Hiroyuki Iwano

Hokkaido University, Sapporo, Hokkaidō, Japan

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Publications (20)66.06 Total impact

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    ABSTRACT: The left ventricle fills in early diastole because of a progressive intraventricular pressure difference (IVPD) that extends from the left atrium to the left ventricular (LV). The aim of this study was to test the hypothesis that in patients with symptomatic heart failure (HF) regardless of LV ejection fraction (EF), an increase in left atrial (LA) pressure maintains early diastolic filling because of a preserved IVPD from the left atrium to the mid left ventricle, while the IVPD from the mid left ventricle to the apex is diminished because of reduced LV suction. One hundred fifty-one patients with HF (50 with HF with preserved EF [HFpEF; EF ≥ 50%] and 101 with HF with reduced EF [HFrEF; EF < 50%]) and 28 normal controls were prospectively enrolled. The IVPDs from the left atrium to the LV apex (total IVPD), the left atrium to the mid left ventricle (basilar IVPD), and the mid left ventricle to the apex (apical IVPD) were determined using color M-mode Doppler echocardiographic data to integrate the Euler equation. The propagation of early diastolic filling was also assessed by color M-mode Doppler. The mean LV EF was 0.63 ± 0.07 in patients with HFpEF, 0.32 ± 0.09 in those with HFrEF, and 0.64 ± 0.06 in controls. Peak early diastolic transmitral flow velocities (E) were similar among the groups, and basilar IVPDs were maintained in the HFpEF and HFrEF groups (HFpEF, 1.59 ± 0.62 mm Hg; HFrEF, 1.49 ± 0.75 mm Hg; controls, 1.80 ± 0.61 mm Hg; P = NS, analysis of variance). However, apical IVPDs were decreased in both HF groups (HFpEF, 1.18 ± 0.56 mm Hg [P < .01 vs controls]; HFrEF, 0.87 ± 0.48 mm Hg [P < .01 vs controls]; controls, 1.65 ± 0.62 mm Hg), resulting in decreased total IVPDs in patients with HF (HFpEF, 2.55 ± 0.80 mm Hg [P < .01 vs controls]; HFrEF, 2.16 ± 0.80 mm Hg [P < .01 vs controls]; controls, 3.17 ± 0.91 mm Hg). E/e' ratios were increased in patients with HF, consistent with elevated LA pressure. In patients with HF, E was correlated with basilar IVPD but not with apical IVPD, whereas propagation of the filling was correlated with the apical IVPD but not with the basilar IVPD. In patients with HFpEF and those with HFrEF, apical IVPDs were reduced while basilar IVPDs were maintained by elevated LA pressure, resulting in preserved E. Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 02/2015; · 2.98 Impact Factor
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    ABSTRACT: Background:Fractional flow reserve (FFR) measured on catheterization is now widely used for the diagnosis of functional myocardial ischemia in patients with coronary artery disease (CAD). FFR, however, is invasive and carries potential procedural complications. Therefore, the aim of this study was to compare the diagnostic capability in functionally significant stenosis identified on FFR, between cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI), single-photon emission computed tomography MPI (SPECT-MPI), and dobutamine stress echocardiography (DSE) in patients with CAD.Methods and Results:A total of 25 patients who had at least 1 angiographic stenosis ≥50% on coronary angiography was studied. CMR-MPI, SPECT-MPI and DSE were done before FFR measurement. FFR was measured in all 3 major epicardial coronary arteries. Out of 71 vascular territories excluding 4 territories due to inadequate imaging, 29 (41%) had FFR <0.80. The sensitivity of CMR-MPI was significantly higher than that of SPECT-MPI and DSE (P=0.02 and P=0.001, respectively). The area under the receiver operating characteristic curve (AUC) for CMR-MPI (AUC, 0.92) was significantly greater than for SPECT-MPI (AUC, 0.73; P=0.006) and DSE (AUC, 0.69; P<0.001).Conclusions:CMR-MPI performed well in the detection of functionally significant stenosis defined according to FFR, and had the highest diagnostic sensitivity among the 3 modalities tested in patients with CAD.
    Circulation Journal 08/2014; · 3.69 Impact Factor
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    ABSTRACT: Many echocardiographic features of constrictive pericarditis (CP) have been reported, but each alone has a limitation either in sensitivity or in specificity. Continuous-wave Doppler-derived flow velocity of pulmonary regurgitation can reflect the diastolic right ventricular pressure pattern characteristic of CP and be useful for its detection.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 08/2014; · 2.98 Impact Factor
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    ABSTRACT: The effect of diastolic dysfunction (DD) on the timing of left ventricular (LV) diastolic longitudinal and circumferential expansion and their load dependence is not known. This study evaluated the timing of the peak early diastolic LV inflow velocity (E), mitral annular velocity (e′), and longitudinal and circumferential global strain rates (SRE) in 161 patients in sinus rhythm. The intraventricular pressure difference (IVPD) from the left atrium to the LV apex was obtained using color M-mode Doppler data to integrate the Euler equation. The diastolic function was graded according to the guidelines. In normals (N = 57), E, e′, longitudinal SRE, and circumferential SRE occurred nearly simultaneously during the IVPD. With DD (N = 104), e′ and longitudinal SRE were delayed occurring after the IVPD (e′: 18 ± 23 msec, longitudinal SRE: 13 ± 21 msec from the IVPD), whereas circumferential SRE (−8 ± 28 msec) and E (−2 ± 13 msec) were not delayed. The normal dependence of e′ and longitudinal SRE on IVPD was reduced in DD; while the relation of circumferential SRE and E to IVPD were unchanged in DD. Thus, normally, the LV expands symmetrically during early diastole and both longitudinal and circumferential expansions are related to the IVPD. With DD, early diastolic longitudinal LV expansion is delayed, occurring after the IVPD and LV filling, resulting in their relative independence from the IVPD. In contrast, with DD, circumferential SRE and mitral inflow are not delayed and their normal relation to the IVPD is unchanged.
    Physiological Reports. 07/2014; 2(7).
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    ABSTRACT: Left ventricular (LV) diastolic dysfunction is often observed in healthy older subjects without structural heart disease, although its exact mechanisms have not been established. A decrease in the aorto-septal angle (ASA), an alteration of LV shape due to aortic elongation, is also frequently seen in elderly subjects. The objective of this study was to evaluate whether it can contribute to LV diastolic dysfunction in healthy subjects. Echocardiography was performed in 77 healthy subjects (42 men, mean age 43.2 ± 13.8 years) to measure the ASA, early diastolic transmitral flow velocity (E), isovolumic relaxation time (IRT), and early diastolic mitral annular velocity (e'). The LV peak early diastolic longitudinal strain rate (GSRE ) was measured using a two-dimensional speckle tracking imaging technique. ASA was significantly correlated with E (r = 0.54, p < 0.001), IRT (r = -0.41, p < 0.001), e' (r = 0.57, p < 0.001), and GSRE (r = 0.63, p < 0.001) and shown by stepwise multivariate analysis to be the strongest independent determinant of E, IRT, and GSRE , and one of the independent determinants of e'. The alteration of LV shape associated with reduced ASA may be one of the causes of LV diastolic dysfunction independently of age in otherwise healthy subjects. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound, 2014;
    Journal of Clinical Ultrasound 01/2014; · 0.80 Impact Factor
  • Journal of Cardiac Failure 10/2013; 19(10):S170. · 3.07 Impact Factor
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    ABSTRACT: Background: We previously reported that the strain rate dispersion index (SRDI), an index of left ventricular (LV) contractility loss because of mechanical dyssynchrony, better predicted the acute response to cardiac resynchronization therapy (CRT) than time-delay indices. However, it remains unclear whether the SRDI can predict the chronic response. Additionally, the SRDI needs to be simplified for use in clinical practice. Methods and Results: Echocardiography was performed in 40 heart failure patients who underwent CRT. The SRDI, the average of segmental peak systolic strain rates minus global peak systolic strain rate, was calculated, together with strain-derived time-delay indices (St-SD) in the longitudinal, circumferential and radial directions using a speckle-tracking method. As simplified indices, the longitudinal parameters were calculated from the apical 4-chamber view in addition to 3 apical views. LV end-systolic volume (ESV) significantly decreased 6 months after CRT. Although circumferential St-SD and all SRDIs correlated with the changes in ESV (ΔESV), multivariate analysis revealed that the circumferential SRDI was the single independent determinant of ΔESV. During the 20±14 months after CRT, cardiac events occurred in 14 patients. Kaplan-Meier analyses revealed that all SRDIs were significant predictors of cardiac events whereas none of St-SDs was. Conclusions: The SRDI predicted the reduction in both LV volume and cardiac events after CRT better than time-delay indices. Additionally, a simplified SRDI could be as good a predictor of CRT response as the original.
    Circulation Journal 08/2013; · 3.69 Impact Factor
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    ABSTRACT: Background Assessing left ventricular (LV) hypertrophy (LVH) is an important step in the echocardiographic diagnosis of aortic stenosis (AS). We aimed to investigate the causes of discrepancies between the degrees of AS and LVH. Methods The study subjects consisted of 149 consecutive patients with AS having aortic valve area <2.0 cm2 (mean age 72.5 ± 11.9 years, 67 men and 82 women). Coexisting cardiac diseases were determined based on echocardiographic findings and comprehensive clinical judgment. Echocardiographic measurements included LV mass index (LVMI), aortic valve area index (AVAI), transaortic mean pressure gradient (MPG), valvulo-arterial impedance (Zva), energy loss coefficient (ELCo), and energy loss index (ELI). Results LVMI was not significantly correlated with AVAI and Zva, and had a weak correlation with MPG (r = 0.305, p = 0.0001). There were 55 patients in group A (non-severe AS without significant LVH), 58 in group B (non-severe AS with significant LVH), 7 in group C (severe AS without significant LVH), and 29 in group D (severe AS with significant LVH). Coexisting cardiac diseases were more frequently observed (p = 0.0003) in group B (50 %) than in group A (18 %). In group C, ELCo and (ELI − AVAI)/ELI were significantly greater than in group D (p = 0.043 and 0.007, respectively). Conclusion Significant LVH seen in less than moderate AS is often due to coexisting cardiac diseases, and there may be an overestimation of AS severity due to pressure recovery among patients with apparently severe AS who do not have significant LVH.
    Journal of Echocardiography 06/2013; 11(2).
  • Hiroyuki Iwano, William C Little
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    ABSTRACT: Heart failure (HF) occurs across the entire range of left ventricular (LV) ejection fractions (EF), not just reduced EF. Nearly half or more patients presenting with HF have a preserved EF>0.50 (HFpEF). Diastolic dysfunction is apparent in all patients with HF, regardless of EF. A preserved EF indicates that the end-diastolic volume is appropriate for the stroke volume, and a reduced EF indicates that the end-diastolic volume is enlarged relative to stroke volume (i.e. the LV is dilated). Most therapies proven to be effective in HF with a reduced EF (ACE-inhibitors, angiotensin receptor blockers, beta-blockers, and cardiac resynchronization) reverse LV dilation. These therapies have not been proven to be effective in HFpEF. Increasing c-GMP may be a treatment target in HFpEF, and potential ways of increasing c-GMP are being studied. Finally, comorbidities are important in HFpEF and are additional targets for therapy.
    Journal of Cardiology 05/2013; · 2.57 Impact Factor
  • International Journal of Cardiology 04/2013; 164(2):S18. · 6.18 Impact Factor
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    ABSTRACT: Background: Adaptive servo-ventilation (ASV) improves cardiac function in patients with heart failure (HF). We compared the hemodynamics of control and HF patients, and identified the predictors for acute effects of ASV in HF. Methods and Results: We performed baseline echocardiographic measurements and hemodynamic measurements at baseline and after 15min of ASV during cardiac catheterization in 11 control and 34 HF patients. Heart rate and blood pressure did not change after ASV in either the control or HF group. Stroke volume index (SVI) decreased from 49.3±7.6 to 41.3±7.6ml/m(2) in controls (P<0.0001) but did not change in the HF patients (from 34.8±11.5 to 32.8±8.9ml/m(2), P=0.148). In the univariate analysis, pulmonary capillary wedge pressure (PCWP), mitral regurgitation (MR)/left atrial (LA) area, E/A, E/e', and the sphericity index defined by the ratio between the short-axis and long-axis dimensions of the left ventricle significantly correlated with % change of SVI from baseline during ASV. PCWP and MR/LA area were independent predictors by multivariate analysis. Moreover, responders (15 of 34 HF patients; 44%) categorized by an increase in SVI showed significantly higher PCWP, MR, and sphericity index. Conclusions: Left ventricular structure and MR, as well as PCWP, could predict acute favorable effects on hemodynamics by ASV therapy in HF patients.
    Circulation Journal 01/2013; · 3.69 Impact Factor
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    ABSTRACT: PURPOSE: Diastolic function is impaired in patients with end-stage heart failure. Favorable structural changes by surgical ventricular reconstruction (SVR) are thought to improve diastolic function, however, previous studies reported the contradictory results. We hypothesized that cardiac oxidative metabolism and diastolic dysfunction might improve in parallel to the reduction of left ventricular chamber size after SVR. METHODS: We studied 11 patients underwent SVR associated with mitral valve repair for end-stage heart failure due to dilated cardiomyopathy. Diastolic function was assessed by echocardiography and myocardial oxidative metabolism was measured by the monoexponential clearance (k-mono) of (11)C-acetate positron emission tomography at baseline and 1 month after SVR. RESULTS: All patients had preoperative severe diastolic dysfunction [E/A 4.11 ± 1.18, deceleration time (DT) 134 ± 26 ms]. The study patients were divided into 2 groups according to the changes in diastolic function after SVR; unchanged or worsened diastolic function in 6 patients (55 %, Non-responder) and improved diastolic function in 5 (45 %, Responder). K-mono and wall stress decreased only in responder. The changes in k-mono before and after SVR correlated with those in deceleration time (r =  -0.63; p < 0.05) and wall stress (r = 0.75; p < 0.01). CONCLUSIONS: Improvement of diastolic dysfunction in patients with end-stage heart failure by SVR was in parallel to that in oxidative metabolism. It suggests that SVR reduced excessive metabolism during the diastolic phase, in part, via the improvement in diastolic function and the reduction in LV wall stress.
    European Journal of Nuclear Medicine 11/2012; · 4.53 Impact Factor
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    ABSTRACT: Background Left ventricular (LV) diastolic dysfunction is often observed in healthy subjects and can be a cause of heart failure with preserved ejection fraction (EF). We aimed to investigate the role of LV diastolic asynchrony as a cause of diastolic dysfunction in healthy subjects. Methods In 40 healthy subjects, two-dimensional speckle tracking imaging (2DSTI) was performed to measure the peak early diastolic longitudinal strain rates (Esr) of the apical, mid-ventricular, and basal segments of the septum and posterior wall. A mean value of the Esr of the 6 segments (mEsr) was calculated. The time from aortic valve closure to the Esr was measured for each segment, and the standard deviation (SDTEsr) was calculated. The peak global early diastolic strain rate (gEsr) was measured with a region of interest (ROI) on the whole LV myocardium. LV flow propagation velocity (FPV) was measured using conventional Doppler techniques. Results SDTEsr was not correlated with age, but was significantly correlated with body mass index (BMI) (r = 0.41, p < 0.01). Although no significant correlation was observed between mEsr and FPV, gEsr and SDTEsr significantly correlated with FPV (r = 0.41, p < 0.01; r = −0.54, p < 0.001). As a result of the multiple regression analysis, SDTEsr was the single determinant of FPV. Conclusions Diastolic asynchrony, associated with overweight but not with aging, may contribute to diastolic dysfunction in healthy subjects.
    Journal of Echocardiography 09/2012; 10(3).
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    ABSTRACT: Early diastolic mitral annular velocity (e') obtained by tissue Doppler imaging (TDI) is widely used to evaluate left ventricular (LV) diastolic function based on the assumption that it reflects myocardial relaxation in the long-axis direction. In this study, we aimed to determine whether or not e' truly reflects early diastolic longitudinal myocardial relaxation, and which is the most useful for evaluating LV diastolic function among e' measured at the interventricular-septal annulus (IS-e'), that measured at the lateral annulus (LW-e') or their mean value (M-e'). IS-e', LW-e', and M-e' were measured using colour TDI in 15 patients with hypertrophic cardiomyopathy, 13 patients with hypertension, and 19 control subjects. Using two-dimensional speckle-tracking imaging, early diastolic myocardial strain rates (SR(E)) were measured for the IS (IS-SR(E)), LW (LW-SR(E)), and entire LV myocardium (G-SR(E)). IS-e' was excellently correlated with IS-SR(E) (r = 0.90, P < 0.001); the correlation was better than that between LW-e' and LW-SR(E) (r = 0.75, P < 0.001). IS-e' and M-e' were well correlated with G-SR(E) (r = 0.88, P < 0.001 and r = 0.86, P< 0.001, respectively) and with LV early diastolic flow propagation velocity (FPV) (r = 0.77, P < 0.001 and r = 0.78, P < 0.001, respectively). The correlations of LW-e' to G-SR(E) (r = 0.80, P < 0.001) and FPV (r = 0.75, P < 0.001) did not reach this level. IS-e' well reflected LV longitudinal myocardial relaxation and LV diastolic function, and was found to be more useful in evaluating LV diastolic function than LW-e'.
    European Heart Journal – Cardiovascular Imaging 09/2011; 12(12):917-23. · 2.65 Impact Factor
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    ABSTRACT: Time-delay indexes are limited in predicting the response to cardiac resynchronization therapy (CRT), partly because they do not reflect the residual left ventricular (LV) contractility. We computed a novel index of LV contractility loss due to dyssynchrony (the strain rate (SR) dispersion index: SRDI) by using the speckle-tracking SR and compared the efficacy of the SRDI, time-delay indexes, and strain delay index (SDI), the previously reported index of wasted energy due to dyssynchrony, for predicting the acute response to CRT. Echocardiography was performed in 19 heart failure patients (LV ejection fraction (EF) 25 ± 6%) before and 2 weeks after CRT. The standard deviation of time to peak velocity, or strain, was calculated as time-delay indexes. The SRDI was calculated as the average of segmental peak systolic SR minus global peak systolic SR. Longitudinal SDI (L-SDI), longitudinal SRDI (L-SRDI), and circumferential SRDI (C-SRDI) significantly correlated with the change in global longitudinal strain (Δglobal LSt), whereas the time-delay indexes did not. Although the time-delay indexes were comparable between responders (Δglobal LSt ≥ 0.3%) and nonresponders, the L-SDI, L-SRDI, and C-SRDI were greater in responders. The area under the receiver operating characteristic curve of the L-SRDI, L-SDI, and C-SRDI for predicting responders was 0.89, 0.81, and 0.78, respectively. The SRDI correlated fairly well with an improvement in global LV systolic function after CRT.
    Circulation Journal 07/2011; 75(9):2167-75. · 3.69 Impact Factor
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    ABSTRACT: The aim of this study was to investigate the effects of surgical ventricular reconstruction (SVR) on cardiac efficiency as a surrogate marker for cardiac function and oxidative metabolism in patients with severe heart failure. Our new integrated overlapping left ventriculoplasty, modified SVR, combined with mitral complex reconstruction, reduce left ventricular (LV) volume associated with improvement of symptoms of heart failure. Twelve consecutive patients with end-stage heart failure due to nonischemic dilated cardiomyopathy (DCM) (n = 6) and ischemic dilated cardiomyopathy (ICM) (n = 6) who underwent SVR were studied. Myocardial oxidative metabolism per gram of tissue was estimated by monoexponential clearance of (11)C-acetate positron emission tomography (K(mono)). Forward stroke volume at the LV outflow tract was measured by echocardiography. Cardiac efficiency was estimated by the ratio of external work (stroke volume at the LV outflow tract index × systolic blood pressure × heart rate) to K(mono) before and 1 month after SVR. After SVR, medians of New York Heart Association functional class significantly improved from 3 to 1.5 (p < 0.01) in both DCM and ICM patients. End-systolic and end-diastolic volume and LV mass significantly decreased in both groups. Stroke volume at the LV outflow tract increased from 43 ± 8 ml to 52 ± 11 ml (p = 0.028) in DCM patients, but not in ICM patients (49 ± 21 ml to 59 ± 26 ml, p = 0.12). K(mono) × LV mass, as an index of global LV oxidative metabolism, decreased in DCM patients (13.6 ± 1.9 g/min vs. 8.6 ± 1.5 g/min, p = 0.03) and ICM patients (12.0 ± 3.4 g/min vs. 9.2 ± 1.0 g/min, p = 0.06). As a result, cardiac efficiency increased in all patients with DCM (3.34 ± 0.46 × 10E6 vs. 4.74 ± 0.88 × 10E6 mm Hg·ml·min/m(2), p = 0.03) and in 5 of 6 patients with ICM (4.54 ± 1.66 × 10E6 vs. 5.99 ± 2.11 × 10E6 mm Hg·ml·min/m(2), p = 0.12). Combined surgery with SVR and mitral complex reconstruction reduced LV volume in association with improvement of cardiac efficiency in patients with severe heart failure.
    JACC. Cardiovascular imaging 07/2011; 4(7):762-70. · 14.29 Impact Factor
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    ABSTRACT: The relationship between myocardial oxidative metabolism and pressure overload in aortic valve stenosis (AS) is not fully elucidated. We identified the determinants of myocardial oxidative metabolism by measuring its changes after aortic valve replacement (AVR) in patients with AS. Myocardial 11C-acetate clearance rate constant (Kmono), an index of oxidative metabolism, was measured non-invasively by using positron emission tomography in 16 patients with moderate to severe AS and 7 healthy controls. The severity of AS was assessed by echocardiography. Of 16 patients, 5 were reexamined at 1 month after AVR. Kmono was significantly higher in patients with AS than healthy controls by 42% (0.068±0.014 vs 0.048±0.007/min, p<0.01). Kmono was significantly correlated with age (r=0.58, p<0.01), left ventricular (LV) mass index (r=0.61, p<0.01) and estimated systolic LV pressure (r=0.81, p<0.001) measured by echocardiography. By multivariate analysis, estimated LV systolic pressure was an independent predictor of Kmono (β=0.93, p<0.01). After AVR, Kmono (from 0.075±0.012 to 0.061±0.014/min, p=0.043) and LV mass index (from 183±49 to 124±41 g/ml2, p=0.043) were significantly decreased despite no significant changes in rate-pressure product. Myocardial oxygen metabolism was increased in patients with AS, which was decreased after AVR. The increased myocardial oxidative metabolism in AS was largely attributable to the pressure overload of the LV.
    European Journal of Nuclear Medicine 12/2010; 37(12):2242-8. · 4.53 Impact Factor
  • Choonpa Igaku 01/2010; 37(4):491-497.
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    ABSTRACT: Although a reduction in myocardial blood volume (MBV), an in vivo index of the myocardial microvasculature, measured by myocardial contrast echocardiography in patients with hypertension (HT), can be demonstrated, it is still unknown whether a decreased MBV can be improved by antihypertensive treatment. Eleven HT patients (mean age 58 years, 7 men) with left ventricular hypertrophy (LVH) and 10 age- and sex-matched normal controls were studied. Harmonic power Doppler images were acquired at end-diastole of every 6(th) beat and MBV was calculated as 10(X/10)x100%, where X (dB) is myocardial contrast intensity minus the contrast intensity of the adjacent intracavity blood pool. Baseline blood pressure (BP) and left ventricular mass index (LVMI) in the HT patients were higher and MBV was lower than in the controls (2.52 +/-0.37% vs 3.31 +/-0.61%, P<0.01). MBV did not correlate with mean BP, but was inversely correlated with LVMI (r=0.61, P<0.01). After treatment with valsartan for 6 months, LVMI significantly decreased and MBV increased (2.72 +/-0.26%, P<0.05 vs baseline) in the patients with HT. There was a significant inverse correlation between the changes in MBV and those of LVMI (r=0.62, P<0.05), but not between MBV and mean BP. Valsartan, an angiotensin II receptor blocker, corrected the decreased MBV in association with regression of LVH in patients with HT.
    Circulation Journal 09/2009; 73(11):2098-103. · 3.69 Impact Factor
  • Journal of Cardiac Failure 09/2008; 14(7). · 3.07 Impact Factor