Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 80 , Issue 8
Showing 1-42 articles out of 42 articles from the selected issue
Message From the Editor-in-Chief
Reviews
  • Yee-Ping Sun, Shunichi Homma
    Type: REVIEW
    2016 Volume 80 Issue 8 Pages 1665-1673
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 22, 2016
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    A patent foramen ovale (PFO) is common and found in nearly 25% of healthy individuals. The majority of patients with PFO remain asymptomatic and they are not at increased risk for developing a stroke. The presence of PFO, however, has been found to be higher in patients with cryptogenic stroke, suggesting there may be a subset of patients with PFO who are indeed at risk for stroke. Paradoxical embolization of venous thrombi through the PFO, which then enter the arterial circulation, is hypothesized to account for this relationship. Although aerated-saline transesophageal echocardiography is the gold standard for diagnosis, aerated-saline transthoracic echocardiography and transcranial Doppler are often used as the initial diagnostic tests for detecting PFO. Patients with cryptogenic stroke and PFO are generally treated with antiplatelet therapy in the absence of another condition for which anticoagulation is necessary. Based on the findings of 3 large randomized clinical trials, current consensus guidelines do not recommend percutaneous closure, though this is an area of controversy. The following review discusses the relationship of PFO and cryptogenic stroke, focusing on the epidemiology, pathophysiological mechanisms, diagnostic tools, associated clinical/anatomic factors and treatment. (Circ J 2016; 80: 1665–1673)

  • Sasha A. Singh, Elena Aikawa, Masanori Aikawa
    Type: REVIEW
    2016 Volume 80 Issue 8 Pages 1674-1683
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: July 14, 2016
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    The use of mass spectrometry (MS)-dependent protein research is increasing in the cardiovascular sciences. A major reason for this is the versatility of and ability for MS technologies to accommodate a variety of biological questions such as those pertaining to basic research and clinical applications. In addition, mass spectrometers are becoming easier to operate, and require less expertise to run standard proteomics experiments. Nonetheless, despite the increasing interest in proteomics, many non-expert end users may not be as familiar with the variety of mass spectrometric tools and workflows available to them. We therefore review the major strategies used in unbiased and targeted MS, while providing specific applications in cardiovascular research. Because MS technologies are developing rapidly, it is important to understand the core concepts, strengths and weaknesses. Most importantly, we hope to inspire the further integration of this exciting technology into everyday research in the cardiovascular sciences. (Circ J 2016; 80: 1674–1683)

  • Chizuko A. Kamiya, Jun Yoshimatsu, Tomoaki Ikeda
    Type: REVIEW
    2016 Volume 80 Issue 8 Pages 1684-1688
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: July 06, 2016
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    Peripartum cardiomyopathy (PPCM) is a rare, but life-threatening condition that occurs during the peripartum period in previously healthy women. Although its etiology remains unknown, potential risk factors include hypertensive disorders during pregnancy, such as preeclampsia, advanced maternal age, multiparity, multiple gestation, and African descent. Several cohort studies of PPCM revealed that the prevalence of these risk factors was quite similar. Clinically, approximately 40% of PPCM patients are complicated with hypertensive disorders during pregnancy. Because PPCM is a diagnosis of exclusion, heterogeneity is a common element in its pathogenesis. Recent genetic research has given us new aspects of the disease. PPCM and dilated cardiomyopathy (DCM) share genetic predisposition: 15% of PPCM patients were found to have genetic mutations that have been associated with DCM, and they showed a lower recovery rate. Other basic research using PPCM model mice suggests that predisposition genes related to both hypertensive and cardiac disorders via angiogenic imbalance may explain common elements of hypertensive disorders and PPCM. Furthermore, hypertensive disorders during pregnancy are now found to be a risk factor of not only PPCM, but also cardiomyopathy in the future. Understanding genetic variations allows us to stratify PPCM patients and to guide therapy. (Circ J 2016; 80: 1684–1688)

2016 JCS Report
Editorials
Original Articles
Aortic Disease
  • Mayu Sakata, Yasuo Takehara, Kazuto Katahashi, Masaki Sano, Kazunori I ...
    Type: ORIGINAL ARTICLE
    Subject area: Aortic Disease
    2016 Volume 80 Issue 8 Pages 1715-1725
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 29, 2016
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    Supplementary material

    Background:An endoleak is a common complication of endovascular abdominal aortic aneurysm repair (EVAR), and it can be associated with aneurysmal growth. This pilot study used 4-dimensional flow-sensitive magnetic resonance imaging (4D-flow) to assess the hemodynamics of different types of endoleaks (I–IV).

    Methods and Results:Magnetic resonance angiography, 4D-flow, and computed tomography angiography (CTA) were performed in 31 patients after nitinol-based stent-graft deployment. With 4D-flow, the 3D streamlines of endoleaks appear as integrated traces along the instantaneous velocity vector field that are color-coded according to the local velocity magnitude of the leak. The 4D-flow analysis identified endoleaks in 18 patients (58.1%), whereas CTA identified endoleaks in 13 patients (41.9%). The 4D-flow analysis created a characteristic image of each type of endoleak. Among patients with endoleaks, 4D-flow identified concomitant multiple endoleaks in 7 (39%) patients, and it further differentiated type II endoleaks from type IIa endoleaks (to-and-fro biphasic flow pattern from a branch vessel) and from type IIb endoleaks (monophasic flow pattern with a connection between the inflow and outflow branches).

    Conclusions:The 4D-flow analysis was more sensitive than CTA for detecting an endoleak, and it could subclassify type II endoleaks. In addition, 4D-flow differentiated between concomitant endoleak types in a single patient. (Circ J 2016; 80: 1715–1725)

Arrhythmia/Electrophysiology
  • Weng-Chio Tam, Yung-Kuo Lin, Wing-Pong Chan, Jen-Hung Huang, Ming-Hsiu ...
    Type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2016 Volume 80 Issue 8 Pages 1726-1733
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 13, 2016
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    Background:Pericardial fat is correlated with the occurrence of atrial fibrillation or coronary atherosclerosis. However, the role of pericardial fat in ventricular arrhythmia remains unclear.

    Methods and Results:Patients who had undergone dual-source computed tomography and 24-h Holter ECG were retrospectively enrolled. Quantification of the volume of pericardial fat surrounding the ventricles was analyzed using threshold attenuation of dual-source CT. The volume of pericardial fat was significantly different among those without ventricular premature beats (VPBs) in 24 h (n=28), those with occasional VPBs (n=54) and those with frequent VPBs (n=34) (12.5±6.1 cm3vs. 14±8.9 cm3vs. 29.9±17.3 cm3, P<0.001). In addition, the number of VPBs strongly correlated with the volume of total pericardial fat (R=0.501, P<0.001), right ventricular (RV) pericardial fat (R=0.539, P<0.001), and left ventricular pericardial fat (R=0.376, P<0.001). Multivariate logistic regression analysis showed that quartiles of RV localized pericardial fat significantly increased the risk of frequent VPBs (OR=3.2, P=0.047). Moreover, the number of VPBs in 24 h was significantly different among the patients with a fat volume within the 25th percentile, 25–75th percentile and 75th percentile.

    Conclusions:Pericardial fat (especially RV pericardial fat) was associated with the frequency of VPBs, which suggests the arrhythmogenic potential of ventricular pericardial fat. (Circ J 2016; 80: 1726–1733)

  • Akira Ueoka, Hiroshi Morita, Atsuyuki Watanabe, Koji Nakagawa, Nobuhir ...
    Type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2016 Volume 80 Issue 8 Pages 1734-1743
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 20, 2016
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    Supplementary material

    Background:Clinical and experimental studies have shown the existence of an arrhythmogenic substrate in the right ventricular outflow tract (RVOT) in patients with Brugada syndrome (BrS). To evaluate the importance of the RVOT, we evaluated the activation pattern of induced ventricular tachyarrhythmias using body surface mapping (BSM) in patients with BrS.

    Methods and Results:We examined 14 patients with BrS in whom ventricular tachyarrhythmias were induced by programmed electrical stimulation. The 87-lead BSM was recorded during induced ventricular tachyarrhythmias, and an activation map and an isopotential map of QRS complexes every 5 ms were constructed to evaluate the activation pattern of ventricular tachyarrhythmias. BSM during 20 episodes of ventricular tachyarrhythmias induced at the RVOT showed that repetitive excitation was generated at the RVOT and propagated to the inferior RV and left ventricle, and then returned to the RVOT. Polymorphic QRS change during ventricular tachyarrhythmias was associated with migration of the earliest activation site and rotor. BSM during 4 episodes of ventricular fibrillation (VF) showed that the excitation front moved randomly with formation of multiple wavefronts.

    Conclusions:Programmed stimulation initiated repetitive firing from the RVOT. Migration and competition of the earliest activation site and rotor and local conduction delay changed the QRS morphology. Degeneration of the reentrant circuit into multiple wavefronts resulted in VF. (Circ J 2016; 80: 1734–1743)

  • Ken Okumura, Kazuo Matsumoto, Yoshinori Kobayashi, Akihiko Nogami, Rob ...
    Type: ORIGINAL ARTICLE
    Subject area: Arrhythmia/Electrophysiology
    2016 Volume 80 Issue 8 Pages 1744-1749
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 30, 2016
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    Supplementary material

    Background:Outcomes of cryoballoon ablation for paroxysmal atrial fibrillation (PAF) have been reported in the Western countries but not in Japan. The CRYO-Japan PMS study was a single-arm, observational, multicenter, prospective study of the 2nd-generation cryoballoon Arctic Front AdvanceTM. We evaluated device- and procedure-related complications and clinical outcomes at 6 months.

    Methods and Results:The 616 patients (male, 72%; mean age, 63±11 years) were enrolled from 33 Japanese hospitals. Of all patients, 610 had PAF, and procedural data were analyzed in 607. A subset of 328 patients was followed for 6 months for the primary efficacy analysis. AF recurrence outside the 3-month blanking period or repeat ablation was considered treatment failure. Pulmonary vein isolation was achieved in 606/607 patients (99.8%); 1 patient (0.3%) had a repeat ablation during the blanking period. Freedom from AF at 6 months was 88.4% (95% CI: 84.1–91.6%). Device- and/or procedure-related adverse events included phrenic nerve injury unresolved at hospital discharge in 9/616 patients (1.5%), which resolved within 6 months in 7, pericardial effusion in 5/616 (0.8%), and tamponade in 4/616 (0.6%). One non-device-related death from pneumonia was reported 6 days post-procedure.

    Conclusions:Cryoballoon ablation is safe and effective for Japanese PAF patients, with 88.4% AF freedom at 6 months post-ablation. (Circ J 2016; 80: 1744–1749)

Cardiac Rehabilitation
  • Tetsuo Arakawa, Leon Kumasaka, Michio Nakanishi, Masatoshi Nagayama, H ...
    Type: ORIGINAL ARTICLE
    Subject area: Cardiac Rehabilitation
    2016 Volume 80 Issue 8 Pages 1750-1755
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 30, 2016
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    Background:The regional clinical alliance path (RCAP) after discharge from an acute-phase hospital is emerging as a tool for bridging acute-phase treatment and chronic-phase disease management. However, the optimal application of RCAP for acute myocardial infarction (AMI) remains unknown in Japan, and therefore a nationwide survey of hospitals was conducted.

    Methods and Results:In 2009, questionnaires were sent to 1,240 cardiology training hospitals authorized by the Japanese Circulation Society. The response rate was 62.9% (780/1,240). Of the 780 responding hospitals, 708 treated AMI, and in these hospitals the number of AMI patients and percutaneous coronary intervention (PCI) procedures performed were, respectively, 59±52 and 200±206 per year. The implementation rate of emergency PCI was high (91%), but that of outpatient cardiac rehabilitation (OPCR) was very low (18%). The implementation rate of RCAP after AMI was significantly lower (10%) than after stroke (57%). Cardiac rehabilitation (CR) was adopted as part of RCAP in only 19% (13/70) of currently operating RCAP programs.

    Conclusions:This first Japanese nationwide survey of RCAP after AMI showed that in contrast to the broad dissemination of acute-phase invasive treatment for AMI, there was infrequent implementation of OPCR, RCAP after AMI, and RCAP including CR. It will be necessary to broaden the use of RCAP after AMI, including OPCR. (Circ J 2016; 80: 1750–1755)

Cardiovascular Surgery
  • Satoshi Itoh, Naoyuki Kimura, Hideo Adachi, Atsushi Yamaguchi
    Type: ORIGINAL ARTICLE
    Subject area: Cardiovascular Surgery
    2016 Volume 80 Issue 8 Pages 1756-1763
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 23, 2016
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    Supplementary material

    Background:Although bilateral internal mammary artery (BIMA) grafting is performed with increasing regularity in elderly patients, whether it is truly beneficial, and therefore indicated, in these patients remains uncertain. We retrospectively investigated early and late outcomes of BIMA grafting in patients aged ≥75 years.

    Methods and Results:We identified 460 patients aged ≥75 years from among 2,618 patients who underwent either single internal mammary artery (SIMA) grafting (n=293) or BIMA grafting (n=107). Early outcomes did not differ between the SIMA and BIMA patients (30-day mortality: 1.7% vs. 0%, P=0.39; sternal wound infection: 1.0% vs. 4.7%; P=0.057). Late outcomes, 10-year survival in particular, were improved in the BIMA group (36.6% vs. 48.1%, P=0.033). In the analysis of the results in propensity score-matched groups (196 patients in the SIMA group, 98 patients in the BIMA group), improved 10-year survival was documented in the BIMA group (34.8% vs. 47.6%, P=0.030). Cox proportional regression analysis showed SIMA usage (non-use of BIMA) to be a predictor for late mortality (hazard ratio: 0.65, 95% confidence interval: 0.43–0.98, P=0.042). We further compared outcomes between the total non-elderly patients (n=2,158) and total elderly patients (n=460). BIMA usage was similar, as was 30-day mortality (1.0% vs. 1.3%, respectively).

    Conclusions:A survival advantage, with no increase in early mortality, can be expected from BIMA grafting in patients aged ≥75 years. (Circ J 2016; 80: 1756–1763)

Critical Care
  • Kenji Nakatsuma, Hiroki Shiomi, Takeshi Morimoto, Yutaka Furukawa, Yos ...
    Type: ORIGINAL ARTICLE
    Subject area: Critical Care
    2016 Volume 80 Issue 8 Pages 1764-1772
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 28, 2016
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    Supplementary material

    Background:Inter-facility transfer for primary percutaneous coronary intervention (PCI) from referring facilities to PCI centers causes a significant delay in treatment of ST-segment elevation acute myocardial infarction (STEMI) patients undergoing primary PCI. However, little is known about the clinical outcomes of STEMI patients undergoing inter-facility transfer in Japan.

    Methods and Results:In the CREDO-Kyoto acute myocardial infarction (AMI) registry that enrolled 5,429 consecutive AMI patients in 26 centers in Japan, the current study population consisted of 3,820 STEMI patients who underwent primary PCI within 24 h of symptom onset. We compared long-term clinical outcomes between inter-facility transfer patients and those directly admitted to PCI centers. The primary outcome measure was a composite of all-cause death or heart failure (HF) hospitalization. There were 1,725 (45.2%) inter-facility transfer patients, and 2,095 patients (54.8%) with direct admission to PCI centers. The cumulative 5-year incidence of death/HF hospitalization was significantly higher in the inter-facility transfer patients than in those with direct admission (26.9% vs. 22.2%; log-rank P<0.001). After adjusting for potential confounders, the risk for death/HF hospitalization was significantly higher (adjusted hazard ratio: 1.22, 95% confidence interval: 1.07–1.40, P<0.001) in the inter-facility transfer patients than in those directly admitted.

    Conclusions:Inter-facility transfer was associated with significantly worse long-term clinical outcomes for patients with STEMI undergoing primary PCI. (Circ J 2016; 80: 1764–1772)

Heart Failure
  • Hideaki Suzuki, Yasuharu Matsumoto, Hideki Ota, Koichiro Sugimura, Jun ...
    Type: ORIGINAL ARTICLE
    Subject area: Heart Failure
    2016 Volume 80 Issue 8 Pages 1773-1780
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 07, 2016
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    Supplementary material

    Background:Depressive symptoms and memory impairment are prevalent in patients with chronic heart failure (CHF). Although the mechanisms remain to be elucidated, the hippocampus (an important brain area for emotion and memory) may be a possible neural substrate for these symptoms.

    Methods and Results:We prospectively enrolled 40 Stage C patients, who had past or current CHF symptoms, and as controls 40 Stage B patients, who had structural heart disease but had never had CHF symptoms, in Brain Assessment and Investigation in Heart Failure Trial (B-HeFT) (UMIN000008584). As the primary index, we measured cerebral blood flow (CBF) in the 4 anterior-posterior segments of the hippocampus, using brain MRI analysis. Depressive symptoms, immediate memory (IM) and delayed memory (DM) were assessed using Geriatric Depression Scale (GDS), and Wechsler Memory Scale-revised (WMS-R), respectively. Hippocampus CBF in the most posterior segment was significantly lower in Stage C than in Stage B group (P=0.029 adjusted for Holm’s method). Multiple regression analysis identified significant association between hippocampus CBF and GDS or DM score in Stage C group (all P<0.05). GDS score was significantly higher, and IM and DM scores were lower in Stage C patients with hippocampus CBF below the median than those with hippocampus CBF above the median (all P<0.05).

    Conclusions:Hippocampus abnormalities are associated with depressive symptoms and cognitive impairment in CHF patients. (Circ J 2016; 80: 1773–1780)

    Editor’s picks

    Circulation Journal Awards for the Year 2016
    Second Place in the Clinical Investigation Section

Hypertension and Circulatory Control
  • Takeshi Ideguchi, Toshihiro Tsuruda, Yuji Sato, Kazuo Kitamura
    Type: ORIGINAL ARTICLE
    Subject area: Hypertension and Circulatory Control
    2016 Volume 80 Issue 8 Pages 1781-1786
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 13, 2016
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    Background:Atrial standstill is one of the important clinical consequences on the heart in severe hyperkalemia, but it occurs even at modest potassium ion elevation. The extent to which other factors might potentiate the electrocardiographic changes induced by hyperkalemia remains unclear.

    Methods and Results:This was a retrospective review of the data on 12,639 hospital admissions over a 15-year period. A total of 778 patients with hyperkalemia were identified, 28 of whom had atrial standstill, and had several parameters measured prior to any treatment of hyperkalemia. Patients with atrial standstill were older (P=0.036), had lower diastolic blood pressure (DBP; P<0.0001) and serum sodium concentration (P<0.0001), higher serum potassium (P<0.0001), and high prevalence of angiotensin converting-enzyme inhibitor (ACEI; P=0.009) or mineral corticoid receptor (MR)-blocker (P=0.006), compared with those without atrial standstill. On multivariate logistic regression, DBP <67 mmHg (P=0.006), serum sodium ion <135 mmol/L (P=0.006) and serum potassium ion >6.1 mmol/L (P=0.018) were identified as independent indicators of atrial standstill, after adjusting for sex, age, chronic maintenance hemodialysis, diuretics use or ACEI/angiotensin receptor blocker and MR blocker.

    Conclusions:Hyponatremia and decline in DBP are associated with atrial standstill in patients with hyperkalemia. (Circ J 2016; 80: 1781–1786)

  • Kazuki Shiina, Hirofumi Tomiyama, Yoshifumi Takata, Chisa Matsumoto, M ...
    Type: ORIGINAL ARTICLE
    Subject area: Hypertension and Circulatory Control
    2016 Volume 80 Issue 8 Pages 1787-1794
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 15, 2016
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    Background:Recent studies have shown that visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular disease. However, it has not been clarified whether obstructive sleep apnea (OSA) is associated with visit-to-visit BPV.

    Methods and Results:The 56 subjects with OSA and 26 control subjects without OSA were examined. Office BP was measured on 5 separate consecutive occasions prior to a polysomnography examination. The visit-to-visit BPV was expressed as the standard deviation and the coefficient of variation of the 5 systolic BP measurements. In subjects with an apnea-hypopnea index (AHI) of more than 20 episodes per hour, the visit-to-visit BPV was also measured after the start of continuous positive airway pressure (CPAP) therapy. Overall, the AHI positively correlated with the standard deviation and the coefficient of variation of systolic BP. In a multivariate analysis, the plasma noradrenaline level and the AHI were independently and positively correlated with the standard deviation and the coefficient of variation of the systolic BP. Among the patients who underwent CPAP therapy, good adherence with CPAP therapy significantly reduced the visit-to-visit BPV.

    Conclusions:OSA is associated with abnormal visit-to-visit BPV and sympathetic activation seems to be related in some way. (Circ J 2016; 80: 1787–1794)

Imaging
  • Samer S. Merchant, Yasuhiro Kosaka, H. Joseph Yost, Edward W. Hsu, Luc ...
    Type: ORIGINAL ARTICLE
    Subject area: Imaging
    2016 Volume 80 Issue 8 Pages 1795-1803
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 15, 2016
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    Supplementary material

    Background:Ventricular non-compaction is characterized by a thin layer of compact ventricular myocardium and it is an important abnormality in the mouse heart. It is reminiscent of left ventricular non-compaction, a fairly common human congenital cardiomyopathy. Non-compaction in transgenic mice has been classically evaluated by measuring the thickness of the compact myocardium through histological techniques involving image analysis of 2-dimensional (D) sections. Given the 3D nature of the heart, the aim of this study was to determine whether a technique for the non-destructive, 3D assessment of the mouse embryonic compact myocardium could be developed.

    Methods and Results:Micro-computed tomography (micro-CT), in combination with iodine staining, enabled the differentiation of the trabecular from the compact myocardium in wild-type mice. The 3D and digital nature of the micro-CT data allowed computation anatomical techniques to be readily applied, which were demonstrated via construction of group atlases and atlas-based descriptive statistics. Finally, micro-CT was used to identify the presence of non-compaction in mice with a deletion of the cell cycle inhibitor protein, p27Kip1.

    Conclusions:Iodine staining-enhanced micro-CT with computational anatomical analysis represents a valid addition to classical histology for the delineation of compact myocardial wall thickness in the mouse embryo. Given the quantitative 3D resolution of micro-CT, these approaches might provide helpful information for the analysis of non-compaction. (Circ J 2016; 80: 1795–1803)

  • Tomasz Roleder, Elżbieta Pociask, Wojciech Wańha, Magdalena Dobrolińsk ...
    Type: ORIGINAL ARTICLE
    Subject area: Imaging
    2016 Volume 80 Issue 8 Pages 1804-1811
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 21, 2016
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    Background:The OCTOPUS registry prospectively evaluates the procedural and long-term outcomes of saphenous vein graft (SVG) PCI. The current study assessed the morphology of de novo lesions and in-stent restenosis (ISR) in patients undergoing PCI of SVG.

    Methods and Results:Optical coherence tomography (OCT) of SVG lesions in consecutive patients presenting with stable CAD and ACS was carried out. Thirty-nine patients (32 de novo and 10 ISR lesions) were included in the registry. ISR occurred in 5 BMS and 5 DES. There were no differences in the presence of plaque rupture and thrombus between de novo lesions and ISR. Lipid-rich tissue was identified in both de novo lesions and in ISR (75% vs. 50%, P=0.071) with a higher prevalence in BMS than in DES (23% vs. 7.5%; P=0.048). Calcific de novo lesions were detected in older grafts as compared with non-calcific atheromas (159±57 vs. 90±62 months after CABG, P=0.001). Heterogeneous neointima was found only in ISR (70% vs. 0, P<0.001) and was observed with similar frequency in both BMS and DES (24% vs. 30%, P=0.657). ISR was detected earlier in DES than BMS (median, 50 months; IQR, 18–96 months vs. 27 months; IQR, 13–29 months, P<0.001).

    Conclusions:OCT-based characteristics of de novo and ISR lesions in SVG were similar except for heterogeneous tissue, which was observed only in ISR. (Circ J 2016; 80: 1804–1811)

Ischemic Heart Disease
  • Nobutaka Wakasa, Tatsuhiko Kuramochi, Naoto Mihashi, Noriko Terada, Yo ...
    Type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2016 Volume 80 Issue 8 Pages 1812-1819
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 24, 2016
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    Background:Fractional flow reserve (FFR) is an important physiological measure of intermediate coronary artery stenosis. Pressure signal drift (PD) is widely recognized but has largely been ignored in FFR measurements. We sought to determine the effect of PD on FFR-derived decision-making.

    Methods and Results:We analyzed 1,218 FFR measurements for intermediate stenosis in 940 patients, in which the pullback maneuver confirmed PD ≤3 mmHg. The primary objectives were to determine the frequency and magnitude of PD and its effect on decision-making on the basis of an FFR cutoff of 0.80. In all, 479 (39.3%) measurements showed PD. PD was significantly associated with age, hypertension, reference diameter, left anterior descending artery lesion location, and read-out FFR values. Classification discordance between read-out and PD-corrected FFR values was detected in 44 (3.6%) measurements in total and in 9.2% of PD cases. The decision changed from FFR ≤0.80 to FFR >0.80 in 40 (3.3%) and vice versa in 4 (0.3%) measurements. PD showed no effect on decision-making when the FFR read-out value was ≤0.76 or ≥0.83.

    Conclusions:PD is not uncommon, and its effect on FFR-based decision-making was not negligible in the range between 0.77 and 0.82 where reclassification occurred in 18.7% of FFR measurements. (Circ J 2016; 80: 1812–1819)

  • Yuichi Saito, Hideki Kitahara, Toshihiro Shoji, Satoshi Tokimasa, Taka ...
    Type: ORIGINAL ARTICLE
    Subject area: Ischemic Heart Disease
    2016 Volume 80 Issue 8 Pages 1820-1823
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 28, 2016
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    Background:Based on the Japanese Circulation Society guideline of vasospastic angina, incremental doses of acetylcholine (ACh) are prescribed for coronary spasm provocation: 20 and 50 μg for the right coronary artery (RCA), and 20, 50 and 100 μg for the left coronary artery (LCA). However, the requirement for each dose of ACh has not been fully evaluated.

    Methods and Results:A total of 249 patients who underwent ACh provocation test for both the RCA and LCA were included. The positive diagnosis of intracoronary ACh provocation test was defined as total or subtotal coronary artery narrowing accompanied by chest pain and/or ischemic ECG changes. Positive ACh provocation test was observed in 116 patients (47%). Patients without vasospasm in the LCA had a lower incidence of vasospasm in the RCA induced by 20 μg of ACh compared with those with vasospasm in LCA (0.8% vs. 27.5%, P<0.001). Similarly, vasospasm in the LCA induced by 20 μg of ACh was observed less frequently in patients without than with vasospasm in the RCA (6.1% vs. 26.7%, P<0.001). In all patients without vasospasm in the other coronary artery, intracoronary administration of 50 μg of ACh was performed without any complications.

    Conclusions:Skipping the provocation test with 20 μg of ACh in patients without coronary artery spasm in the other coronary artery may be possible. (Circ J 2016; 80: 1820–1823)

Myocardial Disease
  • Ken Kato, Hideki Kitahara, Yoshihide Fujimoto, Yoshiaki Sakai, Iwao Is ...
    Type: ORIGINAL ARTICLE
    Subject area: Myocardial Disease
    2016 Volume 80 Issue 8 Pages 1824-1829
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 07, 2016
    JOURNALS FREE ACCESS FULL-TEXT HTML
    Supplementary material

    Background:Because it is difficult to distinguish between focal takotsubo cardiomyopathy and aborted myocardial infarction, there is little information about the prevalence and clinical features of focal takotsubo cardiomyopathy.

    Methods and Results:Our cardiac catheterization databases were queried to identify patients with focal takotsubo cardiomyopathy and other types of takotsubo cardiomyopathy. We defined focal takotsubo cardiomyopathy as hypo-, a- or dyskinesis in both anterolateral and septal segments without obstructive coronary artery disease explaining the wall motion abnormality. A total of 10 patients were diagnosed with focal takotsubo cardiomyopathy. The control group comprised patients with takotsubo cardiomyopathy with apical, mid-ventricular, or basal ballooning. Clinical features and in-hospital outcomes were compared between patients with focal takotsubo cardiomyopathy and those with other types of takotsubo cardiomyopathy. Among the 144 patients with takotsubo cardiomyopathy, the apical, mid-ventricular, basal, and focal types occurred in 85 (59.0%), 49 (34.0%), 0 (0%), and 10 patients (6.9%), respectively. The left ventricular ejection fraction was significantly higher in the focal group compared with the apical and mid-ventricular group (56±13 vs. 45±13 vs. 46±12%, P=0.03). In-hospital outcome was not significantly different among the 3 groups.

    Conclusions:Focal takotsubo cardiomyopathy is not rare. Biplane left ventriculography is useful for its diagnosis. (Circ J 2016; 80: 1824–1829)

  • Cesare de Gregorio, Giuseppe Dattilo, Matteo Casale, Anna Terrizzi, Ro ...
    Type: ORIGINAL ARTICLE
    Subject area: Myocardial Disease
    2016 Volume 80 Issue 8 Pages 1830-1837
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 28, 2016
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    Background:We sought to assess left atrial (LA) morphology and function in patients with transthyretin cardiac amyloidosis (TTR-CA) and hypertrophic cardiomyopathy (HCM). Primarily, longitudinal deformation (reservoir) and pump function were the focus of vector-velocity strain echocardiography imaging.

    Methods and Results:The study group comprised 32 patients (mean age 57.7±15.4 years, 16 in each group), and 15 healthy controls. Diagnosis of TTR-CA was based on echocardiography and either gadolinium-enhanced (LGE) cardiac magnetic resonance (cMRI) or radionuclide imaging. At baseline, there were no differences in age, body surface area, blood pressure and risk factors among the groups. Left ventricular (LV) mass was greater in patients than in controls, and slight LA dilatation was found in the TTR-CA group. LA reservoir was 14.1±4.7% in TTR-CA, 20.0±5.6% in HCM, and 34.0±11.8% in controls (<0.001). In addition, LA pump function chiefly was impaired in the former group, irrespective of LA chamber size and LV ejection fraction. LGE in the atrial wall was seen in 9/10 TTR-CA versus 0/8 HCM patients undergoing cMRI (P<0.001). LA reservoir ≤19% and pump function ≤–1.1% best discriminated TTR-CA from HCM patients in the receiver-operating characteristic analysis.

    Conclusions:LA reservoir and pump function were significantly impaired in both TTR-CA and HCM patients compared with controls, but mainly in the former group, irrespective of LA volume and LV ejection fraction, likely caused by a more altered LA wall structure. (Circ J 2016; 80: 1830–1837)

Pediatric Cardiology and Adult Congenital Heart Disease
  • Katsuyasu Kouda, Kumiko Ohara, Yuki Fujita, Harunobu Nakamura, Masayuk ...
    Type: ORIGINAL ARTICLE
    Subject area: Pediatric Cardiology and Adult Congenital Heart Disease
    2016 Volume 80 Issue 8 Pages 1838-1845
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 07, 2016
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    Background:Only a few studies have examined the relationship between fat distribution measured by dual-energy X-ray absorptiometry (DXA) and blood pressure (BP), and no cohort study has targeted a pediatric population.

    Methods and Results:The source population comprised all students registered as fifth graders in the 2 elementary schools in Hamamatsu, Japan. Of these, 258 children participated in both baseline (at age 11) and follow-up (at age 14) surveys. Body fat distribution was assessed using trunk-to-appendicular fat ratio (TAR) and trunk-to-leg fat ratio (TLR) measured by DXA. Relationships between BP levels and fat distribution (TAR or TLR) were examined after stratification by tertiles of whole-body fat.Systolic BP at follow-up was significantly (P<0.05) associated with both TAR (boys, β=0.33; girls β=0.36) and TLR (girls β=0.35) at baseline, after adjusting for confounding factors such as baseline BP in the lowest tertile of whole-body fat. Moreover, adjusted means of systolic and diastolic BPs in girls showed a significant increase from the lowest to highest tertile of TAR within the lowest tertile of whole-body fat.

    Conclusions:Body fat distribution in childhood could predict subsequent BP levels in adolescence. Children with a relatively low body fat that is more centrally distributed tended to show relatively high BP later on. (Circ J 2016; 80: 1838–1845)

  • Marc-André Koerten, Koichiro Niwa, András Szatmári, Balint Hajnalka, Z ...
    Type: ORIGINAL ARTICLE
    Subject area: Pediatric Cardiology and Adult Congenital Heart Disease
    2016 Volume 80 Issue 8 Pages 1846-1851
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 21, 2016
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    Background:The 2011 guidelines of the European Society of Cardiology (ESC) on the management of cardiovascular diseases during pregnancy define the maternal predictors for neonatal complications. The aim of this study was to determine whether these are associated with an increased number of miscarriages/stillbirths and terminations of pregnancy (TOPs) also in patients with congenital heart defects (CHD).

    Methods and Results:The 634 women from Germany, Hungary and Japan were surveyed concerning the issues of sexuality and reproductive health, as well as their general life situation and medical care. 25% of the recorded pregnancies in women with CHD resulted in miscarriage, stillbirth or TOP. Affecting 16.8% of all recorded pregnancies, miscarriages or stillbirths occurred more frequently than in the general population and more than previously recorded for patients with CHD. TOP occurred in 8% of the surveyed pregnancies. Underlying maternal predictors for neonatal events had an influence on the number of TOP; among those with underlying predictors, TOP was recorded 3-fold more than in those without such predictors (15.6% vs. 5.5%). Remarkably, a significant deficit regarding the level of information on potential pregnancy-associated risks was observed in all 3 participating countries.

    Conclusions:Pregnant women with CHD should always be treated and counseled individually by cardiologists, gynecologists, obstetricians and anesthetists with appropriate expert knowledge. (Circ J 2016; 80: 1846–1851)

Pulmonary Circulation
  • Takanari Fujii, Hideshi Tomita, Kazuto Fujimoto, Shinichi Otsuki, Tosh ...
    Type: ORIGINAL ARTICLE
    Subject area: Pulmonary Circulation
    2016 Volume 80 Issue 8 Pages 1852-1856
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: July 07, 2016
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    Background:Percutaneous stenting for branch pulmonary artery stenosis is an established interventional choice in congenital heart disease. The apparent morphologic change in the vessel diameter often differs from the hemodynamic result.

    Methods and Results:We performed a subanalysis of the data from the Japanese Society of Pediatric Interventional Cardiology (JPIC) stent survey. The factors that may have contributed to morphologic effectiveness included reference vessel diameter (RVD), minimum lumen diameter (MLD) and percent diameter stenosis (%DS) and the relation between morphologic and hemodynamic effectiveness was evaluated in 206 lesions treated with stenting. We defined a “50% increase in MLD” as “morphologically effective”, while “achievement of either a reduced pressure gradient greater than 50% or an increase of perfusion ratio to the affected side to the contralateral side greater than 20%” as “hemodynamically effective”. Morphologic effectiveness was achieved in 84% of patients. Before stenting, %DS was significantly larger, while RVD was smaller in the “effective” group than in the “non-effective” group. The cutoff value for effective stenting was 51% for %DS and 14.7 mm for RVD before stenting. Hemodynamic effectiveness was obtained more often in the “morphologic effective” group.

    Conclusions:RVD and %DS were the 2 main contributors to acute morphologic effectiveness. There was a significant relationship between “morphologic effectiveness” and “hemodynamic effectiveness”, judging from increased perfusion of the affected lung and/or decreased pressure gradient. (Circ J 2016; 80: 1852–1856)

Renal Disease
  • Keita Takae, Masaharu Nagata, Jun Hata, Naoko Mukai, Yoichiro Hirakawa ...
    Type: ORIGINAL ARTICLE
    Subject area: Renal Disease
    2016 Volume 80 Issue 8 Pages 1857-1862
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 17, 2016
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    Supplementary material

    Background:Growing evidence suggests that high serum uric acid (SUA) levels are causally related to increased risk of chronic kidney disease (CKD). However, few studies have investigated the influence of elevated SUA levels on the incidence of kidney dysfunction and albuminuria separately in community-based populations.

    Methods and Results:A total of 2,059 community-dwelling Japanese subjects aged ≥40 years without CKD were followed for 5 years. CKD was defined as kidney dysfunction (estimated glomerular filtration rate <60 ml/min/1.73 m2) or albuminuria (urine albumin-creatinine ratio ≥30 mg/g). The odds ratio (OR) for the development of CKD was estimated according to quartiles of SUA (≤4.0, 4.1–4.9, 5.0–5.8, and ≥5.9 mg/dl). During the follow-up, 396 subjects developed CKD, of whom 125 had kidney dysfunction and 312 had albuminuria. The multivariable-adjusted risk of developing CKD increased with higher SUA levels (OR 1.00 [reference] for ≤4.0, 1.21 [95% confidence interval, 0.84–1.74] for 4.1–4.9, 1.47 [1.01–2.17] for 5.0–5.8, and 2.10 [1.37–3.23] for SUA ≥5.9 mg/dl, respectively). Similarly, there were positive associations between SUA level and the adjusted risk of developing kidney dysfunction (OR 1.00 [reference], 2.30 [1.10–4.82], 2.81 [1.34–5.88], and 3.73 [1.65–8.44]) and albuminuria (1.00 [reference], 1.12 [0.76–1.65], 1.35 [0.90–2.03], and 1.81 [1.14–2.87], respectively).

    Conclusions:Higher SUA levels were a significant risk factor for the development of both kidney dysfunction and albuminuria in a general Japanese population. (Circ J 2016; 80: 1857–1862)

Valvular Heart Disease
  • Shunsuke Nishimura, Chisato Izumi, Masataka Nishiga, Masashi Amano, Sa ...
    Type: ORIGINAL ARTICLE
    Subject area: Valvular Heart Disease
    2016 Volume 80 Issue 8 Pages 1863-1869
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 21, 2016
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    Background:The optimal timing of aortic valve replacement (AVR) is controversial in patients with asymptomatic severe aortic stenosis (AS) except when very severe. Prediction of progression of severe AS is helpful in deciding on the timing of AVR. The purpose of this study was to clarify the predictors of progression rate and clinical outcomes of severe AS.

    Methods and Results:We retrospectively investigated 140 consecutive patients with asymptomatic severe AS (aortic valve area [AVA], 0.75–1.0 cm2). First-year progression rate and annual progression rate of AVA and of aortic jet velocity (AV-Vel) were calculated. Cardiac events were examined and the predictors of rapid progression and cardiac events were analyzed. The median follow-up period was 36 months. The median annual progression rate was −0.05 cm2/year for AVA and 0.22 m/s/year for AV-Vel. Dyslipidemia, moderate-severe calcification, and first-year AV-Vel progression ≥0.22 m/s/year were independent predictors of cardiac events. Cardiac event-free rate was lower in patients with AV-Vel first-year progression rate ≥0.22 m/s/year than in those with a lower rate. Diabetes and moderate-severe calcification were related to first-year rapid progression.

    Conclusions:The annual progression rate of severe AS was −0.05 cm2/year for AVA and 0.22 m/s/year for AV-Vel. Patients with first-year rapid progression or severely calcified aortic valve should be carefully observed while considering an early operation. (Circ J 2016; 80: 1863–1869)

Rapid Communication
  • Tomoyoshi Tamura, Kei Hayashida, Motoaki Sano, Masaru Suzuki, Takayuki ...
    Type: RAPID COMMUNICATION
    2016 Volume 80 Issue 8 Pages 1870-1873
    Published: July 25, 2016
    Released: July 25, 2016
    [Advance publication] Released: June 22, 2016
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    Supplementary material

    Background:Hydrogen gas inhalation (HI) ameliorates cerebral and cardiac dysfunction in animal models of post-cardiac arrest syndrome (PCAS). HI for human patients with PCAS has never been studied.

    Methods and Results:Between January 2014 and January 2015, 21 of 107 patients with out-of-hospital cardiac arrest achieved spontaneous return of circulation. After excluding 16 patients with specific criteria, 5 patients underwent HI together with target temperature management (TTM). No undesirable effects attributable to HI were observed and 4 patients survived 90 days with a favorable neurological outcome.

    Conclusions:HI in combination with TTM is a feasible therapy for patients with PCAS. (Circ J 2016; 80: 1870–1873)

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