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Cardiac resynchronization therapy (CRT) is a new method of treatment for refractory heart failure. However, for children, its indication, efficacy, and long-term prognosis remain unclear. This study describes the use of CRT for a 3-year-old girl with intractable heart failure caused by isolated left ventricular non-compaction (LVNC) with narrow QRS complex. Echocardiography showed diffuse hypokinetic left ventricular (LV) wall motion (ejection fraction =29.3%) with dyssynchrony between the apex, posterior and lateral walls, where numerous prominent trabeculations existed, and severe mitral regurgitation. Biventricular resynchronization using epicardial pacing leads was performed under general anesthesia. Pacing sites for optimal synchronization in the ventricular walls where chosen using tissue Doppler imaging, and AV delay was adjusted to achieve maximal systolic blood pressure and maximal cardiac output. Over a follow-up period of 2 years, she exhibited significant and sustained improvement in LV function and clinical symptoms. BNP levels decreased from 1,960 to 82 pg/ml. QRS duration (103 ms) on ECG did not change after CRT. We conclude that pediatric CRT provides a highly useful adjunct for the treatment of heart failure, even in patients with a narrow QRS duration, and might improve the prognosis of patients with LVNC. (Circ J 2009; 73: 2173-2177)

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