Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atri... more Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atrial functional mitral regurgitation and tricuspid regurgitation in patients with atrial fibrillation. Methods From October 2008 to August 2016, we performed mitral and tricuspid valve repairs in 45 patients with permanent atrial fibrillation, chronic heart failure, preserved left ventricular ejection fraction, and at least moderate functional mitral regurgitation and mild functional tricuspid regurgitation. The follow-up period ranged from 56 to 3283 days (2-109 months; median 932 days). Results All patients underwent both mitral and tricuspid annuloplasty. Mitral regurgitation and tricuspid regurgitation improved from 2.6 ± 0.6 (0-3) and 2.0 ± 0.7 (0-3) preoperatively to 0.4 ± 0.3 (0-3) and 0.8 ± 0.5 (0-3) at the most recent echocardiography (p < 0.0001 and p < 0.0001), respectively. Further, the New York Heart Association functional class dramatically improved from 2.8 ± 0.7 to 1.5 ± 0.7 (p < 0.0001). Postoperative cardiovascular events occurred in 10 patients, including 3 with re-admissions for heart failure. The event-free rates were 93%, 87%, and 52% at 1, 3, and 5 years after surgery, respectively. The preoperative left atrial volume index was the independent predictor of postoperative cardiovascular events. Conclusions Our results suggest that mitral and tricuspid valve repairs lead to reductions in regurgitations and heart failure symptoms in patients with atrial functional mitral and tricuspid regurgitations. The preoperative left atrial size should be recognized as an important risk factor of postoperative cardiovascular events.
PURPOSE In this study, we examined the hypothesis that the preferential conduction property along... more PURPOSE In this study, we examined the hypothesis that the preferential conduction property along left lateral ridge (LLR) might affect the arrhythmogenicity of left pulmonary veins (LPVs). METHODS The study population included 40 consecutive AF patients. Radiofrequency energy (RF) was sequentially delivered along the LLR from a lower to upper manner during postero-lateral CS pacing during an isoproterenol infusion. RESULTS The conduction time during pacing from the CS was significantly prolonged during radiofrequency (RF) deliveries (before vs. after, upper; 91±26ms vs. 127±38ms, p<0.001, lower; 86±21ms vs. 103±22ms, p<0.001). Remarkable prolongation of more than 30ms was observed in 19 of 40 patients (48%) (both LPVs, 6; only the upper LPVs, 12; and only the lower LPV, 1). Sites with a remarkable prolongation were observed at the carina between the LPVs,[4] anterior site of the upper LPV carina,[10] anterior wall of the lower LPV,[3] and bottom of the lower LPVs [2] Thirty-t...
Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atri... more Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atrial functional mitral regurgitation and tricuspid regurgitation in patients with atrial fibrillation. Methods From October 2008 to August 2016, we performed mitral and tricuspid valve repairs in 45 patients with permanent atrial fibrillation, chronic heart failure, preserved left ventricular ejection fraction, and at least moderate functional mitral regurgitation and mild functional tricuspid regurgitation. The follow-up period ranged from 56 to 3283 days (2-109 months; median 932 days). Results All patients underwent both mitral and tricuspid annuloplasty. Mitral regurgitation and tricuspid regurgitation improved from 2.6 ± 0.6 (0-3) and 2.0 ± 0.7 (0-3) preoperatively to 0.4 ± 0.3 (0-3) and 0.8 ± 0.5 (0-3) at the most recent echocardiography (p < 0.0001 and p < 0.0001), respectively. Further, the New York Heart Association functional class dramatically improved from 2.8 ± 0.7 to 1.5 ± 0.7 (p < 0.0001). Postoperative cardiovascular events occurred in 10 patients, including 3 with re-admissions for heart failure. The event-free rates were 93%, 87%, and 52% at 1, 3, and 5 years after surgery, respectively. The preoperative left atrial volume index was the independent predictor of postoperative cardiovascular events. Conclusions Our results suggest that mitral and tricuspid valve repairs lead to reductions in regurgitations and heart failure symptoms in patients with atrial functional mitral and tricuspid regurgitations. The preoperative left atrial size should be recognized as an important risk factor of postoperative cardiovascular events.
Background: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion... more Background: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia. Methods: Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value. The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (p < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, p < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (p = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥ 15 cm (p = 0.036, HR 2.90), and severe dissection (p = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency. CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.
Background Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation ... more Background Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without leftventricular (LV) systolic dysfunction, as a result of left atrial enlargement. The purpose of this study was to evaluate the prognostic significance of residual functional MR in hospitalized heart failure patients with chronic AF and preserved LV ejection fraction (pEF) after medical therapies. Methods In this retrospective multi-center study, the determinants of post-discharge prognosis (cardiac death and re-hospitalization for worsening heart failure) were examined in 54 hospitalized heart failure patients with chronic AF and pEF at discharge. Results Of the 54 patients, 53 (98%) had mild or higher degrees of functional MR at hospitalization.At discharge, 47 (87%) still had functional MR, even after medical therapies [mild in 27 (50%), moderate in 16 (30%), and severe in 4 (7%)]. During the follow-up period (20 ± 16 months) after discharge, 16 (30%) patients met the composite end points. The grading of residual functional MR at discharge was the significant predictor of the end point (hazard ratio per one grade increase: 2.4, 95% confidence interval 1.1-5.5, p = 0.035). The greater the residual functional MR was, the lower the event-free rate from the end point was in the Kaplan-Meier curve analysis (p = 0.0069 for trend). Conclusions A substantial proportion of patients hospitalized due to heart failure with chronic AF have residual functional MR at discharge, even with pEF after medical therapies, and the MR is related to future heart failure events.
We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) sco... more We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. One hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. In a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1-11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8-125; p=0.013). During 18±9 months ...
spective analysis was therefore to investigate the prevalence and the prognostic significance of ... more spective analysis was therefore to investigate the prevalence and the prognostic significance of the occurrence of functional MR and TR despite preserved LV systolic function in patients with AF. Methods Subjects and Data Collection We retrospectively analyzed the echocardiography laboratory database and the medical records at Osaka City General Hospital, Osaka, Japan. We selected patients with AF and preserved LVEF (≥50%) who underwent transthoracic echocardiography (TTE) in the echocardiography laboratory over a period of 2 consecutive years (June 2012-May 2014). We excluded patients with acute decompensated HF (ADHF), a moderate or greater degree of organic valvular heart disease, apparent degenerative changes in mitral or tricuspid valve complex, a history of coronary artery disease or regional LV wall motion abnormality suggesting myocardial ischemia or infarction, or a
An increase in preload induces worsening of congestive heart failure and is an important cause of... more An increase in preload induces worsening of congestive heart failure and is an important cause of hospitalization due to acute decompensated heart failure . It also deteriorates functional mitral regurgitation (FMR) observed in patients with heart failure with reduced left ventricular (LV) ejection fraction . However, little evidence is available regarding the mechanisms of the changes in FMR induced by preload alterations. Passive leg lifting (PLL) is a simple maneuver that rapidly returns 150-200 ml of blood from the veins of the lower extremities to the central circulation . Nitroglycerin (NTG) is a short-lived veno-and arterial vasodilatory agent presumed to influence mainly the preload reduction and, to a lesser extent, the afterload reduction . By using these methods to change the preload condition, we investigated the mechanisms of acute changes in FMR by preload alterations in this study. Twenty-two consecutive patients with LV systolic dysfunction and at least mild FMR referred to the echocardiography laboratory of Osaka City General Hospital were enrolled in this study. LV
A previous study has suggested that isolated mitral annular dilation in patients with lone atrial... more A previous study has suggested that isolated mitral annular dilation in patients with lone atrial fibrillation (AF) does not usually cause functional mitral regurgitation (MR) [1]. In contrast, some other studies have shown that functional MR occasionally occurs in patients with AF and an enlarged left atrium (LA), despite having preserved left ventricular (LV) systolic function [2-4]. This MR is known as atrial functional MR [5]. Despite these earlier studies, the detailed mechanism of atrial functional MR has yet to be fully elucidated. Therefore, the purpose of this study was to clarify the mitral geometric changes in patients with atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE).
OBJECTIVES The purpose of this study was to clarify the prognostic significance of diagnosing whe... more OBJECTIVES The purpose of this study was to clarify the prognostic significance of diagnosing whether the failing heart is functioning on the descending limb of the Starling curve by using echocardiography with passive leg lifting (PLL). BACKGROUND Patients with advanced heart failure can shift to the descending limb of the Starling curve, in which pre-load does not lead to an expected increase in forward left ventricular stroke volume (LVSV). METHODS Thirty-five consecutive patients with left ventricular (LV) ejection fraction of <40% underwent echocardiography at rest during baseline and during PLL to increase pre-load. RESULTS Despite PLL, a paradoxical decrease in forward LVSV was observed in 15 (43%) patients. Changes in forward LVSV inversely correlated with those in functional mitral regurgitation (r ¼ À0.56). The primary endpoint of cardiac death or hospitalization due to worsening heart failure occurred in 15 (43%) patients during follow-up (2.8 AE 2.2 years). There were a number of significant predictors of the primary endpoint in the univariate Cox analysis: baseline E/A ratio (p ¼ 0.0002), paradoxical decrease in LVSV despite PLL (hazard ratio: 4.44; 95% confidence interval: 1.41 to 14.0; p ¼ 0.011), baseline LV end-systolic volume (p ¼ 0.023), and baseline LV ejection fraction (p ¼ 0.034). In the bivariate Cox analysis, an addition of the paradoxical decrease in LVSV significantly enhanced the predictive power of all other univariate predictors. CONCLUSIONS Heart failure patients with LV systolic dysfunction on the descending limb of the Starling curve can be recognized by the paradoxical decrease in LVSV despite PLL, and the prognostic predicting power is additive to the other traditional echocardiographic predictors. Also, our results suggest that functional mitral regurgitation is an important reason for the descending limb of the Starling curve, which is clinically recognized as the pre-load-induced decrease in
We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) sco... more We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. One hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. In a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1-11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8-125; p=0.013). During 18±9 months ...
Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atri... more Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atrial functional mitral regurgitation and tricuspid regurgitation in patients with atrial fibrillation. Methods From October 2008 to August 2016, we performed mitral and tricuspid valve repairs in 45 patients with permanent atrial fibrillation, chronic heart failure, preserved left ventricular ejection fraction, and at least moderate functional mitral regurgitation and mild functional tricuspid regurgitation. The follow-up period ranged from 56 to 3283 days (2-109 months; median 932 days). Results All patients underwent both mitral and tricuspid annuloplasty. Mitral regurgitation and tricuspid regurgitation improved from 2.6 ± 0.6 (0-3) and 2.0 ± 0.7 (0-3) preoperatively to 0.4 ± 0.3 (0-3) and 0.8 ± 0.5 (0-3) at the most recent echocardiography (p < 0.0001 and p < 0.0001), respectively. Further, the New York Heart Association functional class dramatically improved from 2.8 ± 0.7 to 1.5 ± 0.7 (p < 0.0001). Postoperative cardiovascular events occurred in 10 patients, including 3 with re-admissions for heart failure. The event-free rates were 93%, 87%, and 52% at 1, 3, and 5 years after surgery, respectively. The preoperative left atrial volume index was the independent predictor of postoperative cardiovascular events. Conclusions Our results suggest that mitral and tricuspid valve repairs lead to reductions in regurgitations and heart failure symptoms in patients with atrial functional mitral and tricuspid regurgitations. The preoperative left atrial size should be recognized as an important risk factor of postoperative cardiovascular events.
PURPOSE In this study, we examined the hypothesis that the preferential conduction property along... more PURPOSE In this study, we examined the hypothesis that the preferential conduction property along left lateral ridge (LLR) might affect the arrhythmogenicity of left pulmonary veins (LPVs). METHODS The study population included 40 consecutive AF patients. Radiofrequency energy (RF) was sequentially delivered along the LLR from a lower to upper manner during postero-lateral CS pacing during an isoproterenol infusion. RESULTS The conduction time during pacing from the CS was significantly prolonged during radiofrequency (RF) deliveries (before vs. after, upper; 91±26ms vs. 127±38ms, p<0.001, lower; 86±21ms vs. 103±22ms, p<0.001). Remarkable prolongation of more than 30ms was observed in 19 of 40 patients (48%) (both LPVs, 6; only the upper LPVs, 12; and only the lower LPV, 1). Sites with a remarkable prolongation were observed at the carina between the LPVs,[4] anterior site of the upper LPV carina,[10] anterior wall of the lower LPV,[3] and bottom of the lower LPVs [2] Thirty-t...
Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atri... more Objectives This study aimed to determine the mid-term outcomes of surgical valve repairs for atrial functional mitral regurgitation and tricuspid regurgitation in patients with atrial fibrillation. Methods From October 2008 to August 2016, we performed mitral and tricuspid valve repairs in 45 patients with permanent atrial fibrillation, chronic heart failure, preserved left ventricular ejection fraction, and at least moderate functional mitral regurgitation and mild functional tricuspid regurgitation. The follow-up period ranged from 56 to 3283 days (2-109 months; median 932 days). Results All patients underwent both mitral and tricuspid annuloplasty. Mitral regurgitation and tricuspid regurgitation improved from 2.6 ± 0.6 (0-3) and 2.0 ± 0.7 (0-3) preoperatively to 0.4 ± 0.3 (0-3) and 0.8 ± 0.5 (0-3) at the most recent echocardiography (p < 0.0001 and p < 0.0001), respectively. Further, the New York Heart Association functional class dramatically improved from 2.8 ± 0.7 to 1.5 ± 0.7 (p < 0.0001). Postoperative cardiovascular events occurred in 10 patients, including 3 with re-admissions for heart failure. The event-free rates were 93%, 87%, and 52% at 1, 3, and 5 years after surgery, respectively. The preoperative left atrial volume index was the independent predictor of postoperative cardiovascular events. Conclusions Our results suggest that mitral and tricuspid valve repairs lead to reductions in regurgitations and heart failure symptoms in patients with atrial functional mitral and tricuspid regurgitations. The preoperative left atrial size should be recognized as an important risk factor of postoperative cardiovascular events.
Background: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion... more Background: Chronic total occlusion (CTO) of femoropopliteal artery (FP) continues to be a lesion subset where maintaining long-term patency after endovascular treatment is challenging. We evaluated the efficacy of cutting balloon angioplasty (CBA) for de novo FP-CTOs in patients with symptomatic lower limb ischemia. Methods: Seventy-three limbs of 67 symptomatic patients with de novo FP-CTOs successfully recanalized using CBA alone were enrolled in this study. Primary patency was defined as the absence of recurrent symptoms and no deterioration of the ankle-brachial index (ABI) >0.10 from the immediate postinterventional value. The mean age was 73.5 ± 7.3 years, and 59.7% of patients had diabetes mellitus. Most lesions were classified as Trans-Atlantic Inter-Society Consensus II type C (n = 18; 24.7%) or type D (n = 44; 60.3%), with mean lesion and occluded lengths of 24.8 ± 11.4 and 17.8 ± 11.2 cm, respectively. No procedure-related adverse events occurred, except one distal embolization. The ABI significantly increased after intervention from 0.52 ± 0.12 to 0.80 ± 0.15 (p < 0.0001), with marked improvement in clinical symptoms (Rutherford stage: 2.7 ± 1.0 to 1.1 ± 1.2, p < 0.0001). The mean follow-up period was 31.2 ± 18.0 months, and the primary patency rates at 12 and 24 months were 75.3% and 60.6%, respectively. The independent predictive factors of failed patency were baseline hemoglobin A1c (p = 0.031, hazard radio [HR] 1.51 per 1%), occluded length ≥ 15 cm (p = 0.036, HR 2.90), and severe dissection (p = 0.033, HR 2.85). Vessel calcification and diameter did not affect primary patency. CBA is a feasible option for endovascular treatment of FP-CTOs. Diabetic status, occlusion length, and severe dissection after CBA are independent negative predictors of long-term patency.
Background Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation ... more Background Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without leftventricular (LV) systolic dysfunction, as a result of left atrial enlargement. The purpose of this study was to evaluate the prognostic significance of residual functional MR in hospitalized heart failure patients with chronic AF and preserved LV ejection fraction (pEF) after medical therapies. Methods In this retrospective multi-center study, the determinants of post-discharge prognosis (cardiac death and re-hospitalization for worsening heart failure) were examined in 54 hospitalized heart failure patients with chronic AF and pEF at discharge. Results Of the 54 patients, 53 (98%) had mild or higher degrees of functional MR at hospitalization.At discharge, 47 (87%) still had functional MR, even after medical therapies [mild in 27 (50%), moderate in 16 (30%), and severe in 4 (7%)]. During the follow-up period (20 ± 16 months) after discharge, 16 (30%) patients met the composite end points. The grading of residual functional MR at discharge was the significant predictor of the end point (hazard ratio per one grade increase: 2.4, 95% confidence interval 1.1-5.5, p = 0.035). The greater the residual functional MR was, the lower the event-free rate from the end point was in the Kaplan-Meier curve analysis (p = 0.0069 for trend). Conclusions A substantial proportion of patients hospitalized due to heart failure with chronic AF have residual functional MR at discharge, even with pEF after medical therapies, and the MR is related to future heart failure events.
We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) sco... more We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. One hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. In a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1-11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8-125; p=0.013). During 18±9 months ...
spective analysis was therefore to investigate the prevalence and the prognostic significance of ... more spective analysis was therefore to investigate the prevalence and the prognostic significance of the occurrence of functional MR and TR despite preserved LV systolic function in patients with AF. Methods Subjects and Data Collection We retrospectively analyzed the echocardiography laboratory database and the medical records at Osaka City General Hospital, Osaka, Japan. We selected patients with AF and preserved LVEF (≥50%) who underwent transthoracic echocardiography (TTE) in the echocardiography laboratory over a period of 2 consecutive years (June 2012-May 2014). We excluded patients with acute decompensated HF (ADHF), a moderate or greater degree of organic valvular heart disease, apparent degenerative changes in mitral or tricuspid valve complex, a history of coronary artery disease or regional LV wall motion abnormality suggesting myocardial ischemia or infarction, or a
An increase in preload induces worsening of congestive heart failure and is an important cause of... more An increase in preload induces worsening of congestive heart failure and is an important cause of hospitalization due to acute decompensated heart failure . It also deteriorates functional mitral regurgitation (FMR) observed in patients with heart failure with reduced left ventricular (LV) ejection fraction . However, little evidence is available regarding the mechanisms of the changes in FMR induced by preload alterations. Passive leg lifting (PLL) is a simple maneuver that rapidly returns 150-200 ml of blood from the veins of the lower extremities to the central circulation . Nitroglycerin (NTG) is a short-lived veno-and arterial vasodilatory agent presumed to influence mainly the preload reduction and, to a lesser extent, the afterload reduction . By using these methods to change the preload condition, we investigated the mechanisms of acute changes in FMR by preload alterations in this study. Twenty-two consecutive patients with LV systolic dysfunction and at least mild FMR referred to the echocardiography laboratory of Osaka City General Hospital were enrolled in this study. LV
A previous study has suggested that isolated mitral annular dilation in patients with lone atrial... more A previous study has suggested that isolated mitral annular dilation in patients with lone atrial fibrillation (AF) does not usually cause functional mitral regurgitation (MR) [1]. In contrast, some other studies have shown that functional MR occasionally occurs in patients with AF and an enlarged left atrium (LA), despite having preserved left ventricular (LV) systolic function [2-4]. This MR is known as atrial functional MR [5]. Despite these earlier studies, the detailed mechanism of atrial functional MR has yet to be fully elucidated. Therefore, the purpose of this study was to clarify the mitral geometric changes in patients with atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE).
OBJECTIVES The purpose of this study was to clarify the prognostic significance of diagnosing whe... more OBJECTIVES The purpose of this study was to clarify the prognostic significance of diagnosing whether the failing heart is functioning on the descending limb of the Starling curve by using echocardiography with passive leg lifting (PLL). BACKGROUND Patients with advanced heart failure can shift to the descending limb of the Starling curve, in which pre-load does not lead to an expected increase in forward left ventricular stroke volume (LVSV). METHODS Thirty-five consecutive patients with left ventricular (LV) ejection fraction of <40% underwent echocardiography at rest during baseline and during PLL to increase pre-load. RESULTS Despite PLL, a paradoxical decrease in forward LVSV was observed in 15 (43%) patients. Changes in forward LVSV inversely correlated with those in functional mitral regurgitation (r ¼ À0.56). The primary endpoint of cardiac death or hospitalization due to worsening heart failure occurred in 15 (43%) patients during follow-up (2.8 AE 2.2 years). There were a number of significant predictors of the primary endpoint in the univariate Cox analysis: baseline E/A ratio (p ¼ 0.0002), paradoxical decrease in LVSV despite PLL (hazard ratio: 4.44; 95% confidence interval: 1.41 to 14.0; p ¼ 0.011), baseline LV end-systolic volume (p ¼ 0.023), and baseline LV ejection fraction (p ¼ 0.034). In the bivariate Cox analysis, an addition of the paradoxical decrease in LVSV significantly enhanced the predictive power of all other univariate predictors. CONCLUSIONS Heart failure patients with LV systolic dysfunction on the descending limb of the Starling curve can be recognized by the paradoxical decrease in LVSV despite PLL, and the prognostic predicting power is additive to the other traditional echocardiographic predictors. Also, our results suggest that functional mitral regurgitation is an important reason for the descending limb of the Starling curve, which is clinically recognized as the pre-load-induced decrease in
We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) sco... more We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. One hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. In a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1-11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8-125; p=0.013). During 18±9 months ...
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