Journal of Echocardiography

Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without left-ventricular (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. 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. 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). 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.

Takotsubo cardiomyopathy (TC) is characterized by transient wall motion abnormalities most commonly involving the left ventricle (LV). Although biventricular TC had been considered uncommon condition, recently biventricular TC has been reported as a new variant observed in 19–42% of all TC presentations. Since biventricular TC has a poor prognosis as compared with isolated TC, it is important to distinguish between isolated LV TC and biventricular TC. We present a case of 70-year-old female with dyspnea persisting for 2 days. Electrocardiogram showed symmetrical T-wave inversion in leads V2–V4. Transthoracic echocardiography (TTE) revealed diffuse hypo-kinesis except for the apical inferior LV and LV ejection fraction of 32%. Hyper-kinesis of the right ventricular (RV) basal segment and dys-kinesis of the RV apical segment. 2 weeks after admission, coronary angiography showed no evidence of significant stenosis. LV ejection fraction improved to 51% and wall motion abnormalities of the RV basal and apical segments were ameliorated to normo-kinesis. Electrocardiogram revealed symmetrical and deepened T-wave inversion in leads V2–V3. The presence of a transient abnormality in biventricular wall motion beyond a single coronary artery perfusion territory with new electrocardiographic change met the diagnostic criteria of definite TC defined by Mayo Clinic criteria. 4 weeks after admission, no recurrence of wall motion abnormalities in both ventricles were found and T-wave inversion ameliorated. To our knowledge, this is the first report of biventricular TC with asymmetrical abnormities of wall motion between LV and RV.

A 70-year-old man with a diastolic Levine V/VI musical murmur came to our department. Doppler color-flow imaging showed eccentric severe aortic regurgitation. M-mode echocardiography demonstrated fluttering of the anterior mitral leaflet and fine tremors at the aortic root. The curved M-mode representation of the myocardial strain rate showed that the basal septum was encoded in a mixture of blue and red spots during diastole, showing massive basal septal vibration. In the present case, the force of the regurgitant flow might have caused vibration of the basal septum, thereby possibly leading to distinct thrill.

Inverted left atrial appendage (ILAA) is a rare phenomenon. We describe a patient with mitral stenosis who presented with a homogenous mass in the left atrium, mimicking a large thrombus. The patient was sent to surgery and no thrombus was found; intraoperative examination by the surgeon revealed an ILAA. We briefly discuss the main features of this entity and also some aspects of the differential diagnosis.

Two commercial software systems have become available for quantitation of mitral leaflet and annulus geometry based on three-dimensional (3D) transesophageal echocardiographic (3DTEE) images. The aim of this study is to investigate the accuracy and compatibility of the three-dimensional (3D) measurements by Real View® and MVQ®. 3DTEE images were obtained from phantom models with saddle-shaped annulus of mitral valve prolapse and mitral valve tenting. From reconstructed 3D data, prolapse and tenting volume were calculated by both Real View® and MVQ® and compared with the actual volume. The volume of the phantom models with saddle-shaped annulus measured by Real View® (tenting r = 0.99, prolapse r = 0.99) and MVQ® (tenting r = 0.99, prolapse r = 0.99) showed good agreement with the actual volume. However, significant difference between Real View® and MVQ® was observed in the result of quantification (tenting 2.27 ± 1.5 ml versus 2.53 ± 1.6 ml, prolapse 2.55 ± 1.7 ml versus 2.31 ± 1.6 ml, both P < 0.05). Although the 2 commercially available systems allow accurate quantitative measurements of the 3D volume, discrepancy in the quantified value as a result of differences in the estimation of annular level is observed. Therefore, we should take into account the characteristics of each software when interpreting analytical results.

Stress echocardiography is a versatile modality in the clinical cardiology. In its earlier days, its sole indication was restricted to diagnosing coronary artery disease. However, in response to the rapid development of ultrasound technology and analysis software, the indications have now evolved with expansion to several fields of cardiovascular disease. I reviewed previous stress echocardiography publications, and discussed the current status of stress echocardiography in routine clinical setting. Although its portability and online assessment make possible for immediate diagnosis even at the bedside, establishment of an appropriate procedure and an accurate assessment require some experience. Other imaging competitors, such as multidetector computed tomography and cardiac magnetic resonance are gradually replacing the role of stress echocardiography in some fields. However, stress echocardiography has a potential for other new fields, including valvular heart disease and congestive heart failure. Although primary indication of stress echocardiography for coronary artery disease seems to be not relevant especially in Japan, novel indication of stress echocardiography in other field of cardiovascular disease is rapidly expanding in conjunction with the advent of new technology. Stress echocardiography is not a tool for limited researchers, but rather a fundamental routine method of choice for every sonographer.

Although several previous studies have suggested the presence of right ventricular (RV) diastolic dysfunction in patients with hypertrophic cardiomyopathy (HCM) and those with hypertensive left ventricular hypertrophy (HT-LVH), the mechanisms are still unclear. This study aimed to clarify the relationship between the RV global diastolic dysfunction in these patients and the regional myocardial diastolic function, including synchronicity of the interventricular septum and RV free wall. In 20 age-matched patients with HT-LVH, 20 patients with HCM and 22 control subjects without pulmonary hypertension, RV isovolumic relaxation time (IRTR) was measured using continuous-wave Doppler echocardiography. The early diastolic peak strain rate (E SR) and time from QRS to E SR (T–E SR) were measured in the apical, mid-ventricular and basal segments of the interventricular septum and RV free wall using two-dimensional speckle tracking imaging (2DST). IRTR was more prolonged both in HT-LVH and in HCM than in the controls. The averaged septal E SR was reduced both in HT-LVH and in HCM (P < 0.0001, respectively), but the averaged RV free wall E SR was decreased only in HCM (P = 0.0007). E SR averaged for six septal and RV free wall segments was correlated with IRTR (r = −0.46, P = 0.0001). Neither intergroup difference nor correlation with IRTR was observed in a coefficient of variation of T–E SR for the six segments. RV global diastolic function is impaired in patients with HT-LVH and HCM due to relaxation abnormalities, not an asynchrony, of the myocardium surrounding the RV cavity. The detection of RV free wall relaxation abnormality using 2DST may be useful to differentiate HCM from HT-LVH.