With recent advances in cardiovascular and neonatal medicine, the number of patients with heart disease who are giving birth has increased, and the range and severity of heart disease where pregnancy and delivery are possible are expanding. It is very important to understand that hemodynamics during pregnancy and delivery are significantly affected by changes in fluid circulation, hematology, respiratory function, endocrinology, and the autonomic nervous system for clinical management in peripartum women with heart disease. Because the cardiocirculatory changes associated with pregnancy and delivery are marked in some diseases and conditions, the maternal and fetal risks are high. Echocardiography is widely used to assess such maternal pregnancy risks. Echocardiography, a noninvasive method providing detailed information, is quite useful in evaluating hemodynamics during pregnancy. It is preferable that women with heart disease be assessed for hemodynamic status several times during pregnancy and during the puerperal period. The first assessment should be performed immediately before pregnancy or during the first trimester when changes in hemodynamics are still slight. Patients with mild to moderate risk should be evaluated for hemodynamics again during the late second trimester at around 30 weeks of gestation. Patients with severe risk require more frequent hemodynamic assessment. Hemodynamics should be reassessed during the peripartum period. Since childcare, including breast feeding, may increase cardiac load, patients with severe heart disease must be followed up carefully after childbirth.

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There are two types of stroma in interlobular stromal fibrous tissue: (1) a surrounding stroma that is densely packed with fibrous connective tissues and surrounds the lobules and an extralobular duct (isoechoic) and (2) an edematous stroma with loosely packed fibrous connective tissues (hyperechoic). The isoechoic structure includes “extralobular duct - TDLU” in the surrounding stroma. The isoechoic structure shows the running of the duct. Normal isoechoic structures have two types of regularities, i.e., toward the nipple and toward the boundary surface between the lobes, reflecting the course of the mammary ducts. The continuity of the isoechoic structure should be traced by paying attention to these two types of regularities. The site where the isoechoic structure is interrupted in its continuity or disordered in direction should be evaluated for possible pathological changes.

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Non-mass abnormalities are of five subtypes, i.e., abnormalities of the ducts, hypoechoic areas in the mammary gland, architectural distortion, multiple small cysts, and echogenic foci without a hypoechoic area. The main lesions recognized as non-mass abnormalities include ductal carcinoma in situ (DCIS), fibrocystic change, and intraductal papilloma. In the case of DCIS with a non-mass abnormality, a hypoechoic area in the mammary gland is the most frequent finding at 76%, followed by abnormalities of the ducts at 16%. Architectural distortion is found in about 2% of DCIS; however, it is an important finding because it is often observed in small invasive carcinoma and invasive lobular carcinoma. In this article, we explain the five classifications and present some cases.

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Mitral valve repair is an attractive procedure for both patients and surgeons because there are many target diseases, its effectiveness and significance are clearer than those of valve replacement, and experience and skill are required. However, the risk of re-operation remains an issue. Re-operation is generally performed 1-3 years after surgery, which is relatively early, with the early re-operation rate being 5-8%. The condition stabilizes thereafter, and re-operation-free rate in the subsequent 10 years is 80-95%. The pathology likely to lead to re-operation includes active infective endocarditis and extensive prolapse of the anterior leaflet, and the cause includes incomplete repair, injury of the sutured segment, re-dilatation of the annulus, re-elongation of the shortened chorda tendineae, and hemolysis. To achieve a favorable outcome, identification of the mechanism of mitral regurgitation by means of echocardiography and selection of an appropriate repair procedure for it are necessary. For the repair procedure, resection and suture are the basic procedure, and it is necessary to achieve complete leaflet coaptation at completion of repair, and to implant the annuloplasty ring carefully. Prevention of dehiscence in resection and suture is especially important. Intraoperative transesophageal echocardiography should only be performed by an experienced sonographer, and residual regurgitation of 2 cm² or more should be re-investigated and treated. Re-regurgitation during the hospital stay should be treated, and re-operation should be performed if necessary, which results in a favorable late outcome. In this feature article, we describe information required by surgeons before surgery, in addition to the issues described above.

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It is necessary to accurately predict the feasibility of mitral valve (MV) repair using echocardiography when surgical intervention for mitral regurgitation (MR) is considered. It is also important to plan the MV repair procedures preoperatively. Before performing MV repair for primary MR as represented by degenerative MR due to MV prolapse, the feasibility of MV repair is determined by echocardiographic assessments of the location, extent, and etiology of the main lesion. The MV repair procedure, such as leaflet resection or chordal replacement, is planned according to the information on both the main lesion and the sub lesion. In patients at high risk for postoperative left ventricular (LV) outflow tract obstruction due to the systolic anterior motion of MV leaflets, some optional procedure should be performed to avoid the complication. In patients with secondary (functional) MR due to LV dysfunction, it can be predicted by the degree of MV tethering-tenting whether mitral annuloplasty alone can control the MR. On the other hand, mitral annuloplasty would be the primary treatment for atrial functional MR, the concept and etiology of which have been recently established. In conclusion, we, i.e., all of the heart team members, should understand that the morphologic diagnosis using echocardiography is the most important in determining whether MV repair is indicated and which procedure to use.

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Echocardiographic examination plays an extremely important role in mitral valve repair surgery. Three-dimensional (3D) transesophageal echocardiography allows us to examine the valve morphology with ‘en-face’ view of the mitral valve from the surgeon’s view. 3D geometry of the mitral valve and mitral valve complex can be quantitatively measured by using 3D volumetric data, which has been impossible with two-dimensional (2D) echocardiography. Perioperative diagnosis including preoperative/intraoperative/postoperative diagnosis by echocardiologists is essential to achieve successful repair surgery. In this review, the role of echocardiography and the noninvasive cardiologist in the management of mitral valve repair surgery is summarized.

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Aortic regurgitation (AR) causes chronic volume overload, which leads to progressive myocardial damage. Surgery is indicated in patients with severe AR and symptoms. In recent years, outcomes for aortic valve sparing or aortic valve plasty have improved, and more and more institutions in Japan are actively selecting these procedures. Assessment of the aortic valve and aortic valve complex using transthoracic and transesophageal echocardiography before performing these procedures is an essential part of the therapeutic strategy. Not only cardiac cavity size and cardiac function but also the properties of the aortic valve such as prolapse, perforation, calcification, and degeneration can be observed using echocardiography. These findings are used for the procedure-conscious classification of AR. Detailed observation of the aortic valve complex using echocardiography leads to a better understanding of the pathogenesis and anatomical characteristics of AR, and can be very useful for aortic valve plasty. Doctors and sonographers who work in clinical echocardiography may need to make an effort to understand the surgical procedures and provide surgeons with useful echocardiographic information.

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The guideline on surgical intervention for aortic regurgitation or aortic root disease is formulated supposing that aortic valve replacement is the only alternative. As early intervention is advantageous in the case of aortic valve repair, echocardiographers play an important role. Each type can theoretically be repaired. Type Ia can be treated by ascending aortic replacement, but other types can often be combined. Accurate measurement of the root dimension is essential for use of valve-sparing root replacement in type Ib disease. Type Ic is appropriately treated by annuloplasty, but each one has both advantages and disadvantages. External suture annuloplasty is a simple procedure that entails plication of a ventriculo-aortic junction, whereas external ring annuloplasty is technically demanding but involves plication of a basal ring. Internal rigid ring annuloplasty allows simple plication of a basal ring, but the concern remains with regard to the effect of a rigid ring in close proximity to the delicate aortic cusps. The clinical outcomes of patch repair for type Id lesions is favorable; however, their preoperative diagnosis is difficult in the presence of multiple jets. Type II, the most common type, can easily be repaired by central plication of the cusp. It can easily be diagnosed by eccentric jet, lower effective height, and cusp bending. Type III requires cusp extension with the pericardium. However, use of the pericardium has emerged as a risk of failure. Thus, echocardiographic diagnosis is very important; however, cusp height tends to be underestimated. In the diagnosis of bicuspid valve, echocardiographers play the most important role in avoiding stenosis, arranging commissure orientation, and avoiding cusp bulging. We hope that as many aortic valves as possible will be preserved by standardizing aortic valve repair and revising the guideline.

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With advances in the field of cardiovascular surgery, aortic valve-sparing surgery including aortic valvuloplasty and aortic root reconstruction or remodeling has become a therapeutic option for young patients with aortic regurgitation (AR). As a result, progress has been made in terms of anatomical understanding and evaluation of the aortic valve complex, such as aortic root and valve structure. Because aortic valve-sparing surgery is a more complicated procedure than surgical aortic valve replacement, it is necessary to understand in detail not only the anatomy of the aortic valve complex but also the AR mechanism and pathological changes associated with AR. Echocardiography is very useful for assessing the AR severity, anatomy and underlying mechanism for evaluation of the feasibility of aortic valve-sparing surgery and prediction of the long-term postoperative outcome. In this report, we summarize the preoperative evaluation of echocardiography for aortic valve-sparing surgery.

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Purpose: Myocardial ischemic memory can be evaluated by post-systolic shortening (PSS) because it persists for a while after brief ischemia. Recently, early systolic lengthening (ESL) assessed by speckle tracking echocardiography has been reported to be a novel useful parameter for detecting myocardial ischemia. However, it is still unclear whether ESL persists after brief ischemia and can be used for evaluating ischemic memory. Subjects and Methods: The left circumflex coronary artery was occluded for 2 minutes followed by reperfusion in 16 dogs. Short-axis images were acquired at baseline, during occlusion, and 10 and 30 minutes after reperfusion. Circumferential strain was analyzed in the ischemic and non-ischemic areas. Peak systolic strain (ε_S), post-systolic index (PSI) as a parameter of PSS, the amplitude of ESL (ε_ESL), and time from the onset of QRS to the beginning of regional contraction over the initial length (ESL time) were measured. Diagnostic accuracy for evaluating ischemic memory after reperfusion was calculated by receiver operating characteristics (ROC) curve analysis. Results: In the risk area, ε_S decreased and ε_ESL increased during occlusion, which recovered to the baseline level after reperfusion. In contrast, PSI and ESL time significantly increased during occlusion, and the significant increase still persisted at 10 minutes after reperfusion (PSI: 0.02 ± 0.04 vs. 0.19 ± 0.10, p<0.05; ESL time: 88 ± 30 vs. 118 ± 38 ms, p<0.05). The sensitivity and specificity of ischemic memory at 10 minutes after reperfusion were 63% and 81% for ESL time, and 94% and 94% for PSI, respectively. Conclusion: ESL time derived from speckle tracking echocardiography seems to be able to detect ischemic memory. However, PSI was better than ESL time in terms of diagnostic accuracy of ischemic memory.

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In the case of respiratory diseases, the have been some reports of strain elastography in endobronchial ultrasonography (EBUS) for evaluating the mediastinal and hilar lymph nodes, but there are few reports of use of shear wave elastography. We encountered a case of lung cancer (squamous cell carcinoma) and a case of pneumonia adjacent to the pleura in which shear wave velocity could be reliably measured by shear wave elastography from the body surface. We found that the shear wave velocity of lung cancer was faster than that of pneumonia. These findings demonstrate that the shear velocity of subpleural lung lesions can be measured by shear wave elastography from the body surface. These findings also show that shear wave elastography may be useful for the diagnosis of subpleural lung lesions.

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