Association between Cardiac Function and Pulmonary Function in Hypertensive Patients

OBJECTIVE: This study examined the association between cardiac function and pulmonary function in hypertensive patients. METHODS: Hypertensive patients without overt cardiovascular disease were enrolled ( n = 43; mean ± SD age 71 ± 9 years). Pulmonary function was measured by the percentage of predicted forced vital capacity (%FVC) and the ratio of 1 s forced expiratory volume (FEV1) to FVC (FEV1/FVC ratio). Left ventricular ejection fraction (LVEF) and the ratio of peak early diastolic transmitral flow (E) to peak early diastolic mitral annular velocity (e′) (E/e′ ratio) were assessed using echocardiography. RESULTS: Multiple linear regression analysis revealed that E/e′ was independently associated with %FVC and that LVEF was independently associated with FEV1/FVC ratio. Both LVEF and FEV1/FVC ratio were significantly lower in hypertensive former or current smokers than in hypertensive never smokers. CONCLUSIONS: Subclinical cardiac dysfunction was independently associated with reduced pulmonary function in hypertensive patients. Hypertensive patients with decreased pulmonary function may need preventive care to prevent the progression of heart failure.

Raloxifene inhibits menin-dependent estrogen receptor activation in breast cancer cells

BACKGROUND

Menin is a tumor suppressor encoded by Men1 that is mutated in the human-inherited tumor syndrome--multiple endocrine neoplasia type 1. Menin binds to estrogen receptors (ER) to enhance estrogen activity in breast cancer cells.

AIM

Our clinical study showed that the outcome in the case of menin-positive tumors was worse than in the case of menin-negative tumors. We examined the role of raloxifene on the cell growth in a menin-positive breast cancer cell line.

MATERIAL AND METHODS

To examine the mechanism of raloxifene on menin-dependent activation of ER, we employed the mammalian two-hybrid system. We have established a breast cancer cell line that stably expresses menin. Using these cells, we have examined the effect of raloxifene and tamoxifen on cell growth of menin-transfected cells.

RESULTS

The expression of activation function (AF)-2 enhanced menin-mediated luciferase expression in the mammalian two-hybrid assay. Raloxifene attenuated the effect of menin on estrogen response element-luciferase activation, indicating that raloxifene inhibited the binding of menin to AF-2. Raloxifene significantly inhibited the growth of menin-transfected cells in a dose-dependent manner. Tamoxifen also inhibited menin-transfected MCF-7 cells; however, this inhibition was much less than that of raloxifene.

CONCLUSION

Raloxifene inhibits the binding of menin to the AF-2 domain of ERα, suggesting that raloxifene is one of the therapeutic options for menin-positive breast cancer.

Aortic root dilatation as a marker of subclinical left ventricular diastolic dysfunction in patients with cardiovascular risk factors

Consensus is lacking about the clinical importance of aortic root dilatation in assessment of the risk of cardiovascular disease. In this study, correlations between aortic root diameter and echocardiographic features of left ventricular (LV) diastolic function were investigated in 333 patients with at least one cardiovascular risk factor (hypertension, diabetes or dyslipidaemia) and preserved LV systolic function. Aortic root diameter was measured by M-mode echocardiography, and LV diastolic function was evaluated by measuring the peak velocity of early (E) and late (A) diastolic transmitral blood flow and peak early diastolic mitral annular velocity (E') by Doppler echocardiography. Linear regression analysis showed that, in men, age was not related to aortic root diameter but hypertension and LV hypertrophy were, whereas the converse was true in women. The parameters E, E/A ratio and E', were related to aortic root diameter in both sexes. Stepwise multiple regression analysis confirmed that E in women and E' in men were independently associated with aortic root diameter. It is concluded that aortic root dilatation might be a useful marker of subclinical LV diastolic dysfunction. Patients with preserved systolic function showing aortic root dilatation should, therefore, be given preventative therapy against LV diastolic heart failure.

Exendin-4 regulates the expression of the ATP-binding cassette transporter A1 via transcriptional factor PREB in the pancreatic β cell line

BACKGROUND

PRL regulatory element-binding (PREB) protein is a transcription factor that regulates insulin promoter activity in the rat anterior pituitary. The PREB protein is expressed not only in the anterior pituitary but also in pancreatic β cells. Previously, we have reported that PREB plays an important role in glucose-mediated insulin gene expression in pancreatic β cells. The ATP-binding cassette transporter A1 (ABCA1) in pancreatic β cells influences insulin secretion and glucose homeostasis. Exendin-4 (Ex-4), a longacting agonist of the glucagon-like peptide 1, stimulates ABCA1 expression in pancreatic β cells.

AIMS

In this study, we examined the role played by PREB in Ex-4-induced ABCA1 expression in pancreatic β cells.

MATERIAL/SUBJECTS AND METHODS

PREB mRNA and protein expression were evaluated in pancreatic β cell line (INS-1 cells) treated with Ex-4 (10 nM).

RESULTS

Ex-4 stimulated PREB protein and mRNA expression in INS-1 cells. PREB stimulated the activity of the luciferase reporter protein that was under the control of the ABCA1 promoter. Chromatin immunoprecipitation assay showed that PREB mediates its transcriptional activity by directly binding to the ABCA1 promoter region. Finally, we used small interfering RNA to inhibit PREB expression in the cells and demonstrated that the knockdown of PREB expression attenuated the effects of Ex-4 on ABCA1 expression.

CONCLUSION

PREB mediates Ex-4-stimulated transcription of the ABCA1 gene in pancreatic β cells.

Differences in Left Ventricular Diastolic Dysfunction between Eccentric and Concentric Left Ventricular Hypertrophy in Hypertensive Patients with Preserved Systolic Function

Left ventricular (LV) hypertrophy (LVH) may be eccentric or concentric (2 × LV posterior wall thickness relative to LV end-diastolic dimension ≤ 0.42 or > 0.42, respectively). The LV diastolic function between age-matched hypertensive patients with eccentric and concentric LVH was compared in the present study. Echocardiography was used to measure LV mass index (LV mass/body surface area; LVMI) as an index of LVH. LV diastolic function was assessed by measurements of peak early transmitral flow velocity ( E)/peak late transmitral flow velocity ( A) (the E/A ratio), peak early diastolic mitral annular velocity ( e′) and the E/e′ ratio. Although LVMI, E/A and e′ did not differ between the two groups, E/e′ was significantly higher (worse) in patients with concentric LVH (13.4 ± 5.4) than in those with eccentric LVH (11.1 ± 3.6). Among hypertensive patients with LVH, those with concentric LVH may, therefore, have more severe LV diastolic dysfunction than those with eccentric LVH even if their LVMIs, which reflect the degree of LVH, are similar.

Hyperglycemia suppresses ABCA1 expression in vascular smooth muscle cells

Hyperglycemia is a major risk factor for atherosclerotic disease. The ATP-binding cassette transporter A1 (ABCA1) functions as a pivotal regulator of lipid efflux from cells to apolipoproteins and is thus involved in lowering the risk of atherosclerosis. In this study, we have examined the glucose-mediated regulation of the ABCA1 gene expression in vascular smooth muscle cells. ABCA1 expression was examined by real-time polymerase chain reaction (PCR), Western blot analysis, and reporter gene assay. The results showed that the expression of the ABCA1 mRNA and protein decreased after the cells were treated with 22.4 mM glucose for 48 h. The transcriptional activity of the ABCA1 promoter paralleled the endogenous expression of the ABCA1 gene. Next, we used inhibitors of certain signal transduction pathways to demonstrate that the glucose-induced ABCA1 suppression is sensitive to the p38-mitogen-activated protein kinase (MAPK) inhibitors. The expression of a constitutively active form of p38-MAPK in the cells inhibited the ABCA1 promoter activity, irrespective of the presence of glucose. A dominant-negative mutant of p38-MAPK abrogated the inhibitory effect of glucose on the ABCA1 promoter activity. These results indicate that the glucose-induced suppression of ABCA1 expression is partially mediated by the activation of the p38-MAPK pathway.

Exendin-4 regulates glucokinase expression by CaMKK/CaMKIV pathway in pancreatic beta-cell line

AIM

Glucokinase (GK) in pancreatic beta cells is thought to be involved in insulin secretion and glucose homeostasis. This study investigates whether the long-acting agonist of the glucagon-like peptide 1, namely exendin-4, mediates stimulatory effects on GK gene expression through the Ca(2+)/calmodulin (CaM)-dependent protein kinase (CaMK) cascade.

METHODS

GK expression was examined by real-time PCR, western blot analysis and reporter gene assay in rat insulin-secreting INS-1 cells incubated with exendin-4. CaMKIV activity was assessed by detection of activation loop phosphorylation (Thr(196)) of CaMKIV. We investigated the effect of the constitutively active form (CaMKIVc) of CaMKIV on GK promoter activity.

RESULTS

Increased expression level of GK protein was noted in response to rising concentrations of exendin-4 with maximum induction at 10 nM. Real-time PCR analysis showed a significant increase in the amount of GK mRNA in response to rising concentrations of exendin-4. Exendin-4 also stimulated GK promoter activity but failed to do so in the presence of STO-609, a CaMKK inhibitor. This result is consistent with the observations that the upregulation of CaMKIV phosphorylation (at Thr(196)) peaked after 15 min of exposure to exendin-4 and that CaMKIVc enhanced or upregulated GK promoter activity in INS-1 cells. Furthermore, STO-609 significantly suppressed the exendin-4 - upregulated the expression of the GK protein.

CONCLUSION

Activation of the CaMKK/CaMKIV cascade might be required for exendin-4-induced GK gene transcription, indicating that exendin-4 plays an important role in insulin secretion in pancreatic beta cells.

Comparison of left ventricular diastolic filling with myocyte bulk modulus using Doppler echocardiography and acoustic microscopy in pressure-overload left ventricular hypertrophy and cardiac amyloidosis

BACKGROUND

The myocardial bulk modulus has been described as the constitutive properties of the left ventricular (LV) wall and is measured as rho V2 (rho = density, V = sound speed) using acoustic microscopy.

HYPOTHESIS

The study was undertaken to assess the relationship between the myocyte bulk modulus and transmitral inflow patterns in patients with pressure-overload LV hypertrophy (LVH) and cardiac amyloidosis (AMD).

METHODS

In 8 patients with LVH, 8 with AMD, and 10 controls without heart disease, the transmitral inflow pattern was recorded by Doppler echocardiography before death, and myocardial tissue specimens were obtained at autopsy. The tissue density and sound speed in the myocytes were measured by microgravimetry and acoustic microscopy, respectively. The diameters of the myocytes were measured on histopathologic specimens stained by the elastica Van Gieson method.

RESULTS

In the subendocardium, the myocyte bulk modulus was larger in LVH (2.98 x 10(9) N/m2, p < 0.001) and smaller in AMD (2.61 x 10(9) N/m2, p < 0.001) than in the controls (2.87 x 10(9) N/m2). The myocyte diameter in LVH (26 +/- 1 microns) was larger than that in the control (21 +/- 1 microns, p < 0.001) and AMD (20 +/- 1 microns, p < 0.001). The bulk modulus in the subendocardial myocyte significantly correlated with the deceleration time (DT) of the early transmitral inflow (r = 0.689, p = 0.028 in control, r = 0.774, p = 0.024 in LVH, and r = 0.786, p = 0.021 in AMD).

CONCLUSION

The changes in the myocyte elasticity as represented by the bulk modulus were limited to the subendocardial layers and may be related to relaxation abnormalities in LVH and a reduction in LV compliance in AMD.

Antioxidant Effect of a New Calcium Antagonist, Azelnidipine, in Cultured Human Arterial Endothelial Cells

Azelnidipine is a novel dihydropyridine-type calcium antagonist with long-acting anti-hypertensive action and a low reported incidence of tachycardia. We aimed to evaluate its antioxidant activity in cultured human arterial endothelial cells under oxidative stress. Endothelial cells were exposed to 1 mM H2O2 and treated with 100 μM α-tocopherol, 1 nM, 10 nM or 100 nM azelnidipine, 100 nM nifedipine or 100 nM amlodipine. After 3 h, the cell number and level of lipid peroxidation were evaluated by measuring the total protein and 8-iso-PGF2α concentrations, respectively. The total protein concentration was similar with each treatment. Inhibition of 8-iso-PGF2α was greatest with 10 nM azelnidipine (compared with the other drugs); the difference between 10 nM and 100 nM azelnidipine was not significant. We conclude that azelnidipine has a potent antioxidative effect that could be of significant clinical benefit when combined with its long-lasting anti-hypertensive action and low incidence of tachycardia.

Accuracy and reproducibility of coronary flow rate assessment by real-time contrast echocardiography: in vitro and in vivo studies

Real-time myocardial contrast echo (MCE) provides the potential to assess myocardial blood flow from time-intensity refilling curves after high-energy bubble destruction. This study validated the accuracy of this approach and the effect of specific examination variables and instrument settings on results. The effects of examination depth and angle as well as dynamic range, pulse repetition frequency, and line density were assessed with the use of in vitro incremental flow rates produced in an in vitro tissue phantom. In vivo recordings of real-time imaging with an infusion of a contrast agent (Optison) were obtained in 7 open-chest dogs with graded left anterior descending artery stenosis at baseline and during adenosine hyperemia, and were compared with flow probe measurements. After bubble destruction, time-intensity data were fitted to an exponential function, and the rate of intensity increase (b) and peak plateau intensity (A) were derived from refilling curves. In vivo real-time values for b, but not A, correlated closely with flow probe measures (r = 0.93). A similar correlation for b was observed in vitro (r = 0.98). The correlation between flow rate and b was influenced by several examination variables, including depth, angle, and instrument settings. Real-time MCE provides accurate quantification of coronary flow by assessing the rate of microbubble refilling. However, this parameter may be affected by several examination and instrument variables. Therefore, real-time MCE refilling measures are best applied by comparing baseline values with those of stress studies.

Influence of the angiotensin II receptor antagonist losartan on diuretic-induced metabolic effects in elderly hypertensive patients: comparison with a calcium channel blocker

OBJECTIVE

Diuretic therapy frequently induces undesirable biochemical changes and side effects. We compared metabolic effects of a low-dose diuretic (D) given in combination with an angiotensin II receptor antagonist, losartan (L), with those resulting from a diuretic given in combination with a calcium channel blocker, slow-release nifedipine (N).

MATERIAL AND METHODS

Thirty-seven elderly patients with mild to moderate hypertension (mean age: 71 +/- 3 years) were treated with either L+D (n = 18) or N+D (n = 19) for 1 year. Diuretic therapy included low-dose trichlormethiazide or low-dose furosemide in numbers of patients that were similar between L+D and N+D groups. Blood pressure, serum electrolytes, uric acid, blood glucose, renal function and lipid parameters were measured at baseline, 6 months and 1 year.

RESULTS

Effective blood pressure control was observed in both groups at 6 months, and with further improvement at 1 year. Serum potassium was significantly decreased from baseline at 6 months (p < 0.01) and 1 year (p < 0.01) in the N+D group, but not in the L+D group. Serum uric acid was significantly increased from baseline at 6 months (p < 0.01) and 1 year (p < 0.01) in the N+D group, but had minimally decreased at 1 year in the L+D group (p < 0.1). Blood glucose, renal function and lipid parameters did not change in either group.

CONCLUSION

The combination of losartan and low-dose diuretics effectively treated hypertension in elderly patients while minimizing the metabolic consequences of diuretic therapy. Larger trials will be necessary to confirm this finding.

Comparison of real-time and intermittent triggered myocardial contrast echocardiography for quantification of coronary stenosis severity and transmural perfusion gradient

BACKGROUND

Both intermittent triggered and real-time myocardial contrast echocardiography (MCE) have been proposed to detect impaired myocardial perfusion. We compared the ability of these 2 methods to quantify altered myocardial blood flow (MBF) and transmural distribution of MBF produced by graded coronary stenoses.

METHODS AND RESULTS

In 8 open-chest dogs, we created 4 graded left anterior descending coronary artery (LAD) stenoses: 3 levels of reduced adenosine hyperemia (non-flow-limiting at rest) and 1 grade of flow-limiting at rest. Real-time MCE was performed with SonoVue infusion using low-energy power pulse inversion (ATL) imaging, whereas ECG-gated intermittent triggered imaging used high energy at pulsing intervals from 1:1 to 1:10. LAD signal intensity (SI) was plotted versus time by real-time MCE and versus pulsing intervals by triggered MCE and was fitted to a 1-exponential function to obtain plateau SI (A) and the rate of SI rise (b). Visual detection of decreased opacification was equivalent by triggered and real-time MCE. Fluorescent microsphere-derived MBF ratio in LAD/left circumflex artery beds demonstrated close correlation with both real-time imaging (b, r=0.79; Axb, r=0.81) and triggered imaging (b, r=0.78; Axb, r=0.80). The endocardial/epicardial ratio of MBF in the LAD bed demonstrated closer correlation with the endocardial/epicardial ratios of b (r=0.71) and Axb (r=0.67) obtained by real-time than triggered imaging (b, r=0.42; Axb, r=0.52).

CONCLUSIONS

Real-time and triggered MCE are equivalent in their ability to identify coronary stenosis and quantify altered MBF.

Ultrasonographic assessment of coronary flow reserve and abdominal fat in obesity

Recent technological advances in transthoracic Doppler echocardiography (TTDE) have provided noninvasive measurement of coronary flow velocity reserve (CFVR). We aimed to quantitate a correlation between endothelial dysfunction and fat distribution. In 36 patients with obesity, 16 with noninsulin-dependent diabetes mellitus (DM) and 12 healthy volunteers, coronary flow velocity was measured at the distal site of the left anterior descending branch. CFVR was defined as the ratio of hyperemic (IV infusion of 0.15 mg/kg/min adenosine) to basal peak diastolic flow velocity. Abdominal wall fat index (AWFI) was estimated by ultrasonography. Insulin resistance was quantified by the euglycemic hyperinsulinemic clump method. AWFI was significantly related to CFVR (r = -0.46, p = 0.011) and insulin resistance (r = -0.71, p < 0.0001). CFVR could be noninvasively evaluated using TTDE. Coronary endothelial dysfunction indicated as CFVR, body fat distribution and insulin resistance was quantitatively correlated in obesity.

Effect of cibenzoline, a class ia antiarrhythmic agent, on left ventricular diastolic function in hypertrophic cardiomyopathy

We aimed to investigate whether the improvement of left ventricular (LV) diastolic function by cibenzoline, a class Ia antiarrhythmic drug, in hypertrophic obstructive cardiomyopathy (HOCM) is due to LV afterload reduction or a primary lusitropic effect on LV. Twenty-three patients with hypertrophic cardiomyopathy (11; HOCM, 12; non-obstructive HCM; HNCM) were examined. Pulsed-wave Doppler, color M-mode and tissue Doppler echocardiography were performed before and 90 minutes after oral administration of cibenzoline (300 mg), and were compared with a treatment of bisoprolol (5 mg/day, 10 days). Early (E) and late diastolic LV inflow velocity, E flow propagation velocity (FPV) and early diastolic mitral annulus velocity (Ea) were measured. E/FPV and E/Ea were calculated as indices of LV filling pressure. LV outflow pressure gradients estimated using continuous-wave Doppler in HOCM markedly decreased after cibenzoline (83 +/- 42 to 40 +/- 33 mmHg, p < 0.005) and bisoprolol (44 +/- 40 mmHg, p < 0.005). Following cibenzoline, E/FPV and E/Ea were significantly decreased in both HOCM (1.75 +/- 0.53 to 1.32 +/- 0.28, p < 0.05, 18.9 +/- 6.2 to 14.8 +/- 5.0, p < 0.05, respectively) and HNCM (1.75 +/- 0.58 to 1.41 +/- 0.73, p< 0.05, 13.0 +/- 4.3 to 9.7 +/- 3.6, p< 0.01, respectively). Those in HNCM did not change by bisoprolol. Cibenzoline improved LV diastolic function in HCM, whereas bisoprolol did not affect it. Thus, the primary lusitropic effect of cibenzoline rather than LV after load reduction might have contributed to the improvement of diastolic function in HOCM.

Characterization of contraction and perfusion in the lateral border zone between normal and ischemic myocardium following coronary occlusion by myocardial contrast echocardiography

We performed myocardial contrast echocardography with power Doppler imaging during left anterior descending occlusion in 10 dogs, and found that video intensity and dyssynergy in lateral border zones of ischemic myocardium were present, but the video intensity was significantly lower than adjacent nonischemic zones. The results of this study demonstrate that levels of perfusion and contraction, which are intermediate between normal and central ischemic zones, are observed in the border zone with coronary occlusion by myocardial contrast echocardography, and may have implications in identifying myocardium that will be spared necrosis and in measuring ultimate infarct size.

Quantitative assessment of myocardial perfusion during graded coronary stenosis by real-time myocardial contrast echo refilling curves

OBJECTIVES

The present study examined the ability of real-time myocardial contrast echocardiography (MCE) to delineate abnormalities produced by graded coronary stenoses and to correlate signal intensity (SI) parameters derived from destruction/refilling curves with regional myocardial blood flow (MBF) and contractile function.

BACKGROUND

Recent technological advances have enabled myocardial opacification by MCE to be achieved during real-time imaging.

METHODS

In eight open-chest dogs, we created LAD occlusion and graded stenoses that were either flow-limiting at rest (FLS) or reduced adenosine hyperemia (non-flow-limiting at rest = NFLS). Myocardial contrast echo used Optison infusion and low-energy real-time power pulse inversion imaging. High-energy FLASH frames destroyed bubbles every 15 cardiac cycles. Myocardial SI-versus-time plots were fitted to a one-exponential function to obtain the rate of SI rise (b) and peak SI in the last frame.

RESULTS

Dyssynergy was not observed during any NFLS, but perfusion abnormalities were. Visual detection of decreased opacification was possible with severe NFLS and FLS. b demonstrated a significant reduction with severe NFLS and near significant with moderate NFLS; peak SI did not. All exponential parameters were significantly decreased with FL stenosis and occlusion. The MBF ratio in LAD/LCx beds (fluorescent microspheres) correlated with b (r = 0.79) and the product of the peak SI and b (r = 0.80).

CONCLUSIONS

In an open-chest dog model, parameters derived from microbubble refilling of the imaging field by real-time MCE correlate well with myocardial blood flow and can identify coronary stenosis.

Assessment of coronary stenosis severity and transmural perfusion gradient by myocardial contrast echocardiography: comparison of gray-scale B-mode with power Doppler imaging

BACKGROUND

The present study (1) compared the ability of power Doppler imaging with that of gray-scale B-mode tissue imaging to opacify the myocardium and detect coronary stenosis by myocardial contrast echocardiography and (2) compared the response of video intensity (VI) to variable pulsing intervals for each modality.

METHODS AND RESULTS

Four grades of left anterior descending coronary artery (LAD) stenoses were created in 9 open-chest dogs. Stenoses reduced resting LAD flow by 25%, 50%, 75%, and 100% of baseline by flow probe. Myocardial contrast echocardiography was performed during varying ECG gated pulsing intervals (PIs) from 1:1 to 1:10. By gray-scale imaging, background-subtracted LAD bed VI was less than baseline VI at all PIs for the 100% reduced-flow state but not for any other flow state or interval. By power Doppler imaging, LAD bed VI was less than baseline VI at all intervals for 75% and 100% reduced-flow states but only 1:1 and 1:2 for 25% and 50% reduced-flow states, respectively. Correlation of VI and myocardial blood flow (determined by use of fluorescent microspheres) ratios from stenosed versus normal beds was stronger by power Doppler imaging. A transmural opacification gradient with stenosis was visualized and measured by power Doppler imaging, but it was insignificant by gray-scale imaging. The ratio of endocardial/epicardial flow determined by use of fluorescent microspheres was correlated with VI by power Doppler imaging at all PIs.

CONCLUSIONS

Power Doppler imaging has advantages compared with gray-scale imaging in opacifying the myocardium and in detecting coronary stenosis and altered transmural distribution of myocardial perfusion from peak VI. Because VI differences from baseline at long PI vary for mild versus severe (75% and 100%, respectively) reduced-flow states, power Doppler imaging may provide a method to quantify coronary stenoses.

Physical properties of the mitral valve tissue assessed by tissue sound speed in cardiac amyloidosis: relationship to the severity of mitral regurgitation

Cardiac amyloidosis has been documented to show mitral regurgitation (MR) and a thickened mitral valve (MV) due to amyloid deposits. However, the changes in the physical properties of the thickened MV tissue in cardiac amyloidosis, which may be a causative factor of the MR, have not been described. Physical properties of the tissue, which are expressed by the elastic bulk modulus, can be evaluated by tissue sound speed. If biological tissue is assumed to be fluid-like, the tissue sound speed may be given by c= square root of K/rho, where c is the tissue sound speed, K is the elastic bulk modulus, and rho is the density. A reduction in tissue sound speed indicates a reduction in the elastic bulk modulus of the tissue, assuming that there is little change in rho. This suggests that the tissue is less elastic. The purpose of this study was to assess the physical properties of MV tissue by evaluating the sound speed of the MV tissue in cardiac amyloidosis. MV specimens were obtained at autopsy from 20 control adults without cardiovascular diseases and from 20 patients with cardiac amyloidosis. An acoustic microscope operating at 450 MHz was used to measure the tissue sound speed in the tip and basal portions of the MV tissue. The density of MV tissue was measured by microgravimetry. The severity of the MR had been evaluated by Doppler echocardiography before death, and it was compared with the tissue sound speed measured after death. In cardiac amyloidosis showing mild MR, the tissue sound speed of the MV in the tip portion (1605 +/- 19 m/s) and in the basal portion (1791 +/- 64 m/s) were lower than the corresponding values in control subjects (1637 +/- 42 m/s and 1851 +/- 62 m/s). However, these differences were not statistically significant. In cardiac amyloidosis showing moderate MR, the tissue sound speed of MV in the tip portion (1563 +/- 17 m/s) and in the basal portion (1654 +/- 59 m/s) were significantly lower than the corresponding values in the control subjects (p < 0.001) and the patients with mild MR (p < 0.05). No significant differences were observed in the density of MV tissue among the three groups. Therefore, the low value of the MV tissue sound speed in patients with cardiac amyloidosis indicated a reduced elastic bulk modulus, suggesting the less elasticity of the MV tissue. Furthermore, the patients with moderate MR demonstrated the greater reduction in the tissue sound speed than the patients with mild MR. The data suggest that the changes in physical properties of the MV tissue may be one of the causes of MR in cardiac amyloidosis.

Evaluation of progression in nonrheumatic aortic valvular stenosis by scanning acoustic microscopy

To investigate distributions of hardness and thickness in nonrheumatic aortic stenosis (AS), scanning acoustic microscopy was used. The acoustic propagation speed (APS: m/s) and thickness at three sites (tip, middle and base) of aortic valve were measured in 18 cusps from 7 surgical patients with AS (late lesion), 27 showing mild lesions from 9 autopsy cases (early lesion) and 18 healthy from 6 autopsy cases (healthy). These were measured in each layer of cusps: fibrosa (F), spongiosa (S) or ventricularis (V). In early lesions, an increase in APS preceded the thickening and distributed in the tip (1666 +/- 107), the three layers of the middle (F: 1782 +/- 121; S: 1590 +/- 38; V: 1636 +/- 59) and the fibrosa of the base (1736 +/- 203). In late lesions, APS of the tip and three layers of the base were markedly increased. Progressive nonrheumatic AS is characterized by increased hardness that precedes the thickening, and its distribution may be related to mechanical stress.

Relationship between myocardial tissue density measured by microgravimetry and sound speed measured by acoustic microscopy

If myocardial tissue can be assumed to be fluid-like, myocardial tissue elasticity can be estimated by the sound speed of tissue based on the equation K = rho(c)2, where K is the elastic bulk modulus, rho is density, and c is the sound speed of tissue. However, little data exist regarding the relationship between the sound speed of tissue and tissue density. The purpose of the present study was to evaluate the relationship between the sound speed of tissue and tissue density of various diseased myocardia. Myocardial tissue specimens at autopsy were obtained from 10 control patients without cardiovascular disease, 8 patients with pressure overload left ventricular hypertrophy (POLVH), and 8 patients with cardiac amyloidosis (AMD). Myocardial tissue sound speed was measured using a scanning acoustic microscope operating in the frequency of 450 MHz, and tissue density was measured by microgravimetry. The sound speed in POLVH (1639 +/- 17 m/s) was higher and that in AMD (1565 +/- 11 m/s) was lower than that in control patients (1615 +/- 15 m/s) (p < 0.001) at the temperature of 20-22 degrees C. The density in POLVH (1.087 +/- 0.004 g/cm3) was higher and that in AMD (1.072 +/- 0.003 g/cm3) was lower than that in control patients (1.082 +/- 0.003 g/cm3) (p < 0.001). Tissue density correlated with sound speed in all three groups (r = 0.96, p < 0.001). Therefore, myocardial tissue sound speed data obtained by acoustic microscopy enabled us to evaluate tissue elasticity without measuring tissue density directly.

Feasibility of right ventricular myocardial opacification by contrast echocardiography and comparison with left ventricular intensity

To demonstrate the feasibility and quantify the intensity of right ventricular (RV) myocardial opacification by myocardial contrast echocardiography (MCE), we analyzed MCE produced by intravenous injection of 0.15 ml/kg of QW7437 in 8 closed-chest dogs. MCE could produce visual opacification of the RV wall similar in time course to that of the left ventricular wall, and the data supported the potential role of MCE in evaluating RV hypertrophy, contraction, and perfusion abnormalities.

Tissue characterization of myocardial cells by use of high-frequency acoustic microscopy: differential myocyte sound speed and its transmural variation in normal, pressure-overload hypertrophic, and amyloid myocardium

The purpose of the present study was to evaluate the acoustic properties of myocytes in normal, pressure-overload hypertrophic, and amyloid myocardium. Myocardial tissue specimens at autopsy were obtained from 10 subjects without cardiovascular disease, six patients with left ventricular (LV) hypertrophy, and six patients with cardiac amyloidosis. Sound speed of myocytes was measured at subendocardial and subepicardial regions in myocardium by use of a high-frequency (450 MHz) acoustic microscope. In normal myocardium, the sound speed of myocytes was significantly higher in subendocardial region (1,728+/-19 m/sec) than in subepicardial region (1,645+/-22 m/sec) (p<0.0001). A significantly higher sound speed of myocytes was observed in the subendocardial region in LV hypertrophic myocardium (1,779+/-19 m/sec) than that in normal myocardium (p<0.001). In amyloid myocardium, a significantly lower sound speed of myocytes was observed in subendocardial (1,560+/-8 m/sec) and subepicardial (1,594+/-48 m/sec) regions than that in respective regions of the normal myocardium (p<0.0001 and p<0.05, respectively). Transmural variation in sound speed of myocytes measured by high-frequency acoustic microscopy existed in normal left ventricle. The differential myocyte sound speed and its transmural variation was observed in LV hypertrophic and amyloid myocardium as compared with normal myocardium. High-frequency acoustic microscopy can be a promising technique for myocardial tissue characterization at the myocyte level.

Cyclic variation of thickness in an age-related thick mitral valve observed by transthoracic echocardiography

The cyclic variation of thickness during the cardiac cycle in age-related degenerative mitral valve (MV) has not been reported. Transthoracic echocardiography was used to evaluate the cyclic alteration in MV thickness in 40 patients with age-related MV thickening (diastolic MV thickness > or = 4 mm, age 70 +/- 14 years), 10 with mitral valve prolapse (MVP, age 49 +/- 11 years), 10 with rheumatic mitral stenosis (MS, age 66 +/- 9 years), and 31 control subjects (diastolic MV thickness < or = 3.6 mm, 53 +/- 17 years). After determination of the site of maximal thickness during diastole, the maximal and minimal thickness during systole of the anterior MV were measured. The percent change in MV thickness from diastole to systole (%deltaT) was calculated. The mitral regurgitation (MR) area was measured on color Doppler echocardiogram. The %deltaT (mean +/- sd) in age-related thickened MV and MVP groups were similar and significantly greater than that in control (60 +/- 8%, 61 +/- 6% vs 32 +/- 9%, p < 0.001). MR area was significantly greater in the age-related thickened MV group than that in controls (160 +/- 205 mm2 vs 14 +/- 40 mm2, p < 0.05). The %deltaT in MS (10 +/- 6%) was smallest (p < 0.001). A large cyclic alteration in valvular thickness was observed in the age-related degeneration of the MV and may be the cause of large MR despite no leaflet prolapse. The echocardiographic assessment of cyclic variation of MV thickness is feasible for estimating the histologic damage in thick MV.

Evaluation of left atrial wall elasticity using acoustic microscopy

Left atrial wall elasticity is one of the important factors regulating left atrial stiffness and functions. The authors evaluated left atrial wall elasticity by measuring the sound speed through the left atrial wall, based on the hypothesis that high elasticity tissues will yield larger sound speed values through the tissue, and examined age-associated changes in left atrial wall elasticity. Left atrium specimens were obtained from 30 normal subjects (age, 15-95 years) at autopsy. An acoustic microscope, operating at 450 MHz, was used to measure the sound speed in the endocardium and the myocardium of the left atrium. The sound speeds in endocardium and myocardium demonstrated significant correlation with age (r = 0.74, p<0.0001 and r = 0.47, p<0.01, respectively). These findings indicate that left atrial wall elasticity increased with advancing age. These changes may lead to deterioration of left atrial compliance and eventual left atrial failure in older subjects.

Histological observations and the process of ultrasound contrast agent enhancement of tissue plasminogen activator thrombolysis with ultrasound exposure

Although the enhancement of tissue plasminogen activator (tPA) induced thrombolysis by ultrasound has been reported to be augmented by ultrasound contrast agents (UCA), few data exist regarding its process. The present study evaluated the effect of a galactose based UCA on the efficacy of ultrasonic enhancement of tPA thrombolysis and observed the serial changes in the acoustic property and histopathology. A catheter-type transducer capable of ultrasound emission in both continuous (CW) and pulsed wave (PW) was used. The tPA thrombolysis was studied in 30 artificial white thrombi, which were assigned to 4 study groups based on insonation modes and with and without UCA. Each sample was suspended in 100ml saline in a beaker. Five minutes after tPA (8000U) administration, ultrasound was applied for 10min. For the UCA-treated groups, UCA (0.25g) was added 5 min after the start of ultrasound exposure. The alteration of the thrombus was monitored with echography. Weight reduction of the thrombus was -25+/-6% in PW and -30+/-7% in CW, which was significantly enhanced by UCA treatment, 40+/-3% (p<0.005) in PW+UCA and -43+/-7% (p<0.005) in CW+UCA. The area of thrombus echo image minimally decreased with ultrasound alone (-12+/-6%: PW, -23+/-11%: CW). In the UCA groups, UCA induced a remarkable reduction of size (-36+/-3%: PW+UCA, -43+/-7%: CW+UCA) with a high-echo intensity in the superficial layer of the thrombus, where multiple cavity formation was observed by light microscope. UCA markedly enhanced the effect of ultrasound on tPA thrombolysis. The altered acoustic property and corresponding histological microcavity formation in the shallow layer within the thrombus suggests that UCA augmented infiltration of tPA into the thrombus.

Prolongation of left atrial augmentation after handgrip stress in coronary artery disease: observation using pulsed Doppler flowmetry

Although alterations in left ventricular diastolic filling dynamics have been observed during myocardial ischemia, few data exist regarding temporal changes in left ventricular filling during recovery. Therefore, the authors evaluated transmitral inflow pattern during and after handgrip exertion in coronary artery disease (CAD) by using Doppler echocardiography. The study population consisted of 18 normal (N) subjects and 47 patients with CAD. Of the CAD patients, 17 had coronary lesions associated with a limited area of underperfused myocardium (seven with good collateral circulation and 10 with distal lesions) (MILD), 15 patients exhibited a proximal lesion in a single vessel (SVD), and 15 patients had significant multivessel disease (MVD). Transmitral inflow velocities were continuously recorded at baseline, during handgrip exercise (50% of maximal for 1 minute), and for 5 minutes of recovery. Mean blood pressure, heart rate, early diastolic (E) and late atrial (A) inflow velocities, A/E ratio, and percent changes in E, A, and A/E from baseline were measured. In N and MILD, respectively, left ventricular inflow pattern returned to baseline at 3 minutes after handgrip (%E: 0.7 +/- 7.6%, 6.4 +/- 13.7%; %A: -0.2 +/- 7.9%, 3.1 +/- 6.5%; %A/E: -0.1 +/- 9.7%, -1.7 +/- 12.9%). In SVD and MVD, respectively, change in left ventricular inflow pattern was continued at 3 minutes after handgrip (%E: 7.2 +/- 9.4%, -4.3 +/- 17.2%, %A: 15.4 +/- 11.7%, 20.4 +/- 14.6%, %A/E: 7.9 +/- 10.0%, 29.2 +/- 25.6%). Increases in A and A/E in SVD and MVD were significantly higher than in N and MILD. Impaired left ventricular inflow pattern was observed at 3 minutes after handgrip in CAD, which may be reflected from prolonged impairment of diastolic function produced by ischemia. Therefore, temporal observation of left ventricular inflow pattern using the handgrip stress Doppler method may be useful for detection or follow-up of CAD.

Evaluation of acoustic properties of the live human smooth-muscle cell using scanning acoustic microscopy

This study was performed to measure the acoustic propagation speed in live human aortic smooth-muscle cells (HASMC), using scanning acoustic microscopy (SAM) and a novel measurement theory that permits the measurement of the acoustic propagation speed in biological samples of unknown thickness. C-mode and X-Z-mode images of HASMC under three different conditions: growing (G); differential (D); and on hypotonic loading (H), were acquired using 100-MHz, 450-MHz and 600-MHz ultrasound. The images exhibit features related to the cell surface curvature and intracellular structure. The theory supporting the methodology is derived in this article and makes use of the interference fringes within the focusing lens of the high-frequency transducer. The propagation speed in the cells was calculated from the location of the interference fringe on the C-mode images and the fringe shift on the X-Y-mode images with 450-MHz ultrasound. The propagation speed in D (1624 +/- 16 m/s) was significantly higher than those in G (1571 +/- 14 m/s, p < 0.05) and H (1585 +/- 8 m/s, p < 0.05). Scanning acoustic microscope measurements, along with the described theory, are useful for studying the acoustic properties of live cells ex vivo and have applications in both pathophysiology and biomechanics.

[Mitral valve tissue characterization using acoustic microscopy]

Mitral valve hardness in the rough and clear zones was evaluated by measuring the propagation velocity (m/sec) of ultrasound through the valve, based on the hypothesis that harder tissues will have larger ultrasonic velocity values passing through the tissue. Mitral valve specimens were obtained from 16 normal subjects (age, 15-72 years) at autopsy. An acoustic microscope, operating at 450 MHz, was used to measure the ultrasonic velocity through the three layers of the valve: the atrialis; the spongiosa; and the fibrosa. Furthermore, the mean ultrasonic velocity through the three layers was measured. These measurements were conducted in the rough and clear zones of the valve. In the rough zone, the ultrasonic velocities were 1,634 +/- 71 in the atrialis, 1,574 +/- 37 in the spongiosa, and 1,726 +/- 97 m/sec in the fibrosa. In the clear zone, the ultrasonic velocities were 1,691 +/- 117 in the atrialis, 1,575 +/- 44 in the spongiosa, and 1,909 +/- 131 m/sec in the fibrosa. There were significant differences between velocities in the three layers in both the rough and clear zones. Furthermore, the mean ultrasonic velocity in the three layers in the clear zone (1,887 +/- 138 m/sec) was higher than that in the rough zone (1,642 +/- 53 m/sec; p < 0.001). These findings show that fibrosa, which is rich in collagen fibers, is harder than atrialis, which is rich in elastic fibers, and the spongiosa, which is poor in connective tissues, is the softest. The higher mean ultrasonic velocity in the clear zone than in the rough zone indicates that the clear zone is harder than the rough zone, although the clear zone is thinner than the rough zone.

Left ventricular diastolic filling dynamics during isometric exertion in syndrome X assessed with Doppler flowmetry

To study left ventricular diastolic properties in syndrome X, we analyzed transmitral filling dynamics during handgrip exertion. In 14 normal subjects (N), 17 with syndrome X (Syn X), 16 with single-vessel disease (SVD), and 8 with multiple-vessel disease (MVD), transmitral inflow was recorded at baseline and during handgrip (50% of maximal effort for one minute) using pulsed Doppler echocardiography. We measured early diastolic (E) and late atrial (A) inflow velocities, A/E ratio and percent change of A/E from baseline (%A/E). Blood pressure and heart rate increased to the same degree in each group during handgrip. In normal subjects, E did not change with handgrip; A (51 +/- 10 vs 54 +/- 11 cm/sec, P < 0.05) and A/E (1.16 +/- 0.22 vs 1.25 +/- 0.33, P < 0.05) increased minimally. In Syn X subjects, E decreased (51 +/- 10 vs 38 +/- 10 cm/sec, P < 0.0001), A increased (52 +/- 11 vs 60 +/- 14 cm/sec, P < 0.005), and A/E increased markedly (1.07 +/- 0.31 vs 1.68 +/- 0.51, P < 0.0001). The %A/E in Syn X and MVD were significantly larger than that in SVD and N (Syn X: 58 +/- 29%; MVD: 45 +/- 25%; SVD: 22 +/- 21%; N: 8 +/- 13%). Handgrip-induced changes in diastolic filling in syndrome X and are similar to those in MVD and more marked than in SVD. These changes are consistent with impaired ventricular relaxation and support a generalized left ventricular (LV) abnormality in syndrome X.

[Left ventricular diastolic behavior in patients with syndrome X during isometric exercise assessed by Doppler flowmeter]

Left ventricular (LV) diastolic filling during isometric exercise was evaluated in patients with syndrome X using pulsed Doppler echocardiography. The handgrip exercise was performed by 12 normal subjects (group N), 14 patients with syndrome X (group X), and 20 patients with effort angina, who were divided into 13 patients with single vessel disease (group SVD) and seven patients with multiple vessel disease (group MVD). The transmitral inflow patterns before and at the end of exercise were recorded using Doppler flowmetry, to measure the peak velocity of early diastolic flow (E) and the peak velocity of atrial contraction flow (A). The A/E ratio and the % change in A/E (% A/E) at the end of exercise compared with those before were calculated. 1. Group N: E, A, and A/E did not change significantly. 2. Group X: E decreased, A increased, and A/E increased. 3. Group SVD: E did not change significantly. A increased, and A/E increased. 4. Group MVD: E decreased, A increased, and A/E increased. 5. % A/E in group X and group MVD were larger than in group SVD. 6. Systolic blood pressure (SBP) and heart rate (HR) increased during exercise to the same extent in each group. The impairment of LV diastolic filling in group X was more severe than in group SVD, possibly due to more extensive ischemic areas in group X than in group SVD. The extension of ischemic areas in syndrome X may be similar to that in group MVD.

Noninvasive estimation of left ventricular Max(dP/dt) from aortic flow acceleration and pulse wave velocity

The Doppler method of obtaining left ventricular Max(dP/dt) proposed recently was based on the measurement of mitral regurgitation velocity. Since Max(dP/dt) is an isovolumic phase index, its use in cases of mitral regurgitation may be open to argument. However, we had proposed a noninvasive method of estimating left ventricular Max(dP/dt) based on different principles. In our method, Max(dP/dt) had been given by Max(dP/dt) = (rho)cMax (du/dt), where rho is the blood density, c is the pulse wave velocity, and u is the flow velocity in the aorta. We had derived the above equation theoretically, and confirmed its validity by animal experiments. In our previous study, we also applied our method in the clinical setting. The aortic flow velocity was measured by Doppler echocardiography, and the pulse wave velocity by mechanocardiography or Doppler echocardiography. (Rho)cMax(du/dt) obtained noninvasively was compared with Max(dP/dt) measured with a catheter-tip micromanometer. We found an excellent correlation between (rho)cMax(du/dt) and Max(dp/dt), and concluded that (rho)Max(du/dt) is useful in assessing noninvasively the contractile state of the left ventricle. Here, we summarize our method, review previous results, and report new results of the clinical application of our method.

Evaluation of thoracic aortic atherosclerosis by transesophageal echocardiography

Transesophageal echocardiography (TEE) provides excellent images of the thoracic aorta, which cannot be visualized by transthoracic echocardiography. The purpose of this study was to assess atherosis and sclerosis of the thoracic aorta by TEE, to evaluate the risk factors for atherosis and sclerosis, and to assess the relationship between the two components of atherosclerosis. The mean value of the maximum thickness of the intima-media complex in the six segments of the thoracic aorta (MIMC) was used as an index of atherosis, and the stiffness parameter beta was used as an index of sclerosis. The study population consisted of 88 Japanese patients. Multivariate analysis showed that age, low-density lipoprotein cholesterol (or apolipoprotein B), and diabetes mellitus were significantly and independently related to MIMC, whereas age and hypertension were related to the stiffness parameter beta. Both components of atherosclerosis demonstrated a significant although weak relationship. The risk factors for atherosis appear to differ from those for sclerosis in the thoracic aorta, so we should evaluate these two components of atherosclerosis separately. TEE is a useful method of assessing thoracic aortic atherosclerosis because both atherosis and sclerosis can be examined simultaneously.

Sequential change of heterogeneous cerebral blood blow patterns after diffuse brain ischemia

In order to provide an insight into the basic nature of ischemic brain injury, we sequentially studied cerebral blood flow with [99mTc]hexamethylpropyleneamine oxime single photon emission computed tomography (CBF imaging) in a patient with diffuse brain ischemia due to prolonged cardiac arrest. On the 10th postarrest day, concentrated blood flow over superior-medial portion of the occipital lobe was demonstrated. On the 18th postarrest day, the same region became high density on a CT scan, while the concentrated flow on the CBF imaging had diminished. Thus, an abnormal cerebral blood flow (CBF) pattern preceded the density change on CT scan. On the 23rd postarrest day, remarkably concentrated flow over the brainstem was demonstrated. This might have illustrated the reduced metabolic demand of the damaged tissue over the cerebral and cerebellar hemispheres with relative preservation of brainstem perfusion. In patients with diffuse brain ischemia, a CBF imaging may be a useful tool for clarifying pathological process and prognosis.

Takayasu's arteritis with collateral circulation from the right coronary artery to intracranial vessels--a case report

A forty-four-year-old woman with Takayasu's arteritis and involvement of the aortic arch and its main branches complained of precordial pain on effort. Exercise electrocardiograms revealed significant ST segment depression in leads II, III, aVF, and V. Coronary arteriograms demonstrated no stenosis. However, the right coronary arteriogram revealed collateral circulation arising from the sinus node artery to the bilateral vertebral arteries and the left internal carotid artery. The collateral circulation was considered to be an important route of blood flow supply to the brain and, at the same time, a cause of coronary steal syndrome and, consequently, of angina pectoris.

[A case of aortitis syndrome with coronary steal syndrome due to collateral circulation from the right coronary artery to intracranial vessels]

A 44-year old female with aortitis syndrome complained of precordial pain on effort. Exercise electrocardiograms revealed significant ST segment depression in leads II, III, aVF and V. Coronary arteriograms demonstrated no stenosis. However, the right coronary arteriogram revealed collateral circulation arising from the sinus node artery to the bilateral vertebral arteries and the left internal carotid artery. Collateral vessels in aortitis.syndrome arising from the coronary artery to the lung have been reported sporadically. However, to our knowledge, the collateral circulation from the coronary artery to intracranial vessels as seen in the present case has never been reported. In the present case, the left ventricular hypertrophy was observed on electrocardiograms and echocardiograms. It can not be denied that it was a cause of the angina pectoris. However, exercise myocardial scintigraphy showed transient myocardial ischemia at stress on the inferoposterior wall corresponding to leads II, III, aVF and V on electrocardiograms. Therefore, coronary steal syndrome due to the collateral pathway from the coronary artery may be considered a likely cause of the angina pectoris. The collateral circulation was considered to be an important route of blood flow supply to the brain and, at the same time, a cause of coronary steal syndrome and consequently angina pectoris.