Right-sided Infectious Endocarditis Complicated with Atrial Septal Defect

The 18th Annual Scientific Meeting

P-037 Effect of Inhibitors of Renin-angiotensin System on ST-segment Elevation Myocardial Infarction in Patient with Left Ventricular Ejection Fraction more than 40% WOONG JEON1, SANG-HO PARK1, SEUNG-WOON RHA2, JIN-SOO BYUN1, DONG KYU JIN1, BYOUNG GEOL CHOI2, CHEOL UNG CHOI2, CHANG GYU PARK2, HONG SEOG SEO2, DONG JOO OH2 1 Cardiology Department, Soonchunhyang University Cheonan Hospital, Cheonan, Korea, 2Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea Background: It has been known that the inhibitors of renin-anigotensin system (RAS) is effective on long-term survival after primary percutaneous coronary intervention (PCI) in ST-segment elevation acute myocardial infarction (STEMI) with left ventricular ejection fraction!40%. However, the benefit on clinical outcomes in STEMI with LVEF$40% has been not evaluated. Methods: We investigated the 316 patients (pts) that was presented with STEMI with LVEF$40% in Korea University Guro Hospital PCI registry database from september 2004 to june 2011. We compared 2-year clinical outcomes of pts treated with (n5229) and without (n587) RAS inhibitor at discharge. Results: There was no statistic significance except in the incidence of total mortality (6.0% vs 12.%, p50.037) and cardiac death (6.0% vs 0.6%, p50.010). In multivariate logistic regression analysis, the non-use of RAS inhibitor was predictor for cardiac death (OR, 9.859; 95% CI, 1.047-92.834; p50.045). In Kaplan-Meyer Curve, the incidence of cardiac death was higher in the non-use group of the RAS inhibitor (Figure). Conclusions: In our study, the inhibitor of RAS may be effective on cardiac death up to 2-year clinical outcome after PCI in pts with STEMI and LVEF$40%



JHFS

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Nocturnal hypertension is a risk factor for heart failure exacerbation. A case was 91 yearold male. He was transferred to our hospital because of sudden dyspnea. His past history were hypertension, chronic heart failure, arteriosclerosis obliterans, chronic kidney disease and left below knee amputation. Systolic blood pressure exceeded more than 200 mmHg. Chest X-ray showed pleural effusion and pulmonary congestion. We diagnosed clinical scenario one heart failure. Then, we used nicardipine hydrochloride in order to lower the blood pressure. But antihypertensive drugs were not sufficient to improve heart failure. Ambulatory blood pressure monitoring (ABPM) showed riser type blood-pressure transition. After that we shifted hypotensive drugs and diuretics from after breakfast to before sleep, pleural effusion was decreased. Blood-pressure type in ABPM changed from riser to non-dipper pattern, and heart failure was improved. We experienced that ABPM was usefull to control heart failure due to nocturnal hypertension.

P-040 What is the Best Treatment for Severe Tricuspid Valve Regurgitation? NAOKO IKEDA1, MIO EBATO2, MIKI TSUJIUCHI2, TAKUYA MIZUKAMI2, AYAKA NOGI2, HIDEYUKI MAEZAWA2, HIROSHI SUZUKI2, KAORU TANNO1 1 Cardiovasculer Division, Kototoyosu Hospital, Showa University, Tokyo, Japan, 2 Cardiovasculer Division, Fujigaoka Hospital, Showa University, Tokyo, Japan Patients with severe tricuspid valve regurgitation are increasing and we have to choose the best treatment for each patients. We evaluated whether the tricuspid valve dimension will change by various treatment. The study sample consisted of 8 chronic heart failure patients with severe tricuspid valve regurgitation and they were evaluated with echocardiography several times during hospital course. 7569.4 years old, male 25%, leg edema 75%, pacemaker, ICDimplanted 50%, chronic atria fibrillation 87.5% admission times for heart failure 1.2561.7/min, cases with completely unattached valve leaflets 50%, NYHA2.660.9, BMI 2366.5kg/m2, systolic blood pressure 105611mmHg, diastolic blood pressure 60610mmHg, heart rate 6664.5bpm, BNP 7306770 pg/ml, eGFR 35.5619ml/min/1.73m2, LVEF567.362.5% We turned attention to 4 cases who have completely unattached valve leaflets and compared some echocardiac parameters before and after treatment. There were a significant correlation between reduction of RA area and reduction of tricuspid valve regurgitant area. And there were a significant correlation between reduction of RV area and tricuspid valve regurgitant area. However, there were no significant correlation between tricuspid valve dimension and reduction of tricuspid valve regurgitant area. There is little correlation between tricuspid valve dimension and the reduction of tricuspid valve regurgitation among patients with completely unattached valve leaflets. This might be the reason they are getting worse CHF. Surgical treatment would be needed to control tricuspid regurgitation.

P-041 A Case of Myocardial Calcification with the Latent Risk of Congestive Heart Failure SHIMPEI ITO1, AKIHIRO ENDO1, TAIJI OKADA1, TAKU NAKAMURA1, TOMOKO ADACHI1, RYUMA NAKASHIMA1, TAKASHI SUGAMORI1, NOBUYUKI TAKAHASHI1, HIROYUKI YOSHITOMI2, KAZUAKI TANABE1 1 The Forth Department of Internal Medicine, University of Shimane, Shimane, Japan, 2 Department of Clinical Laboratory, Shimane University Hospital, Shimane, Japan Figure. Kaplan-Meyer Curve has shown that there was difference in incidences of cardiac death between use and non-use group of RAS

P-038 Alterations in Ventricular Contractile Mechanisms in Heart Failure with Atrial Fibrillation SHIN-ICHI USHIRODA Ushiroda Medical Clinic, Fukushima, Japan Objective: The aim of this case study was to show the alterations in the ventricular contractile mechanisms in a patient with heart failure (HF) and atrial fibrillation (AF) during the course of treatment, which remained largely unknown. Methods and Results: A new ventricular function curve was created by applying (dZ/dt)min, which represents the peak value of the first derivative of the heart-synchronous thoracic impedance changes, obtained using impedance cardiography. Ventricular beats involved in postextrasystolic potentiation (PESP) were defined by preceding RR interval (RR1)/pre-preceding RR interval (RR2) O 1 [VP(+)]. Ventricular beats not involved in PESP (Frank-Starling mechanism and mechanical restitution: FSM+MR) were defined by RR1/RR2 ! 1 [VP(-)]. The ventricular function curve was divided into two regression curves of VP(-) and VP(+) based on this RR1/RR2 ratio. The degree of PESP was represented by the slope of the regression line between the RR1/RR2 ratio (where RR1/RR2 O 1) and (dZ/dt) min of VP(+). Use of this method in a 76-year-old man with deterioration of HF with AF showed that (1) the ventricular function curve and the regression curve of VP(-) gradually shifted upward, (2) the slope of the regression line representing the degree of PESP gradually decreased as HF with AF improved. Conclusion: In this case, contributions of FSM+MR increased, whereas the contribution of PESP decreased as HF with AF improved.

P-039 The Usefulness of Ambulatory Blood Pressure Monitoring in Heart Failure due to Nocturnal Hypertension YUSUKE UEDA, SHINSUKE MIKAMI, HITOSHI SUSAWA, KENGO KOBAYASHI, HARUKI TANAKA, KOUICHI TANAKA Department of Cardiology, Miyoshi Central Hospital, Hiroshima, Japan

An 88-year-old man was referred to our hospital because of cardiac evaluation before cholecystectomy. He had a history of rheumatic fever at 30 years old and tuberculosis at 86 years old. Electrocardiogram showed abnormal Q waves in I and aVL and negative T waves in V3-6. The results of blood test were almost within normal range. Transthoracic echocardiography demonstrated left ventricular (LV) ejection fraction was 46% and LV wall motion abnormality was detected in the posterolateral wall and apex with hyperechoic calcified mass. A CT scan confirmed the myocardial calcification at the same region. A coronary angiogram showed normal coronary arteries. Right heart catheterization revealed normal pulmonary artery pressure. However stress echocardiography revealed pulmonary hypertension during exercise. Reports of myocardial calcification are limited mainly to case reports and most reported cases have been identified postmortem. Pathologic myocardial calcification occurs by two mechanisms dystrophic and metastatic. We report an interesting case of myocardial calcification. We consider etiology of calcification was due to rheumatic fever because of his past history. His LV myocardial calcification may cause elevated LV filling pressure during exercise.

P-042 Right-sided Infectious Endocarditis Complicated with Atrial Septal Defect MAI SHIMBO, HIROYUKI WATANABE, TATSUMI ABE, TERUKI SATO, TAKASHI KOYAMA, HIROSHI ITO Department of Cardiovascular Medicine, Akita University Graduate School of Medicine, Akita, Japan A 55-year-old female was referred to our hospital due to dyspnea and persistent fever resistant to antibiotics. Echocardiography showed secundum atrial septal defect (ASD) measuring 2 cm in diameter and moderate tricuspid regurgitation (TR) with right ventricular and right atrial enlargement. Moreover, we detected a mobile vegetation measuring 15x10 mm attached to the anterior leaflet of tricuspid valve. Chest CT showed the multiple nodules in bilateral lung parenchyma, suggestive of the septic pulmonary embolism. Blood cultures grew Gram negative bacillus. We have a strong suspicion of right-sided infectious endocarditis (RSIE). Although brain MRI showed evidences of neither stroke nor intracranial aneurysm, given the risk of paradoxical embolism, an urgent surgical treatment consisting of the removal of vegetation, tricuspid valve replacement and ASD patch-closure was performed successfully. Microscopically, friable vegetation

S196 Journal of Cardiac Failure Vol. 20 No. 10S October 2014 consisted of fibrin and platelets mixed with leukocytes and bacterial colonies. A diagnosis of RSIE complicated with ASD was made. She had an uneventful postoperative course. ASD is considered to be a negligible risk for IE because of the slow shunt flow, so that RSIE with ASD is extremely rare. However, TR secondary to right ventricular overload has a potential cause of IE, once it occurs, the paradoxical embolism might lead to fetal complication. We emphasize that, unlike other RSIE, RSIE with ASD needs early surgical treatment to avoid fetal complication.

P-043 Two Cases of Pulmonary Hypertension Associated with Portosystemic Shunt HARUKA SATO, TATSUO AOKI, MASANOBU MIURA, NOBUHIRO YAOITA, SAORI YAMAMOTO, SYUNSUKE TATEBE, KOTARO NOCHIOKA, KIMIO SATOH, KOICHIRO SUGIMURA, HIROAKI SHIMOKAWA Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Case 1: In October 2013, a 57 year-old woman admitted to a hospital for dyspnea and hypoxia. Since echocardiography showed elevated tricuspid regurgitation pressure gradient, she was transferred to our hospital. Computed tomography showed portal-hepatic vein shunt and partial anomalous pulmonary venous return. Right heart catheterization showed that she had pulmonary hypertension (PH) with elevated mean pulmonary arterial pressure (mPAP, 29 mmHg). Furthermore, micro-bubble test showed intrapulmonary shunt. Finally, she was diagnosed as having hepatopulmonary syndrome associated with portal-hepatic vein shunt. For further treatment, transcatheter embolization for portosystemic shunt is scheduled. Case 2: In August 2013, a 25 yearold woman was referred to our hospital for examination of abnormal findings on chest X-ray with dilated pulmonary arteries. At age 9, she underwent partial splenic embolization for extrahepahc portal hypertension and at age of 11, surgical superior mesenteric vein and inferior vena cava shunting. Right heart catheterization showed elevated mPAP (72 mmHg) and high cardiac output (CO 7.3 l/ml, CI 3.2 L/min/m2). Finally, she was diagnosed as having pulmonary hypertension associated with portosystemic shunt based on her past history and hemodynamic findings. Subsequent therapy with tadalafil for 2 months decreased mPAP to 48 mmHg. We hereby report 2 cases of pulmonary hypertension associated with congenital or acquired portosystemic shunt.

P-044 Mismatch between Brain Natriuretic Peptide and Body Fluid Status Assessed by Multi-frequency Bioimpedance in Patients with Acute Decompensated Heart Failure FUMIE OTOMO1, MITSUAKI ENDO2, EIICHI AKIYAMA3, YASUSHI MATSUZAWA3, MASAAKI KONISHI3, HIDEO HIMENO2, SATOSHI UMEMURA4, KAZUO KIMURA3 1 Department of Cardiology, International Goodwill Hospital, Yokohama, Japan, 2 Department of Cardiology, Fujisawa City Hospital, Fujisawa, Japan, 3Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan, 4 Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan Background: The natriuretic peptides have proven useful as an adjunct tool for optimizing fluid management of heart failure patients. However, in the setting of acute decompensated heart failure (ADHF), there are some cases where brain natriuretic peptide (BNP) paradoxically increases despite resolution of signs and symptoms of congestion. Therefore, we investigated the association between BNP and body fluid status assessed by multi-frequency bioimpedance (MFBIA). Methods: Consecutive twenty-four patients (8168 years; 46% men) admitted for ADHF underwent serial BNP and edema index (EI) measurement at admission, on days 2, 5, and at discharge. EI represents a ratio of extracellular water to whole-body water on MFBIA. Results: From admission to discharge, BNP and EI significantly decreased (from 1175.261147.2 to 381.36381.4pg/ml, and from 0.41560.011 to 0.40160.011, respectively, both p!0.01), and changes in BNP correlated with those in EI (r50.53, P50.007). Nevertheless, there are no correlations between changes in BNP and EI on day 2 (r50.13, P50.52) and day 5 (r50.26, p50.21). A mismatch between changes in BNP and EI on day 2 was noted in 7 (29%) patients, who had significantly lower tricuspid annular plane systolic excursion on echocardiography (13.262.5 vs. 17.463.6mm, p50.008) compared to those without a mismatch. Conclusions: In patients with ADHF with right ventricular dysfunction, serial changes in BNP during the acute phase of hospitalization might not aid clinical assessments of congestion.

P-045 Hyponatraemia is Associated with Elevated Pulmonary Capillary Wedge Pressure and Mortality in Patients with Chronic Heart Failure TETSUJI MORISHITA, HIROYASU UZUI, KEN-ICHIRO ARAKAWA, NAOKI AMAYA, KENICHI KASENO, KENTARO ISHIDA, TAKEHIKO SATO, YOSHITOMO FUKUOKA, JONG-DAE LEE, HIROSHI TADA Department of Cardiovascular Medicine, University of Fukui, Fukui, Japan Purpose: The aim of this study was to estimate the prognostic relevance of hyponatraemia and the associations with neurohormonal factors, including interleukin-6 (IL-6), matrix metalloproteinase (MMP)-9 and tissue inhibitor of MMP (TIMP)-1 in patients with heart failure. Methods: Serum sodium level,

circulating levels of IL-6, MMP-9 and TIMP-1 were measured in 118 heart failure patients. Invasive hemodynamic study with dual heart catheterization was performed to measure pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure (EDP). Cardiac death and all-cause mortality were assessed during the follow-up period (average of 85649 months). All patients were divided into four groups based on the serum sodium level; !135, 135 to 139.9, 140 to 144.9 and O 145 mmol/L. Results: Hyponatraemia was found in 58.4% of the patients. A U-shaped associations of serum sodium level with PCWP and EDP were found, with lowest values in patients group with normonatraemia (P!0.05). IL-6 and MMP-9/TIMP-1 rati increased with decreasing serum sodium level (P for trend ! 0.05 and 5 0.083, respectively). Kaplan-Meier analysis demonstrated a higher probability of cardiac death and all-cause death in patients group with hyponatraemia (!140 mmol/L) (P!0.05). Conclusions: Hyponatraemia indicate an increasing mortality risk in patients with heart failure. Our results suggest IL-6 and the disparity between MMP-9 and TIMP-1 contribute to the worsening hemodynamics of failing hearts with hyponatraemia.

P-046 ACE2 and Ang (1-7) Concentration for Patients Urgently Hospitalized due to Cardiovascular Disease SHINJI HISATAKE, TAKAYUKI KABUKI, SHUNSUKE KIUCHI, TAKASHI OKA, JUNICHI YAMAZAKI, TAKANORI IKEDA Division of Cardiovascular Medicine, Department Internal Medicine, the Faculty of Medicine, Toho University Background: Recently the existence of the ACE2/Ang-(1-7)/Mas-receptor-axis in the RAS and the organ-protective -effect by activating this axis have been revealed. There are as yet not many reports about the transition of the ACE2/Ang-(1-7)/Masreceptor-axis under various clinical conditions. Aim: To compare the blood concentration of ACE2 under various pathological conditions to the healthy volunteers. Methods: Among patients who were hospitalized for AHF, AMI, and acute aortic dissection between November-2012 to August-2013, 15 patients who gave their consent became the subjects of this study. At the acute stage of each disease, ACE2 and ACE, Ang-(1-7) concentration, activation of renin, AngII and aldosterone concentration were measured, and then compared and examined against a group of 10 healthy volunteers. Results: There were no significant differences in age and SBP between disease patient group(D) and healthy volunteer group(H). ACE2 concentration was significantly higher in group D compared to group H (10.5266.12 ng/ml vs 4.8361.91 ng/ml, p50.004). Ang-(1-7) concentration was significantly lower in groupD than in groupH (2.3561.50 ng/ml vs 3.6661.29 ng/ml, p50.035). PRA was significantly higher in groupD compared to groupH (4.2364.68 ng/ml/h vs 1.5460.99 ng/ml/h, p50.047). There were no differences in ACE, Ang II, and aldosterone concentrations between the two groups. Conclusion: The patients urgently hospitalized for cardiovascular disease had higher concentration of ACE2, but lower concentration of Ang-(1-7) compared to the healthy volunteers.

P-047 Surrogate Marker of Warfarin Control in Patients with Atrial Fiblliration TATSUYA KOYAMA1, SHINGO SEKI1, RITSU YOSHIDA1, JYUN HASEGAWA1, YOSHITSUGU OHKI1, SEIKO TSUNODA1, TOMOYUKI TAKEMOTO1, KOJI YAMAZAKI1, MICHIHIRO YOSIMURA2 1 Department of Cardiology, Katsushika Medical Center, The Jikei University School of Medicine, Tokyo, Japan, 2Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan Background: Atrial fibrillation is a known risk factor for thromboembolism. D-dimer levels reflect a pro-thrombogenic state and thus might serve as another marker of warfarin control. Aim: This study investigated the correlation of warfarin control marker;PT-INR and pro-thromboembolic marker; D-dimer in patients with atrial fiblliration during oral anticoagulant therapy. Method:This was a single center, retrospective study. Patients with atrial fibrillation (57 males,17 females, mean age 71.868.7 years ) treated with warfarin (target PT-INR: 1.5 to 3.0) were included in this investigation based on the medical chart. D-dimer levels and PT-INR were measured, and followed up to June 2014. Result: The correlation of PT-INR and D-dimer in all patients statistically was found. Espacially the negative relationship between PT-INR and D-dimer in subgroup patients, elderly patients (over 75 years); 28, hypertension patients; 57, patients were statistically found. Conclusion: The correlation of PT-INR and D-dimer in patients of atrial fibrillation was found and thus D-dimer also can serve as surrogate marker of warfarin control.

P-048 Atrioventricular Node Reentrant Tachycardia as a Cause of Recurrent Syncope in a Patient With Non-obstructive Hypertrophic Cardiomyopathy MARIKO YAGI, TETSUO KONNO, YOUJI NAGATA, NOBORU FHJINO, KENSHI HAYASHI, MASAYOSHI KAWAJIRI, MASAKAZU YAMAGISHI Department of Cardiology, Kanazawa University Hospital A 60-year-old male patient was admitted to our hospital for recurrent syncope. On arrival at our hospital, the patient was totally oriented. Blood pressure was 180/