Background: The lesions in the proximal left coronary artery (pLCA) are associated with poorer pr... more Background: The lesions in the proximal left coronary artery (pLCA) are associated with poorer prognosis compared to other lesional sites. Transthoracic Doppler echocardiography (TTDE) can be performed in a short time period and combined with routine echocardiography. Furthermore, the increased coronary flow velocity (CFV) detected by TTDE reflects the presence of pLCA lesions with high specificity (a representative case is shown in Figure A). The aim of this study was to test the hypothesis that an increased CFV in the pLCA is associated with a poor prognosis. Methods: We enrolled 2032 consecutive patients with suspected heart diseases whose CFVs were successfully detected by TTDE combined with routine echocardiography using Vivid 7 (GE Vingmed, Horten, Norway). Patients with a history of coronary artery bypass surgery, hypertrophic cardiomyopathy or severe valvular disease were excluded as these diseases may affect the CFV. For the evaluation of CFV in the pLCA, the average diastolic peak velocity (ADPV) was measured using the pulsed Doppler method. The primary outcome was cardiac death, and patients were followed up over 6.2 years (median). Cox multivariate regression analysis was used to assess the independent association of ADPV with the primary outcome, and net reclassification improvement (NRI) was used to assess the incremental benefit over the traditional risk model. Results: Overall, 52 cardiac deaths were observed. The median ADPV was 23 cm/s. When the patients were classified within the quartile boundaries of ADPV, the Kaplan-Meier curves showed a significantly higher incidence of cardiac death in the group with the highest ADPV than the other groups (p<0.01) (Figure B). Increased ADPV was independently associated with the primary outcome after adjustment for age, sex, the estimated glomerular filtration rate, prior myocardial infarction, the Framingham risk score and left ventricular ejection fraction (p<0.01). Furthermore, the addition of ADPV to the model based on clinical and echocardiographic parameters led to a further significant reclassification improvement (NRI = 0.52, p<0.01). Vascular uptake per territory Location TBR (tissue-to-background ratio) CUL (corrected uptake per lesion) Aortic artery 2.1 (1.8-2.2) 0.9±0.3 Carotid arteries 0.
Introduction: Fabry disease (FD) is an inherited X-linked metabolic storage disorder, leads to a ... more Introduction: Fabry disease (FD) is an inherited X-linked metabolic storage disorder, leads to a deficiency in α-galactosidase A and massive accumulation of intralysosomal glycosphingolipids. Cardiac complications are the main cause of morbidity. It is difficult to diagnose especially female heterozygous patients, because of later onset and slower progression. Case: A 67-years-old female diagnosed as dilated hypertrophic cardiomyopathy with repeated episodes of heart failure referred to our hospital for further evaluation. She had severe symptoms NYHA Class IV. Echocardiography showed diffuse severe hypokinesis (LVEF = 33%) and moderate mitral regurgitation. Urinary mulberry cells were occasionally found in urine test. She also had proteinuria with chronic kidney disease and cataracts, consistent with the findings of FD. We strongly suspected FD, but α-galactosidase activity was in normal range. Genetic testing was refused. We performed CRT-D implantation; however, her symptoms were worsened. Despite multidisciplinary treatments, she died due to multiple organs dysfunction as a result of end-stage heart failure. Discussion: Urinary mulberry cells are the key findings to suspect FD in this case. In general, enzyme replacement therapy leads to significant clinical benefits in FD. If this case had been diagnosed, appropriate treatment could have been conducted effectively. FD should be considered in patients with unexplained left ventricular hypertrophy even in female patients, and repeated urine tests might be helpful to diagnose it.
Background: Paroxysmal nocturnal dyspnea (PND) is a common symptom for patients with acute decomp... more Background: Paroxysmal nocturnal dyspnea (PND) is a common symptom for patients with acute decompensated heart failure (ADHF). Some symptoms of PND are similar to those of sleep apnea (SA) which might be associated with overnight worsening hemodynamics in failing hearts. However, the association between PND, SA, and overnight change in hemodynamics in patients with heart failure remains uncertain. Methods: We studied 28 consecutive patients with reduced ejection fraction who were hospitalized with ADHF. Plasma atrial natriuretic peptide (ANP) levels were measured before and after overnight sleep study. PND was defined as having an episode of PND prior to hospitalization for ADHF. Results: Ten (36%) patients had a history of PND. Respiratory disturbance index (the frequency and severity of sleep apnea) was an independent factor associated with a history of PND (odds ratio 1.24, 95% confidence interval 1.05-1.47, p = 0.011). In those without PND, plasma ANP levels decreased from before sleep to after waking, whereas in those with PND it increased (p = 0.011). In addition, overnight change in plasma ANP levels was independently associated with respiratory disturbance index (p = 0.035). Conclusion: These results thus suggest that in patients with ADHF, SA might be a predisposing cause of PND in association with overnight worsening hemodynamics.
Background: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with balloon pulmo... more Background: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with balloon pulmonary angioplasty (BPA) reportedly improves hemodynamics, exercise capacity, and right ventricular function. However, the effect of BPA on respiratory functions is unclear. Methods: We enrolled consecutive patients with inoperable CTEPH who underwent BPA. BPA was performed primarily on the lower lobe arteries during the first series and on the upper and middle lobe arteries during the second series. We examined right heart catheterization, the respiratory function test, and the cardiopulmonary exercise test, and compared the change in these parameters according to the BPA performed field (divided into the upper-middle and lower lobe before BPA, after BPA, and the follow-up period). Results: In total, 62 BPA sessions were performed in 13 CTEPH patients. Hemodynamics significantly improved after BPA (mPAP: 44±8 to 24±5 mmHg, PVR: 818±383 to 293±68 dyne/s/cm-5), and WHO-FC improved from 3.1±0.3 to 2.2±0.6 after BPA. Hemodynamic improvement tended to be larger in BPA in the lower lung field. The %DLco significantly decreased (p=0.001) in BPA in the lower lung field, and did not appear to recover during the follow-up period. In contrast, %DLco significantly increased in BPA in the upper-middle lung field (p=0.030), and tended to increase until the follow-up period (p=0.077) (Fig). In addition, VE/VCO2 slope significantly improved after BPA in the lower lung field (p=0.014), and showed further improvement at the follow-up period (p=0.007); however, VE/VCO2 slope remained unchanged after BPA in the upper-middle lung field (Fig). Furthermore, during follow-up, change in %DLco and VE/VCO2 slope were significantly different between lower and upper-middle lung field BPA performed (p&amp;amp;lt;0.001 and p=0.020, respectively, Fig). Conclusions: We observed that the effect of BPA in CTEPH patients may have a different effect on respiratory function according to the lung field.
BACKGROUND: Balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension ... more BACKGROUND: Balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension (CTEPH) improves hemodynamics and exercise capacity. However, its effect on respiratory function is unclear. Our objective was to investigate the effect of BPA on respiratory function. METHODS: We enrolled patients with inoperable CTEPH who underwent BPA primarily in lower lobe arteries (first series) and upper and middle lobe arteries (second series). We compared changes in hemodynamics and respiratory function between different BPA fields. RESULTS: Sixty‐two BPA sessions were performed in 13 consecutive patients. Mean pulmonary arterial pressure and pulmonary vascular resistance significantly improved from 44 ± 8 to 23 ± 5 mm Hg and 818 ± 383 to 311 ± 117 dyne/s/cm−5. The percent predicted diffusion capacity of lung for carbon monoxide (Dlco) decreased after BPA in the lower lung field (from 60% ± 8% to 54% ± 8%) with no recovery. Percent Dlco increased after BPA in the upper middle lung field (from 53% ± 6% to 58% ± 6%) and continued to improve during the follow‐up (from 58% ± 6% to 64% ± 11%). The ventilation/Co2 production (Symbole/Symbolco2) slope significantly improved after BPA in the lower lung field (from 51 ± 13 to 41 ± 8) and continued to improve during the follow‐up (from 41 ± 8 to 35 ± 7); however, the Symbole/Symbolco2 slope remained unchanged after BPA in the upper/middle lung field. Changes in % Dlco and the Symbole/Symbolco2 slope differed significantly between lower and upper/middle lung fields. Symbol. No caption available. CONCLUSIONS: The effect of BPA on respiratory function in patients with CTEPH differed depending on the lung field.
Molecular imaging beyond CAD were visualised (1.3±0.9 per patient; p=0.82 vs baseline) with mean ... more Molecular imaging beyond CAD were visualised (1.3±0.9 per patient; p=0.82 vs baseline) with mean activity ratio of 5.2±2.8 (p=0.15 vs baseline). In 7 (70%) subjects the locations of DUA were the same as compared to baseline images. One additional DUA was visualised in 3 (30%) subjects on FU images. Conclusion: In the majority of healthy individuals the areas of left atrial sympathetic activity can be visualised and are reproducible. The difference in activity of localised discrete uptake areas of 123I-mIBG between healthy subjects and patients with arrhythmias deserve further investigation and may play an important role in development and management of atrial fibrillation.
Journal of the American College of Cardiology, Mar 1, 2018
Background: Corticosteroid therapy is recommended for initial treatment for cardiac sarcoidosis (... more Background: Corticosteroid therapy is recommended for initial treatment for cardiac sarcoidosis (CS). However, optimal maintenance dose and evaluation method for activity of CS are not established. We evaluated the activity of CS by 18 F-fluorodeoxyglucose PET (FDG) during maintenance dose period of corticosteroid therapy. Methods: Fifty consecutive patients with CS who underwent FDG before and after corticosteroid therapy were enrolled into analysis. FDG uptake was analyzed quantitatively for each scan and mean/max of standardized uptake in myocardium (SUVmean, SUVmax); cardiac metabolic volume (CMV=volume with SUV>2.5) were measured. All patients were treated with 30 mg/day of prednisolone after diagnosis, which was tapered to a maintenance dose of 5-10 mg/day according to the guideline. If the disease is stable, corticosteroid may be tapered further at a physician's discretion. Patients who have not achieved to maintenance dose of corticosteroid were excluded. Relapse of CS was defined as SUVmax>2.5 with developed myocardial damage evaluated by single photon emission computed tomography or cardiovascular magnetic resonance imaging. Results: Thirty-nine patients were included (the median minimum dose of corticosteroid was 7.5mg (IQR, 1-10). Five of 39 patients (13%) had the evidence of relapse. Patients with relapsed showed significantly greater CMV at diagnosis (208±93 vs. 78±112 ml, p=0.028) and change in left ventricular ejection fraction (-7±11 vs. 3±6 %, p=0.023) than those without. While, SUVmax, LVEF, and conventional biomarker test, such as ACE and lysozyme at diagnosis, and maintenance dosage of corticosteroid were not significant differences patients with and without relapse. All patients with relapse were handled by increasing prednisone and diminished of FDG uptake at follow-up. Conclusion: During maintenance dose period of corticosteroid, relapses were not uncommon. FDG-PET should be recommended to evaluate CS activity.
Cardiac sarcoidosis (CS) can be diagnosed using (18)F-FDG-PET/CT (PET), cardiovascular magnetic r... more Cardiac sarcoidosis (CS) can be diagnosed using (18)F-FDG-PET/CT (PET), cardiovascular magnetic resonance (CMR), and (123)I-BMIPP/(201)TlCl dual myocardial SPECT. This study aims to clarify the relationships among the three modalities with respect to CS. We evaluated 16 patients (male n = 11; age 55 ± 13 years) with confirmed CS who underwent PET, CMR, and dual SPECT with gated SPECT before starting steroid therapy. The left ventricular myocardium was divided into 17 segments to obtain SUVmax for PET images, defect scores from 0 to 4 (0 normal; 4 absent), and mismatch scores for dual SPECT (BMDS, TLDS, and MS) images and late gadolinium enhancement (LGE) scores (0 none; 1 partly positive; 2 homogeneous) on CMR images. Summed BMDS, TLDS, and MS were 18.6 ± 12.6, 12.9 ± 10.9, and 5.7 ± 3.1, respectively. The segmental BMDS and TLDS scores became significantly higher as the LGE scores increased. The MS scores were significantly higher in areas of LGE with a score of 1 than 0 (both, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), but did not significantly differ between areas with LGE scores of 1 and 2. The SUVmax was significantly higher in LGE areas with a score of 1 than 0 (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.025), but did not significantly differ between those with scores of 1 or 2. Regions with a higher SUVmax indicating active myocardial inflammation were mainly located in areas with LGE, where BMIPP and TL mismatches were evident in patients with CS.
Journal of the American College of Cardiology, Sep 1, 2008
To the Editor: Obstructive sleep apnea (OSA), characterized by partial or complete occlusion of t... more To the Editor: Obstructive sleep apnea (OSA), characterized by partial or complete occlusion of the pharynx during sleep, results in persistent inspiratory effort and interruption of airflow. During each episode of apnea, OSA patients develop increased transmural pressure in the aortic wall. Accordingly, to test the hypothesis that the presence of OSA would be associated with greater thoracic aortic size, we prospectively assessed 150 consecutive patients, newly referred to the sleep clinic in our institution, in a crosssectional study to confirm OSA. The patients underwent sleep study and chest computed tomography (CT)-derived thoracic aortic diameter. In this particular period, a chest CT was performed within 3 months of the sleep study upon informed consent to our protocol. Exclusion criteria included: 1) prior history of aortic dissection, aortic valvular disease, and clinical characteristics of Marfan's syndrome; 2) central sleep apnea; 3) treatment for sleep apnea; and 4) dialysis. The outer diameter of the ascending aorta was measured by caliper within the CT image. Overnight sleep study was performed using cardiopulmonary monitoring (Morpheus, Teijin Inc., Tokyo, Japan). The apnea-hypopnea index (AHI) was quantified as the frequency of apneas and hypopneas per hour of bed time. OSA was defined as AHI Ն10/h. The data are presented as mean Ϯ SD or frequencies. To determine the independent factors, the multiple linear regression model with backward elimination technique was used, including older age, male gender, blood pressure, hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease, smoking, and AHI. Comparisons between the 2 groups were performed by Student t test for the unadjusted aortic diameter and by analysis of covariance for the adjusted aortic diameter. The patients' mean age was 60 Ϯ 11 years; 125 (83%) were men, with mean body mass index of 24.7 Ϯ 3.1 kg/m 2. Fifty-nine percent of patients had hypertension. At assessment, 91% of patients had already taken prescribed antihypertensive medications. One hundred ten patients (73%) had OSA. On univariate analysis, older age, male gender, body mass index, systolic blood pressure, pulse pressure, hypertension, dyslipidemia, ischemic heart disease, and AHI were positively correlated with thoracic aortic size. On multivariate analysis, older age (per 10-year increase, coefficient 1.82, 95% confidence interval [CI]: 1.13 to 2.34, p Ͻ 0.001), male gender (coefficient 3.25, 95% CI: 1.63 to 4.87, p Ͻ 0.001), and AHI (per 10-event/h increase, coefficient 0.62, 95% CI: 0.25 to 0.98, p Ͻ 0.001) remained as factors associated with greater thoracic aortic diameter. Contrarily, there was no significant independent relationship between blood pressure/hypertension and thoracic aortic size. Additionally, patients with OSA had a significantly greater thoracic aortic size than those without OSA (p Ͻ 0.001) (Fig. 1), even if adjusted for older age and male gender (p Ͻ 0.001). Increased thoracic aortic size is known to be related to aging, male, genetic mutation including Marfan's syndrome, hyperten
Pulmonary research and respiratory medicine, Oct 28, 2017
Traditionally, patients with pulmonary hypertension (PH) were advised to limit their physical act... more Traditionally, patients with pulmonary hypertension (PH) were advised to limit their physical activity because of the risk of fatal cardiovascular compromise. However, relatively little is known about the risks and benefits of exercise for patients with PH. The present article discussed the effects and safety of pulmonary rehabilitation in PH in light of the current literature. To sum up, exercise training has been reported to significantly improve exercise capacity and quality of life (QoL), whereas the method of intervention, exercise training duration, and patient status (including medically stable patients, immediately after intervention) varied slightly among studies. Furthermore, most of the adverse events were nonfatal and not a direct consequence of exercise training. Accordingly, exercise training in patients with PH seems safe and beneficial. However, the long-term effect of exercise in PH has not been shown. Thus, the precise mechanisms through which pulmonary rehabilitation may influence cardiopulmonary function remains unclear. Future multicenter randomized control trials with longer follow-up duration are needed to further demonstrate the safety, efficacy, and feasibility of exercise training in patients with various types of PH.Although some questions remain, exercise training in patients with PH seems safe and beneficial. Therefore, supervised rehabilitation programs for patients with PH including close monitoring should be encouraged.
Background: The lesions in the proximal left coronary artery (pLCA) are associated with poorer pr... more Background: The lesions in the proximal left coronary artery (pLCA) are associated with poorer prognosis compared to other lesional sites. Transthoracic Doppler echocardiography (TTDE) can be performed in a short time period and combined with routine echocardiography. Furthermore, the increased coronary flow velocity (CFV) detected by TTDE reflects the presence of pLCA lesions with high specificity (a representative case is shown in Figure A). The aim of this study was to test the hypothesis that an increased CFV in the pLCA is associated with a poor prognosis. Methods: We enrolled 2032 consecutive patients with suspected heart diseases whose CFVs were successfully detected by TTDE combined with routine echocardiography using Vivid 7 (GE Vingmed, Horten, Norway). Patients with a history of coronary artery bypass surgery, hypertrophic cardiomyopathy or severe valvular disease were excluded as these diseases may affect the CFV. For the evaluation of CFV in the pLCA, the average diastolic peak velocity (ADPV) was measured using the pulsed Doppler method. The primary outcome was cardiac death, and patients were followed up over 6.2 years (median). Cox multivariate regression analysis was used to assess the independent association of ADPV with the primary outcome, and net reclassification improvement (NRI) was used to assess the incremental benefit over the traditional risk model. Results: Overall, 52 cardiac deaths were observed. The median ADPV was 23 cm/s. When the patients were classified within the quartile boundaries of ADPV, the Kaplan-Meier curves showed a significantly higher incidence of cardiac death in the group with the highest ADPV than the other groups (p<0.01) (Figure B). Increased ADPV was independently associated with the primary outcome after adjustment for age, sex, the estimated glomerular filtration rate, prior myocardial infarction, the Framingham risk score and left ventricular ejection fraction (p<0.01). Furthermore, the addition of ADPV to the model based on clinical and echocardiographic parameters led to a further significant reclassification improvement (NRI = 0.52, p<0.01). Vascular uptake per territory Location TBR (tissue-to-background ratio) CUL (corrected uptake per lesion) Aortic artery 2.1 (1.8-2.2) 0.9±0.3 Carotid arteries 0.
Introduction: Fabry disease (FD) is an inherited X-linked metabolic storage disorder, leads to a ... more Introduction: Fabry disease (FD) is an inherited X-linked metabolic storage disorder, leads to a deficiency in α-galactosidase A and massive accumulation of intralysosomal glycosphingolipids. Cardiac complications are the main cause of morbidity. It is difficult to diagnose especially female heterozygous patients, because of later onset and slower progression. Case: A 67-years-old female diagnosed as dilated hypertrophic cardiomyopathy with repeated episodes of heart failure referred to our hospital for further evaluation. She had severe symptoms NYHA Class IV. Echocardiography showed diffuse severe hypokinesis (LVEF = 33%) and moderate mitral regurgitation. Urinary mulberry cells were occasionally found in urine test. She also had proteinuria with chronic kidney disease and cataracts, consistent with the findings of FD. We strongly suspected FD, but α-galactosidase activity was in normal range. Genetic testing was refused. We performed CRT-D implantation; however, her symptoms were worsened. Despite multidisciplinary treatments, she died due to multiple organs dysfunction as a result of end-stage heart failure. Discussion: Urinary mulberry cells are the key findings to suspect FD in this case. In general, enzyme replacement therapy leads to significant clinical benefits in FD. If this case had been diagnosed, appropriate treatment could have been conducted effectively. FD should be considered in patients with unexplained left ventricular hypertrophy even in female patients, and repeated urine tests might be helpful to diagnose it.
Background: Paroxysmal nocturnal dyspnea (PND) is a common symptom for patients with acute decomp... more Background: Paroxysmal nocturnal dyspnea (PND) is a common symptom for patients with acute decompensated heart failure (ADHF). Some symptoms of PND are similar to those of sleep apnea (SA) which might be associated with overnight worsening hemodynamics in failing hearts. However, the association between PND, SA, and overnight change in hemodynamics in patients with heart failure remains uncertain. Methods: We studied 28 consecutive patients with reduced ejection fraction who were hospitalized with ADHF. Plasma atrial natriuretic peptide (ANP) levels were measured before and after overnight sleep study. PND was defined as having an episode of PND prior to hospitalization for ADHF. Results: Ten (36%) patients had a history of PND. Respiratory disturbance index (the frequency and severity of sleep apnea) was an independent factor associated with a history of PND (odds ratio 1.24, 95% confidence interval 1.05-1.47, p = 0.011). In those without PND, plasma ANP levels decreased from before sleep to after waking, whereas in those with PND it increased (p = 0.011). In addition, overnight change in plasma ANP levels was independently associated with respiratory disturbance index (p = 0.035). Conclusion: These results thus suggest that in patients with ADHF, SA might be a predisposing cause of PND in association with overnight worsening hemodynamics.
Background: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with balloon pulmo... more Background: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with balloon pulmonary angioplasty (BPA) reportedly improves hemodynamics, exercise capacity, and right ventricular function. However, the effect of BPA on respiratory functions is unclear. Methods: We enrolled consecutive patients with inoperable CTEPH who underwent BPA. BPA was performed primarily on the lower lobe arteries during the first series and on the upper and middle lobe arteries during the second series. We examined right heart catheterization, the respiratory function test, and the cardiopulmonary exercise test, and compared the change in these parameters according to the BPA performed field (divided into the upper-middle and lower lobe before BPA, after BPA, and the follow-up period). Results: In total, 62 BPA sessions were performed in 13 CTEPH patients. Hemodynamics significantly improved after BPA (mPAP: 44±8 to 24±5 mmHg, PVR: 818±383 to 293±68 dyne/s/cm-5), and WHO-FC improved from 3.1±0.3 to 2.2±0.6 after BPA. Hemodynamic improvement tended to be larger in BPA in the lower lung field. The %DLco significantly decreased (p=0.001) in BPA in the lower lung field, and did not appear to recover during the follow-up period. In contrast, %DLco significantly increased in BPA in the upper-middle lung field (p=0.030), and tended to increase until the follow-up period (p=0.077) (Fig). In addition, VE/VCO2 slope significantly improved after BPA in the lower lung field (p=0.014), and showed further improvement at the follow-up period (p=0.007); however, VE/VCO2 slope remained unchanged after BPA in the upper-middle lung field (Fig). Furthermore, during follow-up, change in %DLco and VE/VCO2 slope were significantly different between lower and upper-middle lung field BPA performed (p&amp;amp;lt;0.001 and p=0.020, respectively, Fig). Conclusions: We observed that the effect of BPA in CTEPH patients may have a different effect on respiratory function according to the lung field.
BACKGROUND: Balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension ... more BACKGROUND: Balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension (CTEPH) improves hemodynamics and exercise capacity. However, its effect on respiratory function is unclear. Our objective was to investigate the effect of BPA on respiratory function. METHODS: We enrolled patients with inoperable CTEPH who underwent BPA primarily in lower lobe arteries (first series) and upper and middle lobe arteries (second series). We compared changes in hemodynamics and respiratory function between different BPA fields. RESULTS: Sixty‐two BPA sessions were performed in 13 consecutive patients. Mean pulmonary arterial pressure and pulmonary vascular resistance significantly improved from 44 ± 8 to 23 ± 5 mm Hg and 818 ± 383 to 311 ± 117 dyne/s/cm−5. The percent predicted diffusion capacity of lung for carbon monoxide (Dlco) decreased after BPA in the lower lung field (from 60% ± 8% to 54% ± 8%) with no recovery. Percent Dlco increased after BPA in the upper middle lung field (from 53% ± 6% to 58% ± 6%) and continued to improve during the follow‐up (from 58% ± 6% to 64% ± 11%). The ventilation/Co2 production (Symbole/Symbolco2) slope significantly improved after BPA in the lower lung field (from 51 ± 13 to 41 ± 8) and continued to improve during the follow‐up (from 41 ± 8 to 35 ± 7); however, the Symbole/Symbolco2 slope remained unchanged after BPA in the upper/middle lung field. Changes in % Dlco and the Symbole/Symbolco2 slope differed significantly between lower and upper/middle lung fields. Symbol. No caption available. CONCLUSIONS: The effect of BPA on respiratory function in patients with CTEPH differed depending on the lung field.
Molecular imaging beyond CAD were visualised (1.3±0.9 per patient; p=0.82 vs baseline) with mean ... more Molecular imaging beyond CAD were visualised (1.3±0.9 per patient; p=0.82 vs baseline) with mean activity ratio of 5.2±2.8 (p=0.15 vs baseline). In 7 (70%) subjects the locations of DUA were the same as compared to baseline images. One additional DUA was visualised in 3 (30%) subjects on FU images. Conclusion: In the majority of healthy individuals the areas of left atrial sympathetic activity can be visualised and are reproducible. The difference in activity of localised discrete uptake areas of 123I-mIBG between healthy subjects and patients with arrhythmias deserve further investigation and may play an important role in development and management of atrial fibrillation.
Journal of the American College of Cardiology, Mar 1, 2018
Background: Corticosteroid therapy is recommended for initial treatment for cardiac sarcoidosis (... more Background: Corticosteroid therapy is recommended for initial treatment for cardiac sarcoidosis (CS). However, optimal maintenance dose and evaluation method for activity of CS are not established. We evaluated the activity of CS by 18 F-fluorodeoxyglucose PET (FDG) during maintenance dose period of corticosteroid therapy. Methods: Fifty consecutive patients with CS who underwent FDG before and after corticosteroid therapy were enrolled into analysis. FDG uptake was analyzed quantitatively for each scan and mean/max of standardized uptake in myocardium (SUVmean, SUVmax); cardiac metabolic volume (CMV=volume with SUV>2.5) were measured. All patients were treated with 30 mg/day of prednisolone after diagnosis, which was tapered to a maintenance dose of 5-10 mg/day according to the guideline. If the disease is stable, corticosteroid may be tapered further at a physician's discretion. Patients who have not achieved to maintenance dose of corticosteroid were excluded. Relapse of CS was defined as SUVmax>2.5 with developed myocardial damage evaluated by single photon emission computed tomography or cardiovascular magnetic resonance imaging. Results: Thirty-nine patients were included (the median minimum dose of corticosteroid was 7.5mg (IQR, 1-10). Five of 39 patients (13%) had the evidence of relapse. Patients with relapsed showed significantly greater CMV at diagnosis (208±93 vs. 78±112 ml, p=0.028) and change in left ventricular ejection fraction (-7±11 vs. 3±6 %, p=0.023) than those without. While, SUVmax, LVEF, and conventional biomarker test, such as ACE and lysozyme at diagnosis, and maintenance dosage of corticosteroid were not significant differences patients with and without relapse. All patients with relapse were handled by increasing prednisone and diminished of FDG uptake at follow-up. Conclusion: During maintenance dose period of corticosteroid, relapses were not uncommon. FDG-PET should be recommended to evaluate CS activity.
Cardiac sarcoidosis (CS) can be diagnosed using (18)F-FDG-PET/CT (PET), cardiovascular magnetic r... more Cardiac sarcoidosis (CS) can be diagnosed using (18)F-FDG-PET/CT (PET), cardiovascular magnetic resonance (CMR), and (123)I-BMIPP/(201)TlCl dual myocardial SPECT. This study aims to clarify the relationships among the three modalities with respect to CS. We evaluated 16 patients (male n = 11; age 55 ± 13 years) with confirmed CS who underwent PET, CMR, and dual SPECT with gated SPECT before starting steroid therapy. The left ventricular myocardium was divided into 17 segments to obtain SUVmax for PET images, defect scores from 0 to 4 (0 normal; 4 absent), and mismatch scores for dual SPECT (BMDS, TLDS, and MS) images and late gadolinium enhancement (LGE) scores (0 none; 1 partly positive; 2 homogeneous) on CMR images. Summed BMDS, TLDS, and MS were 18.6 ± 12.6, 12.9 ± 10.9, and 5.7 ± 3.1, respectively. The segmental BMDS and TLDS scores became significantly higher as the LGE scores increased. The MS scores were significantly higher in areas of LGE with a score of 1 than 0 (both, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), but did not significantly differ between areas with LGE scores of 1 and 2. The SUVmax was significantly higher in LGE areas with a score of 1 than 0 (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.025), but did not significantly differ between those with scores of 1 or 2. Regions with a higher SUVmax indicating active myocardial inflammation were mainly located in areas with LGE, where BMIPP and TL mismatches were evident in patients with CS.
Journal of the American College of Cardiology, Sep 1, 2008
To the Editor: Obstructive sleep apnea (OSA), characterized by partial or complete occlusion of t... more To the Editor: Obstructive sleep apnea (OSA), characterized by partial or complete occlusion of the pharynx during sleep, results in persistent inspiratory effort and interruption of airflow. During each episode of apnea, OSA patients develop increased transmural pressure in the aortic wall. Accordingly, to test the hypothesis that the presence of OSA would be associated with greater thoracic aortic size, we prospectively assessed 150 consecutive patients, newly referred to the sleep clinic in our institution, in a crosssectional study to confirm OSA. The patients underwent sleep study and chest computed tomography (CT)-derived thoracic aortic diameter. In this particular period, a chest CT was performed within 3 months of the sleep study upon informed consent to our protocol. Exclusion criteria included: 1) prior history of aortic dissection, aortic valvular disease, and clinical characteristics of Marfan's syndrome; 2) central sleep apnea; 3) treatment for sleep apnea; and 4) dialysis. The outer diameter of the ascending aorta was measured by caliper within the CT image. Overnight sleep study was performed using cardiopulmonary monitoring (Morpheus, Teijin Inc., Tokyo, Japan). The apnea-hypopnea index (AHI) was quantified as the frequency of apneas and hypopneas per hour of bed time. OSA was defined as AHI Ն10/h. The data are presented as mean Ϯ SD or frequencies. To determine the independent factors, the multiple linear regression model with backward elimination technique was used, including older age, male gender, blood pressure, hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease, smoking, and AHI. Comparisons between the 2 groups were performed by Student t test for the unadjusted aortic diameter and by analysis of covariance for the adjusted aortic diameter. The patients' mean age was 60 Ϯ 11 years; 125 (83%) were men, with mean body mass index of 24.7 Ϯ 3.1 kg/m 2. Fifty-nine percent of patients had hypertension. At assessment, 91% of patients had already taken prescribed antihypertensive medications. One hundred ten patients (73%) had OSA. On univariate analysis, older age, male gender, body mass index, systolic blood pressure, pulse pressure, hypertension, dyslipidemia, ischemic heart disease, and AHI were positively correlated with thoracic aortic size. On multivariate analysis, older age (per 10-year increase, coefficient 1.82, 95% confidence interval [CI]: 1.13 to 2.34, p Ͻ 0.001), male gender (coefficient 3.25, 95% CI: 1.63 to 4.87, p Ͻ 0.001), and AHI (per 10-event/h increase, coefficient 0.62, 95% CI: 0.25 to 0.98, p Ͻ 0.001) remained as factors associated with greater thoracic aortic diameter. Contrarily, there was no significant independent relationship between blood pressure/hypertension and thoracic aortic size. Additionally, patients with OSA had a significantly greater thoracic aortic size than those without OSA (p Ͻ 0.001) (Fig. 1), even if adjusted for older age and male gender (p Ͻ 0.001). Increased thoracic aortic size is known to be related to aging, male, genetic mutation including Marfan's syndrome, hyperten
Pulmonary research and respiratory medicine, Oct 28, 2017
Traditionally, patients with pulmonary hypertension (PH) were advised to limit their physical act... more Traditionally, patients with pulmonary hypertension (PH) were advised to limit their physical activity because of the risk of fatal cardiovascular compromise. However, relatively little is known about the risks and benefits of exercise for patients with PH. The present article discussed the effects and safety of pulmonary rehabilitation in PH in light of the current literature. To sum up, exercise training has been reported to significantly improve exercise capacity and quality of life (QoL), whereas the method of intervention, exercise training duration, and patient status (including medically stable patients, immediately after intervention) varied slightly among studies. Furthermore, most of the adverse events were nonfatal and not a direct consequence of exercise training. Accordingly, exercise training in patients with PH seems safe and beneficial. However, the long-term effect of exercise in PH has not been shown. Thus, the precise mechanisms through which pulmonary rehabilitation may influence cardiopulmonary function remains unclear. Future multicenter randomized control trials with longer follow-up duration are needed to further demonstrate the safety, efficacy, and feasibility of exercise training in patients with various types of PH.Although some questions remain, exercise training in patients with PH seems safe and beneficial. Therefore, supervised rehabilitation programs for patients with PH including close monitoring should be encouraged.
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Papers by Naoki Serizawa