Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 79 , Issue 4
Showing 1-40 articles out of 40 articles from the selected issue
Message From the Editor-in-Chief
Focus Reviews on Functional Testings
  • Giampaolo Niccoli, Giancarla Scalone, Filippo Crea
    Type: FOCUS REVIEWS ON FUNCTIONAL TESTINGS
    2015 Volume 79 Issue 4 Pages 676-684
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 19, 2015
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    Coronary angiography has long been the only diagnostic tool for the invasive assessment of coronary artery disease. Yet it does not allow establishing the functional severity of epicardial stenoses or vasomotor disorders of the epicardial arteries or coronary microcirculation. Functional tests in the catheterization laboratory have recently emerged as an important adjunct to coronary angiography for providing a comprehensive evaluation of the coronary circulation. In this review, we will describe and interpret the key functional tests used in current clinical practise in different clinical settings. (Circ J 2015; 79: 676–684)
  • Yasushi Matsuzawa, Raviteja R. Guddeti, Taek-Geun Kwon, Lilach O. Lerm ...
    Type: FOCUS REVIEWS ON FUNCTIONAL TESTINGS
    2015 Volume 79 Issue 4 Pages 685-694
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 27, 2015
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    Over the past decades, secondary prevention of cardiovascular (CV) disease has improved and considerably reduced mortality rates. However, there remains a high-rate of new or recurrent CV events in those with established atherosclerotic vascular diseases. Although most of the prevailing therapies target the conventional risk factors, there is notable interindividual heterogeneity in adaptation to risk factors and response to therapies, which affects efficacy. It is desirable to have a methodology for directly assessing the functional significance of atherogenesis, and for managing individual patients based on their comprehensive vascular health. Endothelial function plays a pivotal role in all stages of atherosclerosis, from initiation to atherothrombotic complication. Endothelial function reflects the integrated effect of all the atherogenic and atheroprotective factors present in an individual, and is therefore regarded as an index of active disease process and a significant risk factor for future CV events. Moreover, improvement in endothelial function is associated with decreased risk of CV events, even in the secondary prevention setting. The introduction of endothelial function assessment into clinical practice may trigger the development of a more tailored and personalized medicine and improve patient outcomes. In this review, we summarize current knowledge on the contribution of endothelial dysfunction to atherosclerotic CV disease in the secondary prevention setting. Finally, we focus on the potential of an endothelial function-guided management strategy in secondary prevention. (Circ J 2015; 79: 685–694)
Focus Reviews on Cardiovascular Intervention
  • Danny Dvir, John G. Webb
    Type: FOCUS REVIEWS ON CARDIOVASCULAR INTERVENTION
    2015 Volume 79 Issue 4 Pages 695-703
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 20, 2015
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    Bioprosthetic tissue valves are increasingly utilized during surgical aortic valve replacement. These valves have limited durability and many fail with time, resulting in stenosis, regurgitation, or both. Repeat cardiac surgery has been the standard of care for patients with failed bioprostheses. Transcatheter valve implantation inside failed surgically implanted bioprostheses (valve-in-valve) is a new less invasive alternative to repeat surgery. We review the potential and challenges of valve-in-valve implantation in patients with failing surgical aortic bioprostheses. (Circ J 2015; 79: 695–703)
  • Wai-ki Yiu, Michael S. Conte
    Type: FOCUS REVIEWS ON CARDIOVASCULAR INTERVENTION
    2015 Volume 79 Issue 4 Pages 704-711
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 13, 2015
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    Endovascular treatment of femoropopliteal occlusive disease is challenging and often limited by its unique anatomic, hemodynamic and biomechanical constraints. Despite technical improvement, percutaneous transluminal angioplasty alone is not adequate to provide satisfactory long-term patency. Several randomized controlled trials have shown that primary nitinol stenting can provide a better short-term radiological patency in intermediate lesion, but the results were often limited by intrinsic stent complications, particularly in-stent restenosis. Solutions to long lesions have been more elusive. To date, many novel technologies have been developed with a goal of improving stent design for this specific environment. Interwoven stents are made to provide a higher radial strength and kink resistance. Covered stents are designed to prevent the ingrowth of intimal hyperplasia, which is the main cause of restenosis in bare metal stent. Drug-eluting stents have shown improved patency in clinical trials. Bioabsorbable stents, combining biological agents and mechanical scaffold, provide temporary vascular support while reducing implant-related vascular inflammation in the long term. New developments in balloon angioplasty, such as drug elution, provide a challenge to stenting in this arena. Although these technologies look promising, a uniform reporting system and large-scale comparative studies with longer follow-up are needed to evaluate their clinical effectiveness in the future. (Circ J 2015; 79: 704–711)
Focus Reviews on Imaging
  • Akira Sato, Kazutaka Aonuma
    Type: FOCUS REVIEWS ON IMAGING
    2015 Volume 79 Issue 4 Pages 712-720
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 05, 2015
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    Cardiac multidetector computed tomography (MDCT) has become a useful noninvasive modality for anatomical imaging of coronary artery disease (CAD). Currently, the main clinical advantage of coronary computed tomography angiography (CCTA) appears to be related to its high negative predictive value at low or intermediate pretest probability for CAD. With the development of technical aspects of MDCT, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology, myocardial perfusion, and patient outcomes. The presence of positive vessel remodeling, low-attenuation plaques, napkin-ring sign, or spotty calcification on CCTA could be useful information on high-risk vulnerable plaques. The napkin-ring sign, especially, showed higher accuracy for the detection of thin-cap fibroatheroma. Recently, it was reported that cardiac 3D single-photon emission tomography/CT fusion imaging, noninvasive fractional flow reserve computed from CT, and integrated CCTA and CT myocardial perfusion were associated with improved diagnostic accuracy for the detection of hemodynamically significant CAD. Furthermore, several randomized, large clinical trials have evaluated the clinical value of CCTA for chest pain triage in the emergency department or long-term reduction in death, myocardial infarction, or hospitalization for unstable angina. In this review we discuss the role of cardiac MDCT beyond coronary angiography, including a comparison with other currently available imaging modalities used to examine atherosclerotic plaque and myocardial perfusion. (Circ J 2015; 79: 712–720)
  • Jun Koyama, Shu-ichi Ikeda, Uichi Ikeda
    Type: FOCUS REVIEWS ON IMAGING
    2015 Volume 79 Issue 4 Pages 721-734
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 12, 2015
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    Cardiac amyloidosis is a cardiomyopathy characterized by increased left ventricular (LV) wall thickness and normal or decreased LV cavity size. Congestive heart failure in cardiac amyloidosis is generally considered a predominantly diastolic phenomenon, with systolic dysfunction only occurring in late-stage disease. Echocardiography is a noninvasive, reproducible method of assessing cardiac features and function in cardiac amyloidosis, and some echocardiographic indices are prognostic for the amyloidoses, with M-mode and 2-dimensional echocardiography able to detect increased LV wall thickness. Moreover, Doppler flow measurements can incrementally assess diastolic LV dysfunction, which is characteristic of cardiac amyloidosis, and provide important prognostic information. Additionally, tissue Doppler imaging can detect subtle changes in both systolic and diastolic LV function, which cannot be detected by Doppler flow measurements, and LV longitudinal strain assessed by color tissue Doppler and speckle tracking echocardiography can provide more accurate LV functional and prognostic information than tissue Doppler imaging. This review describes the advances in echocardiography and its crucial role in the diagnosis and management of cardiac amyloidosis. (Circ J 2015; 79: 721–734)
  • Masaaki Uematsu
    Type: FOCUS REVIEWS ON IMAGING
    2015 Volume 79 Issue 4 Pages 735-741
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 13, 2015
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    Although echocardiography is a noninvasive means of visualizing the heart, quantitative and reproducible assessment of myocardial motion remains to be established. Tissue Doppler imaging (TDI) emerged in the early 1990 s as a tool to measure tissue motion velocity. For the purpose of analyzing regional myocardial motion quantitatively, the myocardial velocity gradient (MVG) across the myocardial wall was first introduced by using TDI. MVG is mathematically equal to strain rate. Initially, strain was derived as the time integral of the TDI-derived strain rate, but it revealed substantial errors of measurement, which basically arose from the confusion of Eulerian coordinates with Lagrangian coordinates in fluid dynamics. Speckle tracking echocardiography (STE) has subsequently emerged as a technique that analyzes motion by tracking “speckles” on echocardiograms based on Lagrangian coordinates. Although STE-derived strain is a robust parameter of myocardial deformation, the stress-strain relationship has often been overlooked in the assessment of myocardial function. We should consider (1) blood pressure, (2) left ventricular size, and (3) left ventricular wall thickness, as well as strain. Practical means of normalizing strain by stress should be pursued in the quantitative assessment of myocardial function. Consideration of stress-strain relationships is mandatory when interpreting STE-derived strain. (Circ J 2015; 79: 735–741)
  • Sei Komatsu, Tomoki Ohara, Satoru Takahashi, Mitsuhiko Takewa, Hitoshi ...
    Type: FOCUS REVIEWS ON IMAGING
    2015 Volume 79 Issue 4 Pages 742-750
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: March 12, 2015
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    The mortality rate due to rupture of aortic dissection and aortic aneurysm is approximately 90%. Acute aortic rupture can be fatal prior to hospitalization and has proven difficult to diagnose correctly or predict. The in-hospital mortality rate of ruptured aortic aneurysm ranges from 53 to 66%. Emergency surgical and endovascular treatments are the only options for ruptured aortic dissection and aortic aneurysm. No method of systematic early detection or inspection of vessel injury is available at the prevention stage. Regardless of the improvement in many imaging modalities, aortic diameter has remained a major criterion for recommending surgery in diagnosed patients. Previous reports have suggested a relationship between vulnerable plaque and atherosclerotic aortic aneurysm. Non-obstructive angioscopy is a new method for evaluating intimal injury over the whole aorta. It has been used to identify many advanced atherosclerotic plaques that were missed on traditional imaging modalities before aneurysm formation. Non-obstructive angioscopy has shown that atherosclerosis of the aorta begins before that of the coronary artery, which had been noted on autopsy “in vivo”. Strong or repetitive aortic injuries might cause sudden aortic disruption. Aortic atheroma is also a risk factor of stroke and perivascular embolism. Detecting aortic vulnerable atherosclerotic plaque on non-obstructive angioscopy may not only clarify the pathogenesis of acute aortic rupture and “aortogenic” thromboemboli and atheroemboli but also play a role in the pre-emptive medicine. (Circ J 2015; 79: 742–750)
Editorials
Original Articles
Cardiovascular Surgery
  • Tal Hasin, Yasushi Matsuzawa, Raviteja R. Guddeti, Tatsuo Aoki, Taek-G ...
    Type: ORIGINAL ARTICLE
    Subject area: Cardiovascular Surgery
    2015 Volume 79 Issue 4 Pages 770-777
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:Patients with heart failure (HF) have abnormal endothelial function. Although use of a continuous flow left ventricular assist device (CF-LVAD) results in significant hemodynamic improvement, the effects on systemic endothelial function are unclear.Methods and Results:Eighteen HF patients with CF-LVAD implantation were included in this prospective observational study. We measured reactive hyperemia index (RHI) before and after CF-LVAD implantation to evaluate sequential changes in endothelial function. Patients were followed clinically for the occurrence of adverse cardiovascular events, a composite of death, thrombosis, bleeding, HF, renal failure, and arrhythmia. Preoperative RHI was 1.77±0.39. Early in the postoperative period (7–14 days after operation) RHI significantly decreased to 1.19±0.31 (P<0.001, compared with preoperative RHI). At first and second follow-up (4–6 weeks and 3–7 months after operation) RHI remained lower at 1.48±0.50 (P=0.030) and 1.26±0.37 (P=0.002), respectively, compared with preoperative RHI. The decrease in early postoperative RHI relative to preoperative RHI was significantly associated with adverse cardiovascular events after CF-LVAD (age-adjusted risk ratio for 0.25 decrease in RHI, 1.35; 95% confidence interval: 1.13–1.62, P=0.001).Conclusions:Peripheral endothelial function had a significant and persistent decline up to 5 months following implantation of CF-LVAD, and this decline was associated with adverse cardiovascular events. These findings may provide insight into some of the vascular complications following CF-LVAD in HF patients. (Circ J 2015; 79: 770–777)
  • Min Suk Choi, Dong Seop Jeong, Hae Young Lee, Kiick Sung, Wook Sung Ki ...
    Type: ORIGINAL ARTICLE
    Subject area: Cardiovascular Surgery
    2015 Volume 79 Issue 4 Pages 778-784
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 09, 2015
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    Background:Ascending aorta wrapping is rarely recommended for the management of dilated aorta, because of late complications. The aim of the present study was to analyze the early and late outcomes of the aortic wrapping technique at the time of aortic valve replacement (AVR) for bicuspid aortic stenosis (BAS).Methods and Results:Among patients who underwent primary AVR for BAS between 2002 and 2011, 79 who underwent ascending aortic wrapping (wrapping group) were compared with 144 patients who underwent AVR alone. The preoperative ascending aortic diameters were larger in the wrapping group (40.9±4.2 mm vs. 48.6±4.0 mm, P<0.001). Operative technique was to wrap the ascending aorta transversely with a semi-elliptically resected Dacron graft. The follow-up for the wrapping group was 76.5±35.5 (median 71.1) months. There were no early deaths. Early and late morbidity did not differ between groups. The 24 late deaths, including 10 cardiac-related deaths, occurred in the entire group; 3 sudden deaths occurred only in the AVR group. The 10-year overall survival in the wrapping group was higher than the AVR group (88.1±6.8% vs. 80.0±4.6%, P=0.048). No late aortic complications were detected. The aortic diameter was reduced from 49.5±4.1 mm to 45.3±5.0 mm after wrapping (P<0.001).Conclusions:The aortic wrapping technique may be an option for treating a moderately dilated ascending aorta in selected patients undergoing AVR for BAS. Longer follow-up, however, is necessary to verify later complications. (Circ J 2015; 79: 778–784)
Heart Failure
  • Yuichi Nakamura, Hiroyuki Kunii, Akiomi Yoshihisa, Mai Takiguchi, Take ...
    Type: ORIGINAL ARTICLE
    Subject area: Heart Failure
    2015 Volume 79 Issue 4 Pages 785-793
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:The impact of peripheral artery disease (PAD) on heart failure (HF) prognosis remains unclear.Methods and Results:A total of 388 consecutive decompensated HF patients were divided into 2 groups based on the presence of PAD: HF with PAD (PAD group, n=101, 26.0%) and HF without PAD (non-PAD group, n=287, 74.0%). We compared clinical features, echocardiographic parameters, cardiopulmonary exercise testing results, laboratory findings, as well as cardiac, non-cardiac, and all-cause mortality between the 2 groups. The PAD group, as compared with the non-PAD group, had (1) higher prevalence of coronary artery disease (40.6 vs. 27.5%, P=0.011) and cerebrovascular disease (34.7 vs. 18.2%, P=0.001); (2) higher tumor necrosis factor-α (1.82 vs. 1.49 pg/ml, P=0.023), C-reactive protein (0.32 vs. 0.19 mg/dl, P=0.045), and troponin T (0.039 vs. 0.021 ng/ml, P=0.019); (3) lower LVEF (42.4 vs. 48.5%, P<0.001); (4) lower peak V̇O2(13.4 vs. 15.9 ml·kg–1·min–1, P=0.001); and (5) higher V̇E/V̇CO2slope (38.8 vs. 33.7, P<0.001). On Kaplan-Meier analysis, cardiac, non-cardiac, and all-cause mortality were significantly higher in the PAD group than in the non-PAD group (P<0.05, respectively). On Cox proportional hazard analysis after adjusting for confounding factors, PAD was an independent predictor of cardiac and all-cause mortality (P<0.05, respectively) in HF patients.Conclusions:PAD was common and an independent predictor of cardiac and all-cause mortality in HF patients. (Circ J 2015; 79: 785–793)
Hypertension and Circulatory Control
  • Terukazu Akiyama, Tatsuya Miyazaki, Hiroki Ito, Hirofumi Nogami, Eiji ...
    Type: ORIGINAL ARTICLE
    Subject area: Hypertension and Circulatory Control
    2015 Volume 79 Issue 4 Pages 794-801
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 05, 2015
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    Background:Because the conventional evaluation of autonomic nervous system (ANS) function inevitably uses long-lasting uncomfortable electrocardiogram (ECG) recording, a more simplified and comfortable analysis system has been sought for this purpose. The feasibility of using a portable micro-electromechanical system (MEMS) blood flowmeter to analyze heart rate variability (HRV) for evaluating ANS function was thus examined.Methods and Results:Measurements of the R-R interval (TRR) derived from an ECG, simultaneously with the pulse wave interval (TPP) derived from a MEMS blood flowmeter, in 8 healthy subjects was performed and resultant HRV variables in time and frequency domains were compared. The TRR- and TPP-derived variables were strongly correlated (coefficients of regression for low frequency (LF), high frequency (HF), and LF/HF of 1.1, 0.66, and 0.35, respectively; corresponding coefficients of determination of 0.92, 0.63, and 0.91, respectively (P<0.01)). In addition, the values of LF, HF, and LF/HF, as analyzed using TPP, changed significantly from the supine to the standing position in another 6 subjects.Conclusions:Miniaturized-MEMS blood flowmetry can be used to perform HRV analysis for the evaluation of ANS function, which is as accurate as analysis based on ECG within comparable tolerances. As MEMS blood flowmetry can more easily and comfortably record physiological variables for longer durations than ECG recording, and can further capture skin blood flow information, this device has great potential to be used in a wider area of physiological analyses. (Circ J 2015; 79: 794–801)
Imaging
  • Makoto Natsumeda, Gaku Nakazawa, Tsutomu Murakami, Sho Torii, Takeshi ...
    Type: ORIGINAL ARTICLE
    Subject area: Imaging
    2015 Volume 79 Issue 4 Pages 802-807
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 30, 2015
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    Background:Percutaneous coronary intervention (PCI) guided with fractional flow reserve (FFR) has been shown to improve clinical outcome. Although coronary angiography is the standard method for PCI guidance, the visual severity of stenosis is not always correlated with functional severity, suggesting that there are additional angiographic factors that affect functional ischemia.Methods and Results:To evaluate angiographic predictors of positive FFR in stenotic lesions, angiographic characteristics of 260 consecutive patients (362 lesions) who underwent FFR testing from April 2009 to September 2012 were analyzed. A scoring system (STABLED score) using these predictors was developed and compared with quantitative coronary angiography (QCA). %Diameter stenosis >50% (OR, 8.43; P<0.0001), tandem lesion (OR, 4.00; P<0.0001), true bifurcation (OR, 2.42; P=0.028), lesion length >20 mm (OR, 5.40; P=0.0002), and distance from ostium <20 mm (OR, 1.94; P=0.028) were determined as independent predictors of positive FFR. Area under the ROC curve for probability of positive FFR using the STABLED score (Stenosis 2 points, TAndem lesion 1 point, Bifurcation 1 point, LEsion length 1 point, Distance from ostium 1 point) was 0.85, higher than that for QCA stenosis alone (0.76). STABLED score ≥3 had 72.3% sensitivity and 83.6% specificity for predicting positive FFR, and PPV was 76.7%.Conclusions:Specific angiographic features are applicable for predicting functional ischemia. STABLED score correlates well with FFR. (Circ J 2015; 79: 802–807)
  • Yukio Ozaki, Masaya Ohota, Tevfik F. Ismail, Masanori Okumura, Masato ...
    Type: ORIGINAL ARTICLE
    Subject area: Imaging
    2015 Volume 79 Issue 4 Pages 808-817
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 13, 2015
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    Background:This study evaluated the ability of a newly developed integrated backscatter intravascular ultrasound (IB-IVUS) system (VISIWAVE, Terumo, Tokyo, Japan) to detect optical coherence tomography (OCT)-verified thin cap fibroatheroma (TCFA) and assessed the correlation with peri-procedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI).Methods and Results:One hundred culprit lesions in 100 consecutive patients with ischemic heart disease who consented to repeated IVUS and OCT prior to PCI were studied. Of 100 lesions, 48 had OCT-verified TCFA with a cap thickness <65 µm. Such lesions had larger percentage lipid area and lipid angle >2 quadrants on IB-IVUS. A lipid core abutting lumen (LCAL) was defined as a lipid core pool in the plaque area, directly contacting with the lumen regardless of its circumferential extension. IB-IVUS-identified TCFA defined as a combination of percentage lipid area ≥53.6%, remodeling index ≥1.03, and the presence of LCAL was the best predictor of OCT-verified TCFA with sensitivity, specificity, positive and negative predictive values, and accuracy of 72.9%, 90.4%, 87.5%, 78.3%, and 82.0%, respectively. IB-IVUS-identified TCFA as well as OCT-verified TCFA were significant independent predictors of PMI, after adjusting for other predictors on multivariate analysis.Conclusions:IB-IVUS can be used to identify plaques with a high prevalence of TCFA. Such techniques can therefore potentially be used to identify lesions with an elevated risk of PMI after PCI. (Circ J 2015; 79: 808–817)
Ischemic Heart Disease
  • Byung Jin Kim, Bum Soo Kim, Jin Ho Kang
    Type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2015 Volume 79 Issue 4 Pages 818-824
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 02, 2015
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    Background:Few studies have addressed the relationship between echocardiographic epicardial fat thickness (EFT) and coronary artery calcification in an apparently healthy Asian population, and those that have, are inconsistent.Methods and Results:A total of 2,299 individuals (1,871 men; mean age, 45±8.9 years) were enrolled in the CArdiometabolic risk, Epicardial fat, and Subclinical Atherosclerosis Registry (CAESAR) study and underwent CT for measurement of coronary artery calcium score (CACS) and echocardiography for EFT. According to EFT quartiles, the prevalence of CAC >0 was 8.3%, 16.8%, 24.6%, and 28.3% in the lowest, second, third, and highest EFT quartiles, respectively (P<0.001). On multivariate logistic regression after adjusting for variables with a univariate relationship (P<0.05), the second, third, and highest quartile groups of EFT had higher odds ratios (OR) for the presence of CAC compared with those of the lowest quartile (OR, 1.634; 95% confidence interval (CI): 0.940–2.839; 1.762, 1.019–3.048; and 1.924, 1.107–3.342, respectively), and the increase in absolute EFT was also independently associated with higher OR for the presence of CAC (1.842; 95% CI: 1.057–3.208, P=0.031). Moreover, increasing absolute EFT was associated with increasing CACS on multivariate linear regression (standardized β=0.081, P=0.005).Conclusions:There was an independent relationship between EFT and coronary artery calcification in Korean adults, suggesting that echocardiographic EFT might be an easily accessible tool for early detection of subclinical coronary atherosclerosis. (Circ J 2015; 79: 818–824)
  • Alessia Faccini, Eustachio Agricola, Michele Oppizzi, Alberto Margonat ...
    Type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2015 Volume 79 Issue 4 Pages 825-829
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 06, 2015
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    Background:This observational study was designed to evaluate the prevalence of coronary microvascular dysfunction (CMD) in asymptomatic patients affected by systemic sclerosis (SSc), stratifying the results according to the limited (lcSSc) and the diffuse (dcSSc) forms of the disease.Methods and Results:We enrolled 19 consecutive asymptomatic patients with dcSSc (n=7) or lcSSc (n=12). In all subjects, coronary flow reserve (CFR) was assessed by measuring diastolic coronary flow velocities in the left anterior descending artery by pulsed wave Doppler at baseline and after dipyridamole infusion (0.84 mg·kg−1·6 min−1). Wall motion score index was evaluated at baseline and during stress. We enrolled 20 healthy subjects as controls. Mean CFR was 1.96±0.62 in patients and 2.69±0.47 in controls (P<0.001). Abnormal values of CFR (≤2) were significantly more prevalent in patients than in controls (10/19 vs. 0/20; P<0.001) and in the dcSSc subgroup than in the lcSSc subgroup (6/7 vs. 4/12; P=0.05). An inverse relationship between disease duration (from time of onset of Raynaud’s phenomenon) and CFR value was observed in the lcSSc group (correlation coefficient −0.583; P=0.046). Neither patients nor controls had wall motion abnormalities during dipyridamole administration.Conclusions:A blunted CFR, most likely because of CMD, is more frequent in patients affected by the dcSSc form in the early stages of the disease, whereas it seems to appear later in lcSSc. (Circ J 2015; 79: 825–829)
Molecular Cardiology
  • Fumihiko Takeuchi, Masato Isono, Ken Yamamoto, Mitsuhiro Yokota, Koich ...
    Type: ORIGINAL ARTICLE
    Subject area: Molecular Cardiology
    2015 Volume 79 Issue 4 Pages 830-838
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: February 05, 2015
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    Background:A coronary artery disease (CAD) association study of genetic loci previously identified as being associated with blood pressure (BP) was performed in east Asian populations.Methods and Results:Nine single nucleotide polymorphisms (SNPs) from 9 candidate loci robustly confirmed to be associated with BP in east Asian people, were genotyped. Genotyping was done in up to 17,785 CAD case-control samples (6,522 cases and 11,263 controls). We then tested the associations with other metabolic traits (n≤17,900) and with type 2 diabetes (931 cases and 1,404 controls), and looked up the datasets in silico in other populations. Significant (adjusted P<0.05) CAD associations were found for 5 BP loci: 3 new CAD associations atFIGN,FGF5andNPR3, and 2 previously reported ones atATP2B1andCNNM2. The strongest CAD association was detected atATP2B1rs2681472 (P=1.7×10–8), in the direction inverted to what is generally recognized for BP in the epidemiological studies.CNNM2rs12413409 showed significant association with CAD (P=8.7×10–7) and BMI (P=3.5×10–8, when meta-analyzed with 75,807 east Asian people). The genetic risk score combining BP-raising alleles at each of the SNPs was positively associated with CAD (P=0.011).Conclusions:A substantial proportion of genetic variants associated with BP were also associated with the risk of CAD in east Asian people, and there was some counter-evidence for causal inference. (Circ J 2015; 79: 830–838)
Myocardial Disease
  • Tetsuma Kawaji, Hiroki Shiomi, Takeshi Morimoto, Junichi Tazaki, Masao ...
    Type: ORIGINAL ARTICLE
    Subject area: Myocardial Disease
    2015 Volume 79 Issue 4 Pages 839-846
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:A hyperdynamic state of the basal left ventricle sometimes results in obstruction of the left ventricular outflow tract (LVOT). However, the prevalence, clinical presentation, and prognostic effect of LVOT obstruction in takotsubo cardiomyopathy (TC) have not been fully evaluated.Methods and Results:Among 933 consecutive patients who underwent emergency coronary angiography for suspected acute coronary syndrome, 35 patients (3.8%) were diagnosed as TC. The cumulative 3-year incidence of all-cause death, cardiac death, hospitalization for congestive heart failure (CHF), and recurrent TC was 24.2%, 0.0%, 6.5%, and 12.2%, respectively. Among 27 patients with information of a LVOT pressure gradient, LVOT obstruction was present in 9 (33%). The prevalence of moderate to severe mitral regurgitation (67% vs. 11%, P=0.003), CHF (78% vs. 28%, P=0.02), and hypotension (56% vs. 5.6%, P=0.008) was significantly higher in patients with LVOT obstruction than in those without. Nevertheless, the cumulative 3-year incidence of all-cause death was not significantly different between the 2 groups (49.2% vs. 23.0%, P=0.22) with no cardiac deaths in either group. Hospitalization for CHF and recurrent TC were significantly more frequent in patients with LVOT obstruction (25.0% vs. 0.0%, P=0.04, and 25.0% vs. 6.7%, P=0.02).Conclusions:In 35 consecutive patients with TC, those with significant LVOT obstruction (33%) had a more serious clinical presentation such as CHF and hypotension, but had similar 3-year mortality rate as compared with those without. (Circ J 2015; 79: 839–846)
  • Tatsuya Kawasaki, Kuniyasu Harimoto, Sakiko Honda, Yoshimi Sato, Michi ...
    Type: ORIGINAL ARTICLE
    Subject area: Myocardial Disease
    2015 Volume 79 Issue 4 Pages 847-853
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:Patients with hypertrophic cardiomyopathy (HCM) sometimes develop myocardial fibrosis in association with adverse cardiovascular events. Electrocardiography (ECG) could provide helpful information on myocardial fibrosis in HCM, as in coronary artery disease.Methods and Results:A total of 60 patients with HCM without bundle branch block underwent cardiac magnetic resonance imaging (CMR). The extent or location of late gadolinium enhancement (LGE) was examined in relation to 12-lead ECG. A notch on QRS was defined as at least 2 consecutive spikes in the same polarity with a reversal of direction ≥90° and the initial negative deflection ≥0.05 mV. LGE was associated with notched QRS, leftward QRS axis, and prolonged QRS duration, but not with any other findings such as abnormal Q waves, R-wave amplitude, or ST-T changes. Notched QRS was most useful in determining the presence or absence of myocardial fibrosis, with a sensitivity of 70% and a specificity of 81% using a cut-off of the number of leads with notched QRS ≥2. The number of notched QRS leads was positively correlated with LGE volume (P<0.01) and the lead distribution of notched QRS was informative about the location of LGE.Conclusions:A notch on QRS was useful in estimating myocardial fibrosis as assessed on CMR LGE in HCM patients without bundle branch block. (Circ J 2015; 79: 847–853)
Pediatric Cardiology and Adult Congenital Heart Disease
  • Takekazu Miyoshi, Yasuki Maeno, Haruhiko Sago, Noboru Inamura, Satoshi ...
    Type: ORIGINAL ARTICLE
    Subject area: Pediatric Cardiology and Adult Congenital Heart Disease
    2015 Volume 79 Issue 4 Pages 854-861
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:Because there is limited information on fetal bradyarrhythmia associated with congenital heart defects (CHD), we investigated its prognosis and risk factors.Methods and Results:In our previous nationwide survey of fetal bradyarrhythmia from 2002 to 2008, 38 fetuses had associated CHD. Detailed clinical data were collected from secondary questionnaires on 29 fetuses from 18 institutions, and were analyzed. The 29 fetuses included 22 with isomerism, 4 with corrected transposition of the great arteries (TGA) and 3 with critical pulmonary stenosis; 14 had complete atrioventricular block (AVB), 8 had second-degree AVB, and 16 had sick sinus syndrome; 5 died before birth, and 10 died after birth (5 in the neonatal period). Neonatal and overall survival rates for fetal bradyarrhythmia with CHD were 66% and 48%, respectively. Pacemaker implantation was needed in 17 cases (89%). Beta-sympathomimetics were administered in utero in 13 cases and were effective in 6, but were not associated with prognosis. All cases of corrected TGA or ventricular rate ≥70 beats/min survived. A ventricular rate <55 beats/min had significant effects on fetal myocardial dysfunction (P=0.02) and fetal hydrops (P=0.04), resulting in high mortality.Conclusions:The prognosis of fetal bradyarrhythmia with CHD is still poor. The type of CHD, fetal myocardial dysfunction, and fetal hydrops were associated with a poor prognosis, depending on the ventricular rate. (Circ J 2015; 79: 854–861)
Stroke
  • Eiichi Nomura, Tomohiko Ohshita, Eiji Imamura, Shinichi Wakabayashi, H ...
    Type: ORIGINAL ARTICLE
    Subject area: Stroke
    2015 Volume 79 Issue 4 Pages 862-866
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 23, 2015
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    Background:This study evaluated the rates of new lesions on diffusion-weighted images (DWIs) of magnetic resonance imaging (MRI) and hemorrhagic transformation (HT) during 2 weeks after acute ischemic stroke (AIS) in patients with atrial fibrillation (Af) who were given one of the non-vitamin K antagonist oral anticoagulants (NOACs); this was then compared with those who were given warfarin.Methods and Results:Consecutive AIS patients with Af were enrolled between January 2008 and June 2013, and those selected were patients who had a MRI that included DWIs both on admission and after 2 weeks, and those given only wafrarin (warfarin group) or only one of the NOACs (NOAC group) within 2 weeks of admission. Of all 257 enrolled patients, 50 patients were selected for the NOAC group (median age of 80.0 years) and 125 patients for the warfarin group (median age of 80.0 years). Both NOAC and warfarin were started at a median of the second day after admission. There was no significant difference in the rates of new lesions on DWIs (26.0% vs. 28.0%, P=0.7888) and HT (30.0% vs. 39.2%, P=0.2536) between the NOAC and warfarin groups. The NOAC group had a lower rate of concomitant use of heparin (44.0% vs. 92.8%, P<0.0001) than the warfarin group.Conclusions:This study suggests that NOACs are suitable for AIS patients with Af, perhaps even better than warfarin, given their simplicity. (Circ J 2015; 79: 862–866)
Valvular Heart Disease
  • Reiko Mizuno, Shin-taro Yamagami, Tsukimi Higashi, Yasuki Nakada, Yuki ...
    Type: ORIGINAL ARTICLE
    Subject area: Valvular Heart Disease
    2015 Volume 79 Issue 4 Pages 867-872
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 28, 2015
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    Background:Inflammatory processes are suggested to play a pathogenic role in the development and progression of non-rheumatic aortic stenosis (AS). Major surgery causes an inflammatory reaction. With the increasing prevalence of non-rheumatic AS, the number of affected patients undergoing major surgery increases. We hypothesized that major non-cardiac surgery (MNCS) could accelerate the progression of non-rheumatic AS.Methods and Results:We enrolled 218 consecutive patients with non-rheumatic AS who underwent transthoracic echocardiography (TTE) at least twice more than 6 months apart. Study patients were divided into the MNCS group and the non-MNCS group. The MNCS group consisted of patients who underwent MNCS during the TTE follow-up interval. At baseline, peak pressure gradient across the aortic valve (AVG) was similar between the groups. Also baseline clinical characteristics and TTE follow-up interval were similar. The annual rate of peak AVG increase was much higher in the MNCS group than in the non-MNCS group. The proportion of patients with rapid hemodynamic progression was much higher in the MNCS group than in the non-MNCS group. Multiple logistic regression analysis showed that MNCS was an independent predictor of rapid hemodynamic progression of non-rheumatic AS.Conclusions:The present study indicates for the first time that MNCS is associated with the rapid progression of non-rheumatic AS. (Circ J 2015; 79: 867–872)
  • Hiroyuki Nishi, Koichi Toda, Shigeru Miyagawa, Yasushi Yoshikawa, Sats ...
    Type: ORIGINAL ARTICLE
    Subject area: Valvular Heart Disease
    2015 Volume 79 Issue 4 Pages 873-879
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 30, 2015
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    Background:Little is known about the impact of tricuspid annuloplasty (TAP) on annular dynamics. We assessed tricuspid annular dynamics using 3-D transesophageal echocardiography (3D-TEE) before and after TAP with different types of prosthetic ring.Methods and Results:3D-TEE of the tricuspid valve was acquired in 30 patients (TAP with rigid ring [RR], n=8; TAP with flexible ring [FR], n=10; control, n=12). Tricuspid annular dimensions (circumference, area, annular height, anteroposterior [AP], septolateral [SL] diameter) were measured throughout the cardiac cycle. All postoperative tricuspid annular dimension parameters were significantly reduced by TAP, while the AP/SL ratio was significantly increased (before, 0.96±0.16; after, 1.03±0.06; P<0.05). The difference in annular area between diastole and systole was significantly smaller in the TAP groups (11.6%) than in the control (27.9%, P<0.05). Annular height in the FR patients was significantly lower than in the RR group, while the postoperative AP/SL ratio was lower in the RR than the FR and control groups. Change in annular area was not seen in RR patients, while it was seen in the FR and control groups.Conclusions:Annulus motion and shape differ according to the type of prosthetic ring used, although tricuspid regurgitation was well controlled by all types of ring utilized. The present results provide important information for selection of an appropriate prosthetic ring for TAP. (Circ J 2015; 79: 873–879)
Vascular Biology and Vascular Medicine
  • Soon Jun Hong, Seung Cheol Choi, Jae Young Cho, Hyung Joon Joo, Jae Hy ...
    Type: ORIGINAL ARTICLE
    Subject area: Vascular Biology and Vascular Medicine
    2015 Volume 79 Issue 4 Pages 880-888
    Published: March 25, 2015
    Released: March 25, 2015
    [Advance publication] Released: January 26, 2015
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    Background:Aberrant expression of microRNAs is associated with neointimal hyperplasia (NIH) in type 2 diabetes. We prospectively compared the effects of pioglitazone on coronary NIH and changes in microRNAs according to NIH status in type 2 diabetic patients during 9-month follow-up.Methods and Results:Type 2 diabetic patients were randomly assigned to the pioglitazone (n=36) or control groups (n=36) after coronary stenting. Primary endpoint was the comparison of changes in neointimal volume on OCT and in the level of circulating microRNA-17,-24,-92a,-126 and -145 during 9-month follow-up. Secondary endpoint was the comparison of changes in brachial artery flow-mediated dilation and inflammatory markers such as IL-6, TNF-α, hsCRP, adiponectin, sICAM-1, and sVCAM-1 between the 2 groups. Neointimal volume was significantly lower in the pioglitazone group (25.02±17.78 mm3vs. 55.10±30.01 mm3, P<0.001) with significant increases in circulating microRNA-24 (0.264±0.084 vs. 0.006±0.030, P<0.001) during follow-up. FMD was significantly greater in the pioglitazone than control group at 9 months (0.47±0.14 mm vs. 0.28±0.18 mm, P<0.05, respectively). Decreases in inflammatory markers such as IL-6, TNF-α, and sVCAM-1 were significantly greater in the pioglitazone than the control group during the follow-up.Conclusions:Pioglitazone significantly decreased NIH with increases in circulating microRNA-24 at 9-month follow-up. The decrease in microRNA-24 could be used as a potential predictor of increases in NIH in type 2 diabetic patients. (Circ J 2015; 79: 880–888)
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