Aim: To assess whether combining measurements obtained from carotid ultrasonography in addition to the age, creatinine, and ejection fraction (ACEF) score would improve the predictive ability of outcome in patients with acute coronary syndrome (ACS). Methods: We examined 264 patients with ACS (194 men; mean age: 68 11 years) who underwent percutaneous coronary intervention. The carotid plaque score (cPS) and intima -media thickness (cIMT) were determined by carotid ultrasonography. The modified ACEF score was calculated using the following formula: (age/left ventricular ejection fraction) 1 point for every 10 mL/min reduction in creatinine clearance below 60 mL/min per 1.73 m 2 . The endpoint of this study was major adverse cardiovascular and cerebrovascular events (MACEs), defined as all-cause death, myocardial infarction, stoke, and target vessel revascularization. Results: During the median 4-year follow-up, there were 121 incidents of MACEs. Multivariate Cox proportional hazard regression analysis revealed that cPS ≥ 9.8 (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.01 -2.31) and ACEF score ≥ 1.20 (HR, 1.62; 95% CI, 1.11 -2.39) were significantly associated with MACEs, whereas cIMT was not. When the new combined risk score was calculated by multiplying the cPS by the modified ACEF score, the freedom from MACEs at 5 years was 71% and 31% for the lower and higher scores, respectively (p 0.001). The area under the receiver-operating characteristic curve for MACEs for the ACEF score, cPS, and combined risk score were 0.65, 0.66, and 0.71, respectively (p 0.05). Conclusion:The cPS offers an incremental predictive value when combined to the simple ACEF score in ACS.
Background For mitral valve repair, minimally invasive cardiac surgery as well as transcatheter valvular intervention have been developed. Under these conditions, threedimensional transesophageal echocardiography (3D-TEE) plays a key role for planning the surgical treatment strategy. However, few data exist regarding the role of 3D-TEE in mitral valve repair. Therefore, we examined the impact of 3D-TEE on procedural success of mitral valve repair. Methods and resultsWe examined 86 consecutive patients who underwent mitral valve repair for degenerative mitral valve prolapse. Among them, 39 patients were examined by only two-dimensional transesophageal echocardiography (2D-TEE) and 47 patients underwent 3D-TEE in addition to 2D-TEE. The cardiac surgeons and physicians discussed the repair procedure preoperatively with the echocardiographic images. As a result, 18 patients of the 2D-TEE group and 37 patients of the 3D-TEE group underwent mitral valve repair by small thoracotomy including robotic approach. Simple repair was done in 21 with 2D-TEE and 21 with 3D-TEE and complex repair was done in 18 with 2D-TEE and 26 with 3D-TEE.Importantly, three patients with 2D-TEE before surgery had to undergo reoperation due to recurrent severe mitral regurgitation with dehiscence of the annuloplasty rings, although none with 3D-TEE did. Conclusions These results demonstrate that 3D-TEE is helpful in assessing the morphology of mitral apparatus and complexity of mitral valve repair, particularly in minimally invasive cardiac surgery including robotic ones. We would suggest that sonographers, cardiologists, and cardiac surgeons should be familiar with 3D-TEE and work together throughout the perioperative period for better outcomes.
IntroductionAbnormal papillary muscle (PM) is an unusual cause of left ventricular outflow tract (LVOT) obstruction [1], and is often found in patients with hypertrophic cardiomyopathy (HCM) [2]. Cardiac magnetic resonance (CMR) imaging has been reported to be useful for diagnosis of abnormalities of the PM and mitral valve in HCM patients [3][4][5]. Abnormal PMs with LVOT obstruction are usually treated by surgical correction [6,7], and therefore, reports on medical treatment are limited [8]. In the present report, we describe the case of an HCM patient associated with LVOT obstruction due to abnormal PMs, which was accurately diagnosed by CMR imaging and successfully treated with a betablocker.
Case reportA 65-year-old man with a history of hypertension was admitted to our hospital with fainting and syncope. The patient had experienced recurrent syncope since 20 years of age, and was diagnosed with epilepsy at 49 years of age. Treatment with anticonvulsants was soon discontinued because of skin rash. He had been taking amlodipine (5 mg/day) for hypertension. On admission, his blood pressure was 158/93 mmHg, pulse rate was 61 beats per minute, and systolic heart murmur of grade 4/6 was audible at the apex of the heart. Chest radiography showed mild cardiomegaly, and electrocardiography showed high voltage and mild ST-segment depression.
A B S T R A C TA 65-year-old man with a history of hypertension was admitted to our hospital with fainting and syncope. He had experienced recurrent syncope since 20 years of age. On admission, systolic heart murmur was audible at the apex of the heart. Echocardiography revealed anteriorly displaced papillary muscles (PMs), elongation of the anterior mitral valve leaflet (AML), and systolic anterior motion (SAM) of the AML. Color Doppler imaging showed accelerated flow with a pressure gradient (PG) of 56 mmHg at the left ventricular outflow tract (LVOT). Cardiac magnetic resonance imaging revealed mild asymmetric septal hypertrophy and multiple accessory PMs. Cine images clearly demonstrated SAM and LVOT obstruction due to anteriorly displaced PMs. Based on these findings, the patient was diagnosed as having hypertrophic cardiomyopathy and LVOT obstruction due to abnormal PMs. Oral administration of bisoprolol (2.5 mg/day) was initiated, because the patient rejected surgical treatment. Follow-up echocardiography revealed a gradual decrease in the LVOT-PG to 24 mmHg, and no episodes of fainting or syncope have recurred for 2 years after the initiation of bisoprolol.
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