We need to assess left ventricular myocardial wall motion abnormalities from the standpoint of both systole and diastole. Echocardiographic indices can be classified into two categories, i.e., those for systolic function and those for diastolic function. Diastolic dysfunction is difficult to assess macroscopically, unlike systolic dysfunction. Therefore, various echocardiographic methods have been proposed to assess diastolic wall motion abnormalities. Stress echocardiography and myocardial contrast echocardiography are available in the clinical setting for myocardial ischemia. Also, we need different approaches depending on whether regional function or whole heart function is assessed. Recently, there have been attempts to assess wall motion abnormalities using 3-dimensional echocardiography.

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Purpose: Although heart failure (HF) with preserved left ventricular (LV) ejection fraction (HFPEF) is present in 40-50% of HF patients, echocardiographic prognostic predictors have not been well investigated. The LV chamber usually shows geometrical remodeling from ellipse to sphere as HF advances. Thus, we retrospectively analyzed the data to assess the value of analysis of LV geometrical characteristics in patients with HFPEF. Subjects and Methods: A total of 52 patients with HFPEF (ejection fraction>=50%) were enrolled and studied. An echocardiographic examination was performed on admission and repeated after optimized medical therapy. Echocardiography was used to measure sphericity index (SI) as a ratio of LV radial to longitudinal dimension at discharge. Cardiac events included death and re-hospitalization for worsening of HF. Results and Discussion: There were 14 cardiac events during a mean follow-up period of 690 days. Patients with spherical LV (SI<=1.7) showed significantly lower event-free survival than patients with ellipsoid LV (SI⟩1.7) (log-rank, p⟨0.05). According to multivariate logistic regression analysis, SI<=1.7 was the only independent predictor of death and re-hospitalization for worsening of HF. Conclusion: Spherical LV chamber may be predictive of poor prognosis of HFPEF.

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Purpose: The purpose of this study is to clarify the genesis of TR due to right ventricular permanent pacemaker implantation (PPI). Subjects and Methods: We performed transthoracic echocardiography on 37 patients before and after PPI. No patients showed moderate or severe TR before PPI. After PPI, 29 patients showed no change of TR (N-group), and 8 patients developed moderate or severe TR (TR-group), as assessed by color Doppler echocardiography. We measured the insertion angle of the pacing leads between tricuspid valve orifices and the their anchored positions. In order to identify the anchor portion of the leads, we analyzed the sites of maximum size of the early systolic notch in the IVS that showed asynchrony due to electrical stimulation of pacing leads on M-mode echocardiograms using a line-scan recorder with a paper speed of 50 mm/sec. The mean follow-up period was 63 months. Results: 1. The insertion angle of pacing leads was significantly large in the TR group as compared with the N group (18±10 vs 0±5 degrees, p⟨0.0001). 2. The sites of maximum size of the notch were located at the basal or mid portion of the IVS in the TR group, whereas they were mostly located at the apical IVS in the N group. Conclusion: The genesis of TR after PPI was considered to be due to pacing leads crossing the tricuspid orifice obliquely, compressing the septal leaflets, and anchoring at a higher position of the IVS that disturbed coaptation of tricuspid valves.

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Objective: To investigate sonographic findings of nodes for the early diagnosis of non-Hodgkin lymphoma recurrence. Methods: We focused on 57 nodes from five cases showing recurrence or aggravation and 125 nodes from 18 cases with complete remission (CR nodes) whose course could be followed from pretherapy. We evaluated the following eight parameters: 1. length, 2. width, 3. thickness, 4. thickness/length ratio, 5. clarity of border, 6. echo level, 7. wide hilus, and 8. blood flow. We analyzed those parameters using multivariate logistic regression analysis (MLRA). The size (1 - 3) of the CR nodes was divided into two groups according to whether they measured≥or⟨mean (M)+1 standard deviation (SD). Results: The length of CR nodes was 11.7±3.9 mm. The width and the thickness were divided into an upper cervical group or a caudal to middle cervical group for comparison by unpaired T test (P⟨0.01). The M+1SD of width and thickness in the upper cervical group was 11 mm and 6 mm, respectively. The respective values at the other sites were 9 mm and 4 mm. According to MLRA, width≥M+1SD (P⟨0.001) and thickness≥M+1SD (P⟨0.005) were significant. Conclusion: CR node size was calculated by ultrasonography. The width was suggested to be the most important finding. The useful combination was thickness and width.

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A 74-year-old man presenting with paroxysmal atrial fibrillation was referred to our hospital in December 2008. Two-dimensional echocardiography showed a 2 x 5 cm mass in the posterior wall of the left ventricle. There was no evidence of malignancy and there was no significant change in mass size during the 3-month follow-up period. The mass was thus judged to be a benign cardiac tumor, and the patient was followed at our hospital. He was admitted to our hospital in December 2009, however, when computed tomography angiography of the coronary artery revealed stenosis in the left anterior descending artery. The characteristics of the mass were assessed by computed tomography and two-dimensional echocardiography, and the clinical diagnosis of the mass was thought likely to be cardiac fibroma. Regional left ventricular function was assessed by two-dimensional speckle tracking imaging. Reduced longitudinal and radial strains were found in the basal posterior wall of the left ventricle. Further, the circumferential strain pattern in the posterior wall was precisely opposite to that in the septal wall. The coronary angiogram showed normal right and left circumferential coronary arteries, suggesting that the tumor itself was affecting regional myocardial function around the tumor. Hence two-dimensional speckle tracking imaging may be useful for detecting subclinical regional myocardial dysfunction around a left ventricular tumor.

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A new microbubble agent, Sonazoid^®, provides parenchyma-specific contrast images in ultrasound (US) imaging examinations. With real-time imaging in the vascular and post-vascular phases provided by use of this agent, an accurate diagnosis of liver tumors is possible. A Japanese man in his 50s visited our hospital with complaints of abdominal distension and upper abdominal pain. Abdominal contrast-enhanced computed tomography revealed a 5-cm non-enhanced mass lesion in the caudate region of the pancreas, though no apparent tumor was shown in the liver. A conventional US examination revealed a well-demarcated low-echoic nodule in the S4 region and multiple focal spared areas with a bright hepatic parenchyma, indicating a fatty liver. In addition, contrast-enhanced US with Sonazoid^® demonstrated that the hypoechoic area in the S4 region was slightly stained in the arterial phase and washed out in the portal phase, while only the hypoechoic area in the S4 region showed an accumulation defect in the post-vascular phase, indicating that the lesion should be diagnosed as a metastatic liver tumor. Contrast-enhanced US with Sonazoid^® is useful for differentiating tumors from focal spared areas in fatty livers.

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We report a rare case of desmoid tumor in the chest wall with invasion into the left breast. A 30-year-old woman noticed a mass in her left breast in February 2006. She had a medical examination in our hospital in July 2006, when her breast pain had gradually become worse. At first, mammography showed neither a mass lesion nor bilateral malignant calcification. Ultrasonography showed an irregular hypoechoic mass occupying most of the deep breast tissue, a finding highly suggestive of scirrhous carcinoma. Fine-needle aspiration revealed a classII lesion with no cellular atypia. Core needle biopsy revealed proliferation of collagenous fiber and invasion of benign inflammatory cells. However, MRI showed gradual enhancement without a choline peak on MRS, indicative of benign fibrous tissue. For a second look, ultrasonography, elastography, and the finger compression maneuver were added. Elastography showed the mass lesion to cover a wide area on the chest wall and to be relatively harder than the mammary gland. These MRI ultrasonography, and fine needle biopsy findings led us to consider the possibility of a desmoid tumor. Resection of the mass lesion and part of the pectoralis major muscle was then carried out. Pathologic evaluation of the lumpectomy tissue with immunostaining showed a desmoid tumor comprising fibroblast-like cells.

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