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Plasma BNP Level Is a Strong Parameter for Detecting Increased Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis
The 21st Annual Scientific Meeting
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JHFS
S23
were received before or after corticosteroid therapy. A cardiac event including cardiac death and arrhythmias or heart failure requiring hospitalization occurred 9 patients during the mean follow-up of 79 months. Cardiac-event free survival was significantly worse in patients with MR due to tethering (P < .001) Conclusions: MR associated with CS has variety of mechanism. Existence of tethering MR is strongly related to worsening heart failure and poor outcome in CS.
757 pg/ml, diagnostic accuracy for increased PCWP was as follows: sensitivity 0.889, specificity 0.867, positive predictive value 0.973, negative predictive value 0.591. Conclusion: Compared to conventional echocardiographic parameters, BNP is more useful to predict the increase of PCWP in AS patients.
O2-2
Surgical Outcome of Severe Tricuspid Valve Regurgitation Developed Long after Left-sided Valvular Surgeries Takeshi Kashimura1, Hiromi Kayamori2, Shinya Fujiki2, Takayuki Wakasugi2, Yuka Hayashi2, Tohru Minamino2; 1Department of Advanced Cardiopulmonary Vascular Therapeutics, Niigata University Graduate School of Medicine and Dental Sciences, Niigata, Japan; 2Department of Cadiovascular Biology and Medicine, Niigata University Graduate School of Medicine and Dental Sciences, Niigata, Japan
Strategy for the Management of Unrepaired Ebstein’s Disease in Adult Patients Toshimi Koitabashi1, Teppei Fujita1, Mayu Yazaki2, Toyoji Kaida1, Yuuichirou Iida1, Syunsuke Ishii1, Emi Maekawa1, Yoshiyasu Minami1, Takayuki Inomata2, Junnya Ako1,3; 1 Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan; 2Shizuoka City Shimizu Hospital, Shizuoka, Japan; 3Kitasato University Kitasato Institute Hospital, Tokyo, Japan Background: Ebstein’s Disease (ED) is a rare congenital heart disease with the tricuspid valve dysfunction. Little is known about the clinical course and the optimal strategy for the management of adult ED patients. Method and Result: The clinical course of six consecutive adult patients of unrepaired ED was investigated. Among them, four cases including three asymptomatic pregnant women (32, 36 and 37 y.o.) and one elderly patient (72 y.o.) with severe tricuspid regurgitation (TR) and chronic atrial fibrillation (Af) had no cardiac event. On the other hand, two cases required surgical intervention. One younger patient (32 y.o.) with atrial septal defect and severe TR had surgical repair due to progressive polycythemia by hypoxia. Another elder patient (64 y.o.) with severe TR had tricuspid valve repair due to exacerbated heart failure induced by new onset of Af. Conclusion: The clinical course of unrepaired ED in adult patients is varied. Careful follow-up is important not to miss the optimal timing of surgical intervention in adult ED patients irrespective of their symptom.
O2-3 The Impact of Diastolic Dysfunction on Postoperative Tricuspid Regurgitation and Heart Failure Readmission in Patients with Severe Aortic Stenosis Keigo Yamashita, Takehisa Abe, Nobuoki Tabayashi, Yoshihiro Hayata, Tomoaki Hirose, Yoshio Kaniwa, Rei Tonomura, Hiroshi Nishikawa, Shinya Yokoyama, Shigeki Taniguchi; The Department of Thoracic and Cardiovascular Surgery, Nara Medical University, Nara, Japan Objectives: A clinical significance of left ventricular diastolic dysfunction (LVDD) in patients with severe aortic stenosis (AS) is not fully elucidated. This study sought to evaluate the impact of LVDD on postoperative tricuspid regurgitation and heart failure readmission after aortic valve replacement (AVR) for severe AS. Methods and Results: From January 2007 to December 2016, we consecutively enrolled 101 patients undergoing isolated AVR (+CABG) for severe AS. Patients with LVDD (E/E’ ≥15) were compared with those without LVDD (E/E’ <15). Patients with LVDD showed significant difference in the frequency of postoperative tricuspid regurgitation more than mild 1, 3, and 5 years after surgery (P = .023, 0.046, and 0.025, respectively). KaplanMeier analysis showed that patients with LVDD had a significantly higher rate of heart failure readmission (P = .023) compared with those without LVDD. A multivariate Cox hazards model showed that the independent predictors of heart failure readmission were dialysis (adjusted hazard ratio 5.094, 95% confidence interval 1.654 to 15.690, P = .005) and persistent atrial fibrillation (adjusted hazard ratio 19.158, 95% confidence interval 1.677 to 218.822, P = .017). Conclusions: Presence of preoperative diastolic dysfunction was associated with postoperative tricuspid regurgitation and heart failure readmission. Especially, patients with dialysis or atrial fibrillation have a higher risk of heart failure readmission.
O2-4 Plasma BNP Level Is a Strong Parameter for Detecting Increased Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis Masayoshi Oikawa, Atsushi Kobayashi, Satoshi Suzuki, Takamasa Sato, Akiomi Yoshihisa, Hiroyuki Kunii, Kazuhiko Nakazato, Shu-Ichi Saitoh, Takafumi Ishida, Yasuchika Takeishi; Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan Background: An increased pulmonary capillary wedge pressure (PCWP) is a strong risk factor for the development of congestive heart failure in patients with aortic stenosis (AS). We investigated whether conventional parameters are useful to detect the elevation of PCWP in AS patients. Methods: Ninety-six patients with severe AS (aortic valve area <1.0 cm 2 ) were analyzed in this study. Cardiac catheterization, echocardiography, and plasma B-type natriuretic peptide (BNP) analysis were performed in all patients. Results: PCWP positively correlated with log BNP (r = 0.563) and left ventricular (LV) end-systolic volume index (LVESVI, r = 0.484), but weakly correlated with E/A ratio (r = 0.284), E/E’ ratio (r = 0.243), LV ejection fraction (r = 0.384) and left atrial volume index (LAVI, r = 0.386). Multivariate logistic regression analysis revealed that both log BNP (OR 9.94, 95% CI 2.349–103.565, P = .013) and LAVI (OR 1.063, 95% CI 1.010–1.137, P = .035) were independent predictors of increased PCWP (>18 mmHg). Receiver operating characteristic curve analysis revealed that log BNP showed larger area under the curve for detecting increased PCWP compared to LAVI (0.897 vs. 0.753, P = .07). When the cutoff value of BNP was determined as
O2-5
Background: Early surgical treatment for severe tricuspid regurgitation (TR) is recommended before right or left heart failure develops, however those who have developed severe TR late after left-sided valvular surgery are prone to be treated noninvasively because the risk of repeated surgery is concerned. Methods: Nine patients with severe symptomatic TR treated surgically in our hospital long after left-sided valvular disease were reviewed retrospectively. Results: Average age of the patients were 67 ± 4 years. Prior surgeries had been performed at their age of 37 ± 11 years, and heart failure symptoms had appeared 11 ± 8 years before subsequent surgeries. The second surgeries were performed with aortic valve replacement in 3, with mitral valve replacement in 4, and without left-sided valve surgery were in 2. None of the nine patients died perioperatively, however 4 patients died during a mean follow up period of 2.3 ± 1.7 years. Right heart catheterization was performed after surgery in 6 patients. Systolic regurgitant pressure of right atrium were prone to decrease (P = .66) and cardiac index increased significantly (P = .033), however mean pressure of right atrium and pulmonary artery wedge pressure increased considerably in some patients. Conclusion: Operative risk of surgical treatment for TR late after left-sided valvular surgery is not high, however long-term prognosis is poor with incomplete hemodynamic improvement in some patients.
O3-1 Antegrade Diastolic Pulmonary Artery Flow Implies Right Ventricular Restrictionin Adult Cases Yuri Umeta, Hiroyuki Watanabe, Takako Iino, Mai Shimbo, Wakana Sato, Kumiko Watanabe, Shin Makabe, Hiroshi Ito; Depertment of Cardiovascular Medicine, Akita University Graduate School of Medicine Background: Premature opening of pulmonary valve and subsequent antegrade diastolic pulmonary artery flow (ADPAF) reflect restrictive right ventricular (RV) physiology in children. However, the study of ADPAF has been strangely neglected in adult cases. Purpose: To clarify the clinical implication of ADPAF in adult cases. Methods and Results: We studied 23049 consecutive adult patients who underwent echocardiography in our hospital from 2008 to 2015. ADPAF was found in 17 patients. Causative diseases included congenital heart diseases, cardiomyopathy, severe pulmonary valvular regurgitation, and pericardiac diseases. On cardiac catheterization, simultaneous recording of RV and PA pressures revealed the dip-and-plateau configuration of RV diastolic pressure which exceeded PA pressure during atrial systole. These data suggest that ADPAF reflects the inversion phenomenon between right ventricle and pulmonary artery pressures under the condition of right ventricular restrictive physiology. All patients were divided into two groups based on TAPSE. During a mean follow-up time of 692 days (range 15–2324), five patients died and one patient underwent implant of left ventricular assist system; overall mortality rate was 35.3%. Notably, patients with ADPAF and a TAPSE less than 16 mm had worse prognosis (P = .04). Conclusion: ADPAF could be a sign of right ventricular restriction in adult cases, and suggest a less favorable prognosis in patients with right ventricular dysfunction.
O3-2 Diagnostic Usefulness of Plasma Level of Globotriaosylsphingosine in Patients with Anderson-Fabry Disease Koichiro Sugimura, Saori Yamamoto, Tatsuo Aoki, Shunsuke Tatebe, Nobuhiro Yaoita, Haruka Sato, Katsuya Kozu, Ryo Konno, Kimio Satoh, Hiroaki Shimokawa; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder caused by a deficiency of α-galactosidase(α-Gal A). Currently, genetic sequencing is the only valid tool for the diagnosis of female AFD patients, since enzyme activity in female heterozygotes can be in the normal range. In this study, we thus examined whether plasma level of globotriaosylsphingosine (Lyso-Gb3) is useful for diagnosis of AFD. Methods and Results: Among 351 patients with left ventricular hypertrophy(LVH) from January 2004 to July 2016 (64 ± 14[SD] year-old, 117 female), 9 (2.5%) (54 ± 5 year-old, 6 females) were diagnosed as having AFD by cardiac biopsy, and other 6 patients without LVH by gene sequencing. Thus, we examined a total of 15 AFD patients (11 females, 7 families, 4 mutations). All AFD patients showed increased Lyso-Gb3 level (11.6 ± 3.1 ng/mL, n = 15) compared with non-AFD controls (0.4 ± 0.04 ng/mL, n = 46) (P < .0001). In 2 cases of female heterozygotes with normal α-Gal activity and elevated Lyso-Gb3, Lyso-Gb3 level was a reliable marker for the
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JHFS
S23
were received before or after corticosteroid therapy. A cardiac event including cardiac death and arrhythmias or heart failure requiring hospitalization occurred 9 patients during the mean follow-up of 79 months. Cardiac-event free survival was significantly worse in patients with MR due to tethering (P < .001) Conclusions: MR associated with CS has variety of mechanism. Existence of tethering MR is strongly related to worsening heart failure and poor outcome in CS.
757 pg/ml, diagnostic accuracy for increased PCWP was as follows: sensitivity 0.889, specificity 0.867, positive predictive value 0.973, negative predictive value 0.591. Conclusion: Compared to conventional echocardiographic parameters, BNP is more useful to predict the increase of PCWP in AS patients.
O2-2
Surgical Outcome of Severe Tricuspid Valve Regurgitation Developed Long after Left-sided Valvular Surgeries Takeshi Kashimura1, Hiromi Kayamori2, Shinya Fujiki2, Takayuki Wakasugi2, Yuka Hayashi2, Tohru Minamino2; 1Department of Advanced Cardiopulmonary Vascular Therapeutics, Niigata University Graduate School of Medicine and Dental Sciences, Niigata, Japan; 2Department of Cadiovascular Biology and Medicine, Niigata University Graduate School of Medicine and Dental Sciences, Niigata, Japan
Strategy for the Management of Unrepaired Ebstein’s Disease in Adult Patients Toshimi Koitabashi1, Teppei Fujita1, Mayu Yazaki2, Toyoji Kaida1, Yuuichirou Iida1, Syunsuke Ishii1, Emi Maekawa1, Yoshiyasu Minami1, Takayuki Inomata2, Junnya Ako1,3; 1 Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan; 2Shizuoka City Shimizu Hospital, Shizuoka, Japan; 3Kitasato University Kitasato Institute Hospital, Tokyo, Japan Background: Ebstein’s Disease (ED) is a rare congenital heart disease with the tricuspid valve dysfunction. Little is known about the clinical course and the optimal strategy for the management of adult ED patients. Method and Result: The clinical course of six consecutive adult patients of unrepaired ED was investigated. Among them, four cases including three asymptomatic pregnant women (32, 36 and 37 y.o.) and one elderly patient (72 y.o.) with severe tricuspid regurgitation (TR) and chronic atrial fibrillation (Af) had no cardiac event. On the other hand, two cases required surgical intervention. One younger patient (32 y.o.) with atrial septal defect and severe TR had surgical repair due to progressive polycythemia by hypoxia. Another elder patient (64 y.o.) with severe TR had tricuspid valve repair due to exacerbated heart failure induced by new onset of Af. Conclusion: The clinical course of unrepaired ED in adult patients is varied. Careful follow-up is important not to miss the optimal timing of surgical intervention in adult ED patients irrespective of their symptom.
O2-3 The Impact of Diastolic Dysfunction on Postoperative Tricuspid Regurgitation and Heart Failure Readmission in Patients with Severe Aortic Stenosis Keigo Yamashita, Takehisa Abe, Nobuoki Tabayashi, Yoshihiro Hayata, Tomoaki Hirose, Yoshio Kaniwa, Rei Tonomura, Hiroshi Nishikawa, Shinya Yokoyama, Shigeki Taniguchi; The Department of Thoracic and Cardiovascular Surgery, Nara Medical University, Nara, Japan Objectives: A clinical significance of left ventricular diastolic dysfunction (LVDD) in patients with severe aortic stenosis (AS) is not fully elucidated. This study sought to evaluate the impact of LVDD on postoperative tricuspid regurgitation and heart failure readmission after aortic valve replacement (AVR) for severe AS. Methods and Results: From January 2007 to December 2016, we consecutively enrolled 101 patients undergoing isolated AVR (+CABG) for severe AS. Patients with LVDD (E/E’ ≥15) were compared with those without LVDD (E/E’ <15). Patients with LVDD showed significant difference in the frequency of postoperative tricuspid regurgitation more than mild 1, 3, and 5 years after surgery (P = .023, 0.046, and 0.025, respectively). KaplanMeier analysis showed that patients with LVDD had a significantly higher rate of heart failure readmission (P = .023) compared with those without LVDD. A multivariate Cox hazards model showed that the independent predictors of heart failure readmission were dialysis (adjusted hazard ratio 5.094, 95% confidence interval 1.654 to 15.690, P = .005) and persistent atrial fibrillation (adjusted hazard ratio 19.158, 95% confidence interval 1.677 to 218.822, P = .017). Conclusions: Presence of preoperative diastolic dysfunction was associated with postoperative tricuspid regurgitation and heart failure readmission. Especially, patients with dialysis or atrial fibrillation have a higher risk of heart failure readmission.
O2-4 Plasma BNP Level Is a Strong Parameter for Detecting Increased Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis Masayoshi Oikawa, Atsushi Kobayashi, Satoshi Suzuki, Takamasa Sato, Akiomi Yoshihisa, Hiroyuki Kunii, Kazuhiko Nakazato, Shu-Ichi Saitoh, Takafumi Ishida, Yasuchika Takeishi; Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan Background: An increased pulmonary capillary wedge pressure (PCWP) is a strong risk factor for the development of congestive heart failure in patients with aortic stenosis (AS). We investigated whether conventional parameters are useful to detect the elevation of PCWP in AS patients. Methods: Ninety-six patients with severe AS (aortic valve area <1.0 cm 2 ) were analyzed in this study. Cardiac catheterization, echocardiography, and plasma B-type natriuretic peptide (BNP) analysis were performed in all patients. Results: PCWP positively correlated with log BNP (r = 0.563) and left ventricular (LV) end-systolic volume index (LVESVI, r = 0.484), but weakly correlated with E/A ratio (r = 0.284), E/E’ ratio (r = 0.243), LV ejection fraction (r = 0.384) and left atrial volume index (LAVI, r = 0.386). Multivariate logistic regression analysis revealed that both log BNP (OR 9.94, 95% CI 2.349–103.565, P = .013) and LAVI (OR 1.063, 95% CI 1.010–1.137, P = .035) were independent predictors of increased PCWP (>18 mmHg). Receiver operating characteristic curve analysis revealed that log BNP showed larger area under the curve for detecting increased PCWP compared to LAVI (0.897 vs. 0.753, P = .07). When the cutoff value of BNP was determined as
O2-5
Background: Early surgical treatment for severe tricuspid regurgitation (TR) is recommended before right or left heart failure develops, however those who have developed severe TR late after left-sided valvular surgery are prone to be treated noninvasively because the risk of repeated surgery is concerned. Methods: Nine patients with severe symptomatic TR treated surgically in our hospital long after left-sided valvular disease were reviewed retrospectively. Results: Average age of the patients were 67 ± 4 years. Prior surgeries had been performed at their age of 37 ± 11 years, and heart failure symptoms had appeared 11 ± 8 years before subsequent surgeries. The second surgeries were performed with aortic valve replacement in 3, with mitral valve replacement in 4, and without left-sided valve surgery were in 2. None of the nine patients died perioperatively, however 4 patients died during a mean follow up period of 2.3 ± 1.7 years. Right heart catheterization was performed after surgery in 6 patients. Systolic regurgitant pressure of right atrium were prone to decrease (P = .66) and cardiac index increased significantly (P = .033), however mean pressure of right atrium and pulmonary artery wedge pressure increased considerably in some patients. Conclusion: Operative risk of surgical treatment for TR late after left-sided valvular surgery is not high, however long-term prognosis is poor with incomplete hemodynamic improvement in some patients.
O3-1 Antegrade Diastolic Pulmonary Artery Flow Implies Right Ventricular Restrictionin Adult Cases Yuri Umeta, Hiroyuki Watanabe, Takako Iino, Mai Shimbo, Wakana Sato, Kumiko Watanabe, Shin Makabe, Hiroshi Ito; Depertment of Cardiovascular Medicine, Akita University Graduate School of Medicine Background: Premature opening of pulmonary valve and subsequent antegrade diastolic pulmonary artery flow (ADPAF) reflect restrictive right ventricular (RV) physiology in children. However, the study of ADPAF has been strangely neglected in adult cases. Purpose: To clarify the clinical implication of ADPAF in adult cases. Methods and Results: We studied 23049 consecutive adult patients who underwent echocardiography in our hospital from 2008 to 2015. ADPAF was found in 17 patients. Causative diseases included congenital heart diseases, cardiomyopathy, severe pulmonary valvular regurgitation, and pericardiac diseases. On cardiac catheterization, simultaneous recording of RV and PA pressures revealed the dip-and-plateau configuration of RV diastolic pressure which exceeded PA pressure during atrial systole. These data suggest that ADPAF reflects the inversion phenomenon between right ventricle and pulmonary artery pressures under the condition of right ventricular restrictive physiology. All patients were divided into two groups based on TAPSE. During a mean follow-up time of 692 days (range 15–2324), five patients died and one patient underwent implant of left ventricular assist system; overall mortality rate was 35.3%. Notably, patients with ADPAF and a TAPSE less than 16 mm had worse prognosis (P = .04). Conclusion: ADPAF could be a sign of right ventricular restriction in adult cases, and suggest a less favorable prognosis in patients with right ventricular dysfunction.
O3-2 Diagnostic Usefulness of Plasma Level of Globotriaosylsphingosine in Patients with Anderson-Fabry Disease Koichiro Sugimura, Saori Yamamoto, Tatsuo Aoki, Shunsuke Tatebe, Nobuhiro Yaoita, Haruka Sato, Katsuya Kozu, Ryo Konno, Kimio Satoh, Hiroaki Shimokawa; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Background: Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder caused by a deficiency of α-galactosidase(α-Gal A). Currently, genetic sequencing is the only valid tool for the diagnosis of female AFD patients, since enzyme activity in female heterozygotes can be in the normal range. In this study, we thus examined whether plasma level of globotriaosylsphingosine (Lyso-Gb3) is useful for diagnosis of AFD. Methods and Results: Among 351 patients with left ventricular hypertrophy(LVH) from January 2004 to July 2016 (64 ± 14[SD] year-old, 117 female), 9 (2.5%) (54 ± 5 year-old, 6 females) were diagnosed as having AFD by cardiac biopsy, and other 6 patients without LVH by gene sequencing. Thus, we examined a total of 15 AFD patients (11 females, 7 families, 4 mutations). All AFD patients showed increased Lyso-Gb3 level (11.6 ± 3.1 ng/mL, n = 15) compared with non-AFD controls (0.4 ± 0.04 ng/mL, n = 46) (P < .0001). In 2 cases of female heterozygotes with normal α-Gal activity and elevated Lyso-Gb3, Lyso-Gb3 level was a reliable marker for the