Overview of Systematic Reviews with Meta-Analysis Based on Randomized Controlled Trials of Balneotherapy and Spa Therapy from 2000 to 2019.

BACKGROUND: The objectives of this review were to summarize systematic reviews with meta-analysis of balneotherapy (BT) and spa therapy (ST) based on randomized controlled trials, and to provide a perspective for future research. METHODS: Eligible studies were systematic reviews based on randomized controlled trials with meta-analysis that included at least one group treated with BT or ST. We searched the following databases for articles published in English from the year 2000 to 20 November 2019: Cochrane Database Systematic Review, MEDLINE, CINAHL, Web of Science, and Ichushi-Web. RESULTS: Eighteen studies met all inclusion criteria. Based on the International Classification of Diseases (ICD)-11, among these 18 studies, 8 (44%) were about "#15 Diseases of the musculoskeletal system or connective tissue", 5 (28%) were about "#21 Symptoms, signs or clinical findings, not elsewhere classified", 4 (22%) were about "#11 Diseases of the circulatory system", and 1 study (6%) was about "#8 Diseases of the nervous system". Both BT and ST provided significant pain relief and improved quality of life in chronic diseases of the musculoskeletal system and connective tissues. Additionally, BT and ST with exercise under water improved physical fitness and function in patients across diseases. CONCLUSION: Researchers need to conduct studies on the treatment of many kinds of potential diseases using the keywords of pain relief and QoL. In addition, depending on patients' symptoms, physical fitness, and disabilities, performing exercise under water may improve treatment effects on physical function and fitness.

Value of Transvalvular Flow Rate during Exercise in Asymptomatic Patients with Aortic Stenosis.

BACKGROUND: The optimal management of asymptomatic aortic stenosis (AS) remains controversial. Although exercise stress echocardiography (ESE) has been applied to nonischemic heart disease, the evidence of the prognostic value for asymptomatic AS has been limited. This study aimed to investigate the value of ESE in patients with asymptomatic AS. METHODS: This retrospective observational study included consecutive asymptomatic patients with at least moderate AS (mean pressure gradient ≥ 20 mm Hg or aortic valve area < 1.5 cm2) and preserved left ventricular ejection fraction (≥50%) who underwent ESE. Of these, 10 patients who were referred for aortic valve replacement without symptoms were excluded. A final 99 conservatively managed patients (73 ± 13 years; 54% male) were enrolled in this study. All patients were followed for AS-related events. RESULTS: During the mean follow-up period of 14 ± 11 months, 23 patients underwent from AS-related events. Although no differences were found between the patients with and without adverse events in terms of mean pressure gradient during exercise, the transvalvular flow rate during exercise (Ex-FR) was lower in the patients who experienced adverse events (236 ± 55 vs 274 ± 64 mL/sec, P = .01). Multivariate Cox regression analysis showed a decrease in Ex-FR (<270 mL/sec) independently associated with adverse events in patients with asymptomatic AS (hazard ratio = 3.53, P < .01). CONCLUSIONS: The result of the present study suggests that Ex-FR measured by ESE could play a crucial role in the risk stratification of patients with asymptomatic AS.

Prognostic value of exercise stress echocardiography in patients with secondary mitral regurgitation: a long-term follow-up study.

BACKGROUND: Secondary mitral regurgitation (MR) remains a challenging problem in the diagnosis and treatment of patients with heart failure. Although it is well known that secondary MR is dynamic, the impact of the severity of MR during exercise on long-term outcome has not been fully evaluated. The aim of the present study was to investigate the prognostic value of exercise stress echocardiography (ESE) in patients with secondary MR. METHODS: This prospective study included 118 consecutive patients with secondary MR and left ventricular dysfunction (mean ejection fraction at rest: 38 ± 14%) who underwent semi-supine ESE. Their major cardiovascular events (MACE) including cardiac death were followed up for a median of 41.7 (range: 6-128) months. RESULTS: MR significantly increased from rest to exercise (effective regurgitant orifice: 0.18 ± 0.09 vs. 0.25 ± 0.12 cm2, P < 0.001). The prevalence of severe MR was higher during exercise than those at rest (37% vs. 56%, P < 0.001). During follow-up, MACE occurred in 49 patients (41.5%) including 12 cardiac deaths. Cox proportional-hazard multivariate analysis revealed that older age and MR severity during exercise were significantly associated with increased risk of MACE (hazard ratio: 1.04 and 8.4, respectively, both P < 0.05). CONCLUSIONS: ESE provides prognostic information in patients with secondary MR that is useful for predicting long-term outcome.

Prognostic value of exercise left ventricular end-systolic volume index in patients with asymptomatic aortic regurgitation: an exercise echocardiography study.

BACKGROUND: Surgical timing of chronic aortic regurgitation (AR) remains a matter of debate because of limited data. This study assessed the prognostic value of exercise echocardiography in asymptomatic AR. METHODS: This prospective study included 60 consecutive asymptomatic patients with isolated moderate or severe AR (mean regurgitant volume 56.7 ± 11.8 ml) and preserved ejection fraction who underwent exercise echocardiography. The clinical outcomes were defined by the presence of major adverse cardiovascular events (MACE) and the indication for aortic valve replacement (AVR) with class I or IIa classification in the current guidelines. RESULTS: During the average follow-up of 731 days, 12 patients suffered from the clinical events, including two patients developing MACE (3%) and ten patients indicating for AVR (17%). No difference in left ventricular (LV) ejection fraction at rest was found between the patients with and without the clinical events. The indexed LV diameters and LV volumes were significantly dilated in the patients with the clinical events. The Cox proportional hazards regression analysis resulted that the exercise LV end-systolic volume index (LVESVi) was significantly associated with the clinical outcomes [hazard ratio, 1.116; 95% CI (1.032-1.205); p = 0.006]. The Kaplan-Meier analysis showed that exercise LVESVi was clearly stratified the event-free survival. CONCLUSIONS: Exercise LVESVi might be an independent predictor of prognosis in patients with asymptomatic moderate or severe AR.

HP1 regulates the localization of FANCJ at sites of DNA double-strand breaks.

The breast and ovarian cancer predisposition protein BRCA1 forms three mutually exclusive complexes with Fanconi anemia group J protein (FANCJ, also called BACH1 or BRIP1), CtIP, and Abraxas/RAP80 through its BRCA1 C terminus (BRCT) domains, while its RING domain binds to BRCA1-associated RING domain 1 (BARD1). We recently found that the interaction between heterochromatin protein 1 (HP1) and BARD1 is required for the accumulation of BRCA1 and CtIP at sites of DNA double-strand breaks. Here, we investigated the importance of HP1 and BARD1-HP1 interaction in the localization of FANCJ together with the other BRCA1-BRCT binding proteins to clarify the separate role of the HP1-mediated pathway from the RNF8/RNF168-induced ubiquitin-mediated pathway for BRCA1 function. FANCJ interacts with HP1γ in a BARD1-dependent manner, and this interaction was enhanced by ionizing radiation or irinotecan hydrochloride treatment. Simultaneous depletion of all three HP1 isoforms with shRNAs disrupts the accumulation of FANCJ and CtIP, but not RAP80, at double-strand break sites. Replacement of endogenous BARD1 with a mutant BARD1 that is incapable of binding to HP1 also disrupts the accumulation of FANCJ and CtIP, but not RAP80. In contrast, RNF168 depletion disrupts the accumulation of only RAP80, but not FANCJ or CtIP. Consequently, the accumulation of conjugated ubiquitin was only inhibited by RNF168 depletion, whereas the accumulation of RAD51 and sister chromatid exchange were only inhibited by HP1 depletion or disruption of the BARD1-HP1 interaction. Taken together, the results suggest that the BRCA1-FANCJ and BRCA1-CtIP complexes are not downstream of the RNF8/RNF168/ubiquitin pathway, but are instead regulated by the HP1 pathway that precedes homologous recombination DNA repair.

Value of anatomical aortic valve area using real-time three-dimensional transoesophageal echocardiography in patients with aortic stenosis: a comparison between tricuspid and bicuspid aortic valves.

AIMS: Accurate assessment of disease severity is critical for appropriate treatment of patients with aortic stenosis (AS). This study investigated the influence of aortic-valve morphology on the determination of anatomical aortic-valve area (AVA) in patients with AS. METHODS AND RESULTS: This prospective study included 126 patients with AS who underwent transoesophageal echocardiography (TEE). Aortic-valve area was measured using (i) planimetric two-dimensional (2D) TEE, (ii) volumetric three-dimensional (3D) TEE, and (iii) the continuity equation (CE) obtained with transthoracic echocardiography. Of these, 20 patients also underwent contrast-enhanced multidetector computed tomography (MDCT). Aortic-valve area was measured from multiplanar reconstruction of the MDCT images. Of the 126 patients, 20 (15.9%) were diagnosed with bicuspid AS and 106 were diagnosed with tricuspid AS. There was an excellent correlation between AVAADCT and AVA3DTEE (r = 0.83, P < 0.001) and a somewhat lower correlation between AVAADCT and AVA2DTEE (r = 0.63, P = 0.006). In the tricuspid AS group, both AVA2DTEE and AVA3DTEE significantly correlated with AVACE (r = 0.63, mean difference 0.13 ± 0.24 cm(2), and r = 0.83, mean difference 0.03 ± 0.12 cm(2), respectively, both P < 0.001). In contrast, in the bicuspid AS group, AVA3DTEE significantly correlated with AVACE (r = 0.83, mean difference 0.10 ± 0.18 cm(2), P < 0.001), whereas AVA2DTEE did not (r = 0.42, mean difference 0.48 ± 0.32 cm(2), P = 0.066). CONCLUSION: Aortic-valve morphology influenced the assessment of anatomical AVA in patients with AS, and 3D TEE is useful for assessing anatomical AVA regardless of aortic-valve morphology.

Influence of pulmonary vascular reserve on exercise-induced pulmonary hypertension in patients with systemic sclerosis.

BACKGROUND: Exercise-induced pulmonary hypertension (PH) is considered as an early preclinical functional phase of resting PH in systemic sclerosis (SSc). In this study, we investigated the prevalence of exercise-induced PH in patients with SSc and evaluated the influence of pulmonary vascular reserve on exercise-induced PH. METHODS: This prospective study included 568 SSc patients. The patients with interstitial lung disease and those with left ventricular dysfunction were excluded (n = 50); finally, 518 patients underwent simple exercise echocardiography using a Master's two-step. Systolic pulmonary artery pressure (SPAP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and pulmonary vascular resistance (PVR) were measured before and after exercise. ΔPVR (the difference between rest and post) was used for the assessment of pulmonary vascular reserve. All patients were stratified into the no exercise-induced PH (SPAP <50 mmHg) or exercise-induced PH (SPAP ≥50 mmHg, n = 133) group. RESULTS: Of the study patients, 27% patients were identified as having exercise-induced PH. ΔPVR was higher in the exercise-induced PH than no exercise-induced PH group (0.2 ± 0.3 vs. 0.4 ± 0.4WU, P < 0.0001). A weak correlation was found between postexercise SPAP and postexercise E/e' (r = 0.31, P < 0.0001), whereas a strong correlation was found between postexercise SPAP and postexercise PVR (r = 0.62, P < 0.0001). The analyzed data demonstrated that ΔPVR was independently associated with exercise-induced PH (odds ratio, 3.435; 95% CI, 1.013-11.650, P = 0.033). CONCLUSIONS: The present study demonstrated that exercise-induced PH was common in patients with SSc. Exercise-induced PH might be closely associated with the factors affecting reduced pulmonary vascular reserve in patients with SSc.

Influence of exercise-induced pulmonary hypertension on exercise capacity in asymptomatic degenerative mitral regurgitation.

BACKGROUND: Exercise capacity is helpful in the management of patients with mitral regurgitation (MR). However, the determinants of exercise capacity reduction in MR have remained unclear. This study was designed to objectively assess exercise capacity, identify the echocardiographic predictors of exercise capacity, and investigate its impact on development of symptoms in asymptomatic degenerative MR. METHODS: A total of 49 consecutive asymptomatic patients (age, 58.9±13.1 years; 82% males) with at least moderate degenerative MR (effective regurgitant orifice area=0.40±0.14cm(2); regurgitant volume=60.9±19.6mL) underwent the symptom-limited cardiopulmonary exercise testing for assessing exercise capacity (peak oxygen uptake, peak V˙O2; the minute ventilation/carbon dioxide production, V˙E/V˙CO2 slope). All patients also underwent exercise stress echocardiography for detecting exercise-induced pulmonary hypertension (EIPH) defined by systolic pulmonary arterial pressure (SPAP) ≥60mmHg. RESULTS: The mean peak V˙O2 was 22.6±5.1mL/kg/min (86.7±14.1% of age, gender-predicted); peak V˙O2 widely varied (48-121% of predicted), and was markedly reduced (<80.4% of predicted) in 24% of the study patients. The patients with EIPH had lower 2-year symptom-free survival than those without EIPH (p=0.003). The multivariable analysis demonstrated that EIPH was an independent echocardiographic determinant of peak V˙O2 (p=0.001) and V˙E/V˙CO2 slope (p=0.021). Furthermore, the area under curve of age- and gender-adjusted exercise SPAP was 0.88 (95% confidence interval: 0.78-0.97) for reduced exercise capacity. CONCLUSIONS: In asymptomatic moderate to severe degenerative MR, EIPH was independently associated with exercise capacity and predicted the occurrence of symptoms. Exercise stress echocardiography is an important tool in managing patients with asymptomatic degenerative MR.

Simple exercise echocardiography using a Master's two-step test for early detection of pulmonary arterial hypertension.

BACKGROUND: Early detection of pulmonary arterial hypertension (PAH) is indispensable, although, echocardiography at rest alone does not provide sufficient evidence for it. Here, this study aimed to investigate the usefulness of simple exercise echocardiography using a Master's two-step test for detecting early PAH. METHODS: This study included 52 connective tissue disease patients who had mild symptoms in World Health Organization functional classification 2, suspected as having early PAH, and underwent exercise echocardiography and right heart catheterization. Echocardiography was performed before and after the Master's two-step exercise test; the study patients were classified into the non-PAH (mean pulmonary arterial pressure <25 mmHg, n=37) or PAH (mean pulmonary arterial pressure ≥25 mmHg, n=15) groups. RESULTS: Rest systolic pulmonary artery pressure estimated using echocardiography did not significantly differ between the two groups; however, a significant difference in post-exercise systolic pulmonary artery pressure was found (non-PAH, 58.8±10.8 mmHg; PAH, 80.2±14.3 mmHg, p<0.0001). The multiple logistic regression analysis indicated post-exercise systolic pulmonary artery pressure as an independent predictor of PAH (p=0.013). The area under the curve by post-exercise systolic pulmonary artery pressure was 0.91 for PAH. Post-exercise systolic pulmonary artery pressure ≥69.6 mmHg predicted PAH with the sensitivity of 93% and the specificity of 90%. CONCLUSIONS: Simple exercise echocardiography using the Master's two-step test could detect PAH in mildly symptomatic connective tissue disease patients. The usefulness of this method should be verified for the early detection of PAH.

Early diastolic function during exertion influences exercise intolerance in patients with hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) patients with preserved left ventricular ejection fraction (LVEF) often develop dyspnea and exercise intolerance. Diastolic dysfunction may contribute to exercise intolerance in these patients. This study aimed to clarify our hypothesis as to whether diastolic function rather than systolic function would be associated with exercise intolerance in HCM using two-dimensional (2D) speckle tracking echocardiography during exercise. METHODS: Thirty-three HCM patients (mean age 59.3 ± 15.7 years) underwent 2D speckle tracking echocardiography at rest and during submaximal semi-supine bicycle exercise. Global longitudinal strain (LS), LS rate during systole (LSRs), early diastole (LSRe), and late diastole (LSRa) were measured. The symptom-limited cardiopulmonary exercise testing was performed using a cycle ergometer for measuring the peak oxygen consumption (peak [Formula: see text]). RESULTS: In the multivariate linear regression analysis, peak [Formula: see text] did not associate with strain or strain rate at rest. However, peak [Formula: see text] correlated with LS (ß = -0.403, p = 0.007), LSRe (ß = 6.041, p = 0.001), and LSRa (ß = 5.117, p = 0.021) during exercise after adjustment for age, gender, and heart rate. The first quartile peak [Formula: see text] (14.2 mL/min/kg) was assessed to predict exercise intolerance. The C-statistic of delta LSRe was 0.74, which was relatively greater than that of delta LS (0.70) and delta LSRa (0.58), indicating that early diastolic function rather than systolic and late diastolic function affects exercise intolerance. CONCLUSIONS: LSRe during exercise is closely associated with the peak [Formula: see text]. Early diastolic function during exercise is an important determinant of exercise capacity in patients with HCM.

Relationship between left ventricular ejection fraction and mitral annular displacement derived by speckle tracking echocardiography in patients with different heart diseases.

BACKGROUND: Speckle tracking echocardiography (STE)-derived mitral annular displacement (MAD) utilizes the speckle tracking technique to measure strain vectors, which provides accurate estimates of left ventricular ejection fraction (LVEF). Here, we investigated a link between STE-derived MAD and LVEF in patients with different heart diseases and evaluated its clinical usefulness. METHODS: This study included 266 outpatients and 84 controls. Of the study patients, 52 patients had ischemic heart disease (IHD), 37 patients had dilated cardiomyopathy (DCM), 34 patients had hypertrophic cardiomyopathy (HCM), 74 patients had valvular heart disease (VHD), and 69 patients had hypertensive heart disease (HHD). STE continuously tracked annular motion throughout the cardiac cycle in the apical 4- and 2-chamber views. RESULTS: In all participants, the curvilinear relationship was found between STE-derived MAD and LVEF (R(2)=0.642). The strong correlation between STE-derived MAD and LVEF was also found in the patients with IHD (R(2)=0.733, p=0.001) and in those with DCM (R(2)=0.614, p=0.008). However, such a correlation was not found in the patients with HCM, VHD, or HHD. CONCLUSION: The specificity in the correlation between STE-derived MAD and LVEF was found in patients with each heart disease, which should be taken into account when assessing these parameters.

Neonatal meningitis caused by Streptococcus gallolyticus subsp. pasteurianus.

We encountered a case of neonatal meningitis caused by Streptococcus gallolyticus subsp. pasteurianus. The patient was an 8-day-old boy. Gram staining of the cerebrospinal fluid (CSF) revealed gram-positive cocci in pairs or in short chains. In culture, γ-streptococcus-like colonies grew. The result of 16S rRNA sequence analysis identified S. gallolyticus subsp. pasteurianus. From these results, bacterial meningitis was diagnosed and, as a result of antimicrobial susceptibility testing, single-dose ampicillin therapy was given. Because inflammatory deterioration and spread was suspected from the CSF test results, this therapy was added by panipenem/betamipron. In response to his recovery, antibiotic treatment was stopped and the boy was discharged. This bacterium was classified as S. gallolyticus subsp. pasteurianus in the latest report in 2003. Since this change, there have only been a few cases of neonatal meningitis caused by this bacterium. Here we report this rare case.

Sonographic characterization of 271 hepatic hemangiomas with typical appearance on CT imaging.

PURPOSE: Hepatic hemangioma is the most frequent benign solid tumor that requires differentiation from hepatic malignancy on ultrasonography. Useful ultrasound findings are therefore required for diagnosis. SUBJECTS AND METHODS: The following factors were investigated for 271 masses diagnosed as hepatic hemangioma by contrast-enhanced computed tomography (CT) in 188 patients: hepatic subsegment location, shape, maximum diameter, internal echo level, hyperechoic rim, posterior echoes, marginal hypoechoic band (halo), lateral shadow, blood flow signal in the central portion of the mass, and underlying liver disease. RESULTS: Hepatic masses were classified by internal echo pattern as homogeneous hyperechoic (35.0%), homogeneous hypoechoic (22.9%), isoechoic (5.2%), mixed hyperechoic (22.1%), or mixed hypoechoic (14.8%) masses. Twelve masses were isoechoic, and could be recognized by the hyperechoic rim. Posterior echo enhancement was present in 66 masses. There were no cases of posterior echo attenuation. A halo was present in six masses, with the underlying condition being fatty infiltrated liver in two masses; a hypoechoic region with a small amount of fat deposit was present around the mass, and this resembled a halo. This finding was termed a "pseudohalo." There were no masses in which a lateral shadow was observed. In terms of blood flow signals in the central portion of the mass, pulsatile flow was present in only one mass. CONCLUSIONS: Important ultrasonographic findings of hepatic hemangioma are characterized as the absence of lateral shadow (100%) and no attenuation of posterior echoes (100%), while the presence of a hyperechoic rim is useful for detecting isoechoic hemangioma.

The value of dynamic imaging for standardization of abdominal ultrasonography.

PURPOSE: Digital video recording of dynamic images is a potential way to improve the reproducibility of abdominal ultrasonography (US). Static US and dynamic US were compared using contrast-enhanced computed tomography (CE-CT) as a reference standard, and the value of stored video images was verified. METHODS: The subjects were 120 individuals who had undergone CE-CT ≤1 month before undergoing US. After static US, dynamic US was carried out according to the Scanning Procedure for Abdominal Ultrasonography described in this paper, and records of 30 separate scans were saved on digital video discs (DVD) as individual video files for interpretation. The findings from static US and dynamic US were compared. RESULTS: With respect to the abdominal US signs covered in this evaluation, dynamic US achieved a detection rate equivalent to or better than that of static US. Detection rates were significantly more frequent on dynamic US for: enlarged hepatic hilum lymph nodes (P < 0.001); gallbladder wall thickness (P < 0.01); cystic lesions of the liver, bright liver, and splenomegaly (P < 0.05). CONCLUSION: Dynamic US is a valuable tool because it enables repeated evaluation of target organs with playback speed adjustment.

[Symposium 2: "Co-operation between clinical laboratory realms and knowledge intensive service"--Chairman's remarks].

Due to the advancement of technology, high-level accuracy and reliability have been realized in the clinical laboratory. Standardized assessment of the results is important in pathophysiological analysis rather than the interpretation of the results by each laboratory independently. Co-operation between clinical laboratory in exceeding the realms and knowledge intensiveness in the interpretation of the results could be needed. In addition, inter-professional work may be useful for the efficient use of the clinical laboratory.

Global longitudinal strain by two-dimensional speckle tracking imaging predicts exercise capacity in patients with chronic heart failure.

BACKGROUND: Left ventricular ejection fraction (LVEF) predicts mortality in patients with chronic heart failure (CHF). However, a weak correlation was found between LVEF and peak oxygen uptake ([Formula: see text]) in CHF patients. Global longitudinal strain measured by two-dimensional (2D) strain is regarded as a more useful predictor of cardiac events than LVEF. We investigated whether 2D strain obtained at rest could predict peak [Formula: see text] in patients with CHF. METHODS: Fifty-one patients (mean age of 54.0 ± 12.0 years, 14 females, LVEF 46.0 ± 15.0%) with stable CHF underwent resting echocardiography and cardiopulmonary exercise testing. Leg muscle strength was measured for the evaluation of peripheral factors. Global longitudinal strain (GLS) in the apical 4-, 3-, and 2-chamber views and global circumferential strain (GCS) in the parasternal mid short-axis view were measured. RESULTS: In all patients, peak [Formula: see text] correlated with leg muscle strength (r = 0.55, p < 0.0001), LVEF (r = 0.46, p < 0.001), GLS (r = -0.45, p < 0.001), and GCS (r = -0.41, p = 0.005), respectively. No significant correlation was found between the ratio of early transmitral velocity to peak early diastolic mitral annulus velocity (E/E') and peak [Formula: see text]. In the patients with heart failure and reduced LVEF, a multiple stepwise linear regression analysis based on leg muscle strength, LVEF, E/E', GLS, and GCS was performed to identify independent predictors of peak [Formula: see text], resulting in leg muscle strength and GLS (R (2) = 0.888) as independent predictors of peak [Formula: see text]. CONCLUSION: Global longitudinal strain at rest could possibly predict exercise capacity, which appeared to be more useful than LVEF, E/E', and GCS in CHF patients with reduced LVEF.

Acute myocardial infarction in a young adult patient with simultaneous total occlusion of double coronary arteries.

We report an otherwise healthy 16-year-old male patient with simultaneous double vessel acute myocardial infarction. Coronary angiography (CAG) showed simultaneous total occlusion of the left anterior descending artery (LAD) and the left circumflex artery (LCX). Emergent percutaneous coronary intervention (PCI) was performed on the diseased lesions. After PCI, coronary artery aneurysms were found in both the LAD and LCX. The patient was discharged after a 56-day hospitalization. The New York Heart Association (NYHA) Functional Classification at discharge was II. Medical therapy became ineffective over time because of exacerbated ischemic mitral regurgitation; successful mitral annuloplasty was performed. The post-operative course was uneventful.

Hyperventilation and cold-pressor stress echocardiography combined with automated functional imaging non-invasively detected vasospastic angina.

A 47-year-old male presented with chest discomfort while sleeping. The patient was suspected of having vasospastic angina (VSA) and underwent hyperventilation and cold-pressor stress echocardiography. No chest pain, ECG changes or decreased wall motion was found. However, automated function imaging (AFI) showed decreased peak systolic strain at the apex and postsystolic shortening at both the apex and inferior wall, which was not found before the test. The provocation test revealed 99% stenosis in the right coronary artery #2 at a dose of 50 µg acetylcholine and 90% stenosis in the left coronary artery #8 at a dose of 100 µg. The patient was thus diagnosed as having VSA. The present case demonstrates the usefulness of AFI combined with hyperventilation and cold-pressor stress echocardiography as a screening examination for VSA.

Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation.

AIMS: Left ventricular (LV) shape and LV dyssynchrony are two cofactors associated with functional mitral regurgitation (MR) in patients with heart failure. Both can be accurately examined by real-time three-dimensional echocardiography (3DE). We examined the relationship between dynamic MR and exercise-induced changes in LV shape and synchronicity using 3DE. METHODS AND RESULTS: Fifty patients with systolic LV dysfunction underwent 2D and 3D quantitative assessment of LV function, shape, and synchronicity at rest and during symptom-limited exercise test. According to the magnitude of change in MR, patients were divided into EMR group (15 patients, 30%), if the degree of MR increased during test, and NEMR group. During exercise, the changes in LV volumes and ejection fraction were similar in both groups, whereas changes in mitral valvular deformation parameters, in LV sphericity index, and in the extent of LV dyssynchrony were more pronounced in the EMR group. At rest, only the 3D sphericity index could distinguish the two groups. By stepwise multiple regression model, dynamic changes in the systolic dyssynchrony index, sphericity index, and coaptation distance were associated with dynamic MR (r(2) = 0.45, P = 0.012). CONCLUSION: Dynamic MR during exercise is related to the 3D changes in LV shape and in LV synchronicity.