Background.We aimed to assess right ventricular (RV) function in patients with complete right bundle branch block (CRBBB) using noninvasive techniques.
Methods.The studied subjects were 29 consecutive patients with CRBBB aged over 40 years (mean: 66 years). Six patients had hypertension; the other 23 patients had no cardiovascular disorders. Twenty age-matched healthy subjects (mean: 68 years) served as the controls. The RV volumes at end-diastole (RVEDV) and end-systole were measured via apical four-chamber view, and the RV ejection fraction (RVEF) was calculated. The isovolumic contraction (ICT) and relaxation times (IRT) and the ejection time (RVET) were measured using the recordings of RV inflow or outflow velocities and the electrocardiogram. The total cardiac performance index (TEI index) was calculated as (ICT + IRT) / RVET.
Results.The patients with CRBBB were divided into two groups based on the mean + 2 standard deviations of RV TEI index (=0.40) in the controls: the low value group (23 patients with TEI index<=0.40) and the high value group (6 with TEI index>0.40). The RVEDV was larger and RVEF lower in the high value group compared to the low value group. The ICT and IRT were prolonged while the RVET was shortened in the high value group when compared with the low value group. Arrhythmic events, such as paroxysmal atrial fibrillation or multiple ventricular premature beats, frequently occurred in the high value group (50 %) as compared to the low value group (4 %, p<0.01).
Conclusions.RV dysfunction or arrhythmic events may occur in some patients with CRBBB, and the TEI index may be useful for the detection and evaluation of these patients.

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Background.Although mitral complex geometry alteration has been speculated as a major mechanism for the reduction in mitral regurgitation (MR) after heart failure treatment, it has been difficult to recognize the mechanistic changes of the mitral apparatus because of the complex morphology and anatomical position. We investigated the contributions of the dynamic changes in mitral valve geometry with papillary muscle (PM) alignment to the reduction of functional MR after intensive heart failure treatment.
Methods.Two dimensional/three-dimensional (2D/3D) echocardiography was performed in 10 patients with decompensated heart failure and functional MR before and after intensive therapy. We used novel software to analyze the volumetric images recorded by real-time 3D echocardiography. Reconstructed 3D images showed both leaflets and annulus configuration in relation to PM position. We measured maximum tenting length (max-Tent-L); mean tenting length (mean-Tent-L) and tenting volume (Tent-V); distances from anterior annulus to anterolateral PM (A-tethering length) and posteromedial PM (P-tethering length); the distance between two PM (interpapillary distance); and the angle made by the anterolateral PM, anterior annulus, and posteromedial PM (interpapillary angle).
Results.MR decreased after intensive treatment in all patients (p<0.0001). Leaflet tenting decreased significantly after therapy (max-Tent-L, 16.8±2.5 vs. 13.3±2.0mm, p<0.001; mean-Tent-L, 9.5±2.1 vs. 7.3±1.3mm, p<0.001; Tent-V, 10.3±2.8 vs. 6.2±1.6ml, p=0.0002). P-tethering length shortened (46.9±5.1 vs. 38.6±4.9mm, p<0.001). Interpapillary distance (25.8±5.6 vs. 17.2±4.0mm, p<0.001) and interpapillary angle (32.0±7.3 vs. 23.8±7.5 degree, p<0.001) decreased after treatment.
Conclusions.Dynamic changes in PM position during heart failure treatment resulted in the reduction of mitral valve tenting, which improved functional MR.

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A 71-year-old woman was admitted with sudden-onset shoulder and back pain. The electrocardiograph showed sinus rhythm with ST-segment elevation in leads V_4-6 and abnormal Q waves in leads V_4-5. Echocardiography at the time of admission revealed akinesis in the left ventricular apical wall. However, coronary angiography did not reveal a stenotic lesion in any of the coronary arteries. Left ventriculography revealed apical ballooning with basal hyperkinesis. Ten hours after onset, the patient suddenly collapsed and went into cardiopulmonary arrest. This is a rare case of left ventricular rupture with takotsubo-like left ventricular dysfunction.

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A 68-year-old man was admitted to our hospital with dyspnea and palpitation on slight exertion. Echocardiography revealed a quadricuspid aortic valve with severe aortic regurgitation and turbulent blood flow in the left lateral aspect of the main pulmonary artery just above the pulmonic valve. Coronary angiography depicted a coronary artery fistula arising from the left anterior descending artery and draining into the main pulmonary artery. An aortic valve replacement with a prosthesis and closure of the fistula were performed. This is a rare case of quadricuspid aortic valve combined with coronary- pulmonary artery fistula.

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