Tetsuya Sumiyoshi

Sakakibara Heart Institute, Фучу, Tōkyō, Japan

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Publications (110)352.58 Total impact

  • International journal of cardiology. 12/2014; 177(2):720-2.
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    ABSTRACT: Background A novel real-time three-dimensional echocardiography (RT3DE) system allows fully automated quantification of the left ventricular (LV) volume throughout a cardiac cycle. This study aimed to investigate whether an LV time–volume curve, obtained using fully automated RT3DE, is useful in the evaluation of LV diastolic function. Methods First, 15 patients underwent simultaneous standard two-dimensional echocardiography (2DE), RT3DE, and cardiac catheterization to measure the time constant of the isovolumic-pressure decline (τ). From the LV time–volume curve obtained using RT3DE, peak early filling rate (PFR) during diastole was generated and indexed for LV end-systolic volume. Next 570 patients, who were scheduled for both 2DE and RT3DE examinations, were enrolled to investigate the association between PFR index and 2DE-evidenced diastolic dysfunction and clinical characteristics. Results Of the 585 patients, RT3DE analysis was adequate in 542 patients (feasibility 93%). In the 15 patients, PFR index showed significant correlation with τ (r = −0.65, p = 0.009). In the remaining 527 patients, PFR index was related to age (r = −0.24, p < 0.001) and e′ (r = 0.41, p < 0.001). PFR index decreased in proportion to the grade of 2DE-evidenced diastolic dysfunction. All patients with normal diastolic function had a PFR index greater than 2.0. Conclusions This study demonstrated that a novel, fully automated RT3DE-derived PFR index was the diagnostic tool of choice for the assessment of LV diastolic function.
    Journal of Cardiology. 09/2014;
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    ABSTRACT: Simultaneous dual-isotope SPECT imaging with 201Tl and (123)I-β-methyl-p-iodophenylpentadecanoic acid (BMIPP) is used to study the perfusion-metabolism mismatch. It predicts post-ischemic functional recovery by detecting stunned myocardium. On the other hand, (99m)Tc-MIBI is another radioisotope widely used in myocardial perfusion imaging because of its better image quality and lower radiation exposure than 201Tl. However, since the photopeak energies of (99m)Tc and (123)I are very similar, crosstalk hampers the simultaneous use of these two radioisotopes. To overcome this problem, we conducted simultaneous dual-isotope imaging study using the D-SPECT scanner (Spectrum-Dynamics, Israel) which has a novel detector design and excellent energy resolution. We first conducted a basic experiment using cardiac phantom to simulate the condition of normal perfusion and impaired fatty acid metabolism. Subsequently, we prospectively recruited 30 consecutive patients who underwent successful percutaneous coronary intervention for acute myocardial infarction, and performed (99m)Tc-MIBI/(123)I-BMIPP dual-isotope imaging within 5 days after reperfusion. Images were interpreted by two experienced cardiovascular radiologists to identify the infarcted and stunned areas based on the coronary artery territories. As a result, cardiac phantom experiment revealed no significant crosstalk between (99m)Tc and (123)I. In the subsequent clinical study, (99m)Tc-MIBI/(123)I-BMIPP dual-isotope imaging in all participant yielded excellent image quality and detected infarcted and stunned areas correctly when compared with coronary angiographic findings. Furthermore, we were able to reduce radiation exposure to significantly approximately one-eighth. In conclusion, we successfully demonstrated the practical application of simultaneous assessment of myocardial perfusion and fatty acid metabolism by (99m)Tc-MIBI and (123)I-BMIPP using a D-SPECT cardiac scanner. Compared with conventional (201)TlCl/(123)I-BMIPP dual-isotope imaging, the use of (99m)Tc-MIBI instead of (201)TlCl improves image quality as well as lowers radiation exposure.
    Heart and Vessels 09/2014; · 2.13 Impact Factor
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    ABSTRACT: Although nitrates are widely used as a concomitant therapy with calcium channel blockers (CCBs) for vasospastic angina (VSA), their prognostic contribution remains unclear. The present study aimed to examine the prognostic impact of chronic nitrate therapy in patients with VSA.
    European heart journal. 09/2014;
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    ABSTRACT: Detecting the presence of coronary artery disease (CAD) is critically important in managing patients with heart failure of uncertain cause. The recently introduced (123)I-BMIPP/(201)TlCl dual myocardial single-photon emission computed tomography (dual SPECT) is potentially a non-invasive diagnostic tool in detecting ischemic heart disease. The aim of our study is to evaluate the efficacy of detecting CAD by dual SPECT in patients with heart failure.
    International Journal of Cardiology 08/2014; · 6.18 Impact Factor
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    ABSTRACT: Elevated plasma B-type natriuretic peptide (BNP) is a predictor of outcome and helpful for risk stratification in aortic stenosis (AS). However, left ventricular (LV) diastolic dysfunction progresses with aging and may also influence plasma BNP levels in elderly patients. We hypothesized that plasma BNP levels may be influenced by age in severe AS, and that factors that affect the elevation of plasma BNP levels may be different between elderly and younger patients with AS. We performed echocardiography in 341 patients with severe AS [aortic valve area (AVA)<1.0cm(2)] and classified them into two groups by age (elderly ≥75 years old, n=201; younger patients <75 years old, n=140). We used multivariate linear regression analysis to assess the factors that determine plasma BNP levels in both groups. Age was found to be one of the independent determinants of plasma BNP levels in all patients (β=0.135, p=0.005). Although AVA was similar in the two groups, plasma BNP levels and E/e' were significantly higher in elderly than younger patients [133.0 (IQR, 73.3-329.7)pg/dl vs 92.8 (IQR, 40.6-171.8)pg/dl, p<0.01; 20±8 vs 16±6, p<0.01, respectively). In multivariate stepwise linear regression analysis, AVA index, LV ejection fraction, mass index, E/e', estimated systolic pulmonary artery pressure (eSPAS), and the presence of atrial fibrillation were independent determinants of plasma BNP levels in younger patients. In contrast, the independent determinants of plasma BNP levels in elderly patients were LV ejection fraction, mass index, E/e', eSPAS, the presence of atrial fibrillation, age, and hemoglobin levels, but not AVA index. There may be differences in the factors that influence plasma BNP levels between elderly and younger patients with severe AS. In elderly patients, plasma BNP levels may be influenced more by these factors than AS severity compared with younger patients.
    Journal of Cardiology 05/2014; · 2.30 Impact Factor
  • Journal of Cardiology Cases 04/2014;
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    ABSTRACT: In this study, the coronary findings in 185 autopsy cases with a ruptured abdominal aortic aneurysm (AAA) from the Tokyo Medical Examiner's Office were examined and compared with those in 1,056 patients undergoing AAA repair at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). The number of cases with any significant coronary stenosis was significantly greater in the autopsy cases with a ruptured AAA than in the patients undergoing emergency repair of a ruptured AAA, suggesting that the low prevalence of CAD observed in patients undergoing emergency repair of a ruptured AAA was due to the survival bias before reaching hospital. In addition, we also found that significant coronary left main trunk stenosis was more frequent in CAD cases with a ruptured AAA than in those with an unruptured AAA, findings that suggest novel clinical implications. Large-scale prospective studies are warranted to confirm our findings and to clarify the pathophysiological relationship between coronary atherosclerosis and AAA status.
    Heart and Vessels 03/2014; · 2.13 Impact Factor
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    ABSTRACT: Background: The prognostic value of late gadolinium enhancement (LGE) on contrast-enhanced cardiovascular magnetic resonance (CMR) in Japanese hypertrophic cardiomyopathy (HCM) patients in a large, single-center cohort was investigated. Methods and Results: A total of 345 HCM patients (mean age, 59±17 years; 214 male) underwent CMR with gadolinium enhancement, and were followed (mean duration, 21.8 months) for cardiovascular events. Patients were divided into event-positive and event-negative groups. The clinical and CMR characteristics were compared between the 2 groups, and predictors of cardiovascular events assessed on multivariate analysis. LGE was positive in 252 patients (73%). The annual cardiovascular events rate was significantly higher in patients with LGE than in those without (6.2%/year vs. 0.6%/year, P=0.003). On multivariate analysis, LGE (hazard ratio [HR], 7.436; 95% confidence interval [CI]: 1.001-55.228, P=0.050), increased myocardial mass index (HR, 1.013; 95% CI: 1.002-1.023, P=0.018), reduced left ventricular ejection fraction (HR, 0.965; 95% CI: 0.945-0.985, P=0.001), and atrial fibrillation (HR, 2.257; 95% CI: 1.024-4.976, P=0.043) were significantly associated with cardiovascular events. Conclusions: The presence of LGE, increased myocardial mass index, reduced left ventricular ejection fraction and atrial fibrillation were independent predictors of adverse prognosis in Japanese HCM patients.
    Circulation Journal 02/2014; · 3.58 Impact Factor
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    ABSTRACT: Coronary artery bypass grafting (CABG) is considered the standard treatment for patients with left main disease (LMD). However, percutaneous coronary intervention (PCI) has recently emerged as a treatment option for selected patients. We assessed early and long-term outcomes of patients with LMD who underwent either CABG or PCI in our institution. We reviewed the records of 438 patients with LMD who underwent revascularization between January 2005 and December 2010. Treatment modality, chosen by our heart team, was CABG in 409 patients and PCI in 29. Age, prevalence of women, and mean ejection fraction of patients were not significantly different between groups. Mean logistic European system for cardiac operative risk evaluation score was 7.7. Mean follow-up was 37.1 months. In CABG group, mean number of anastomoses was 4.0 and complete revascularization was achieved in 97.1 %. Bilateral internal thoracic arteries were used in 87.0 %. In PCI group, mean number of stents was 1.3 and complete revascularization was achieved in 44.8 %. Drug-eluting stent was used in 72.4 %. In-hospital mortality was 1.1 % (1.0 %, CABG group vs. 3.4 %, PCI group; p = 0.29). At 3 years, overall survival was 94.3 % (95.3 vs. 81.1 %; p < 0.01) and rate of freedom from major adverse cardiac events and cerebrovascular accidents was 88.9 % (89.8 vs. 77.3 %; p = 0.05). Our heart team's approach resulted in favorable overall results in patients with LMD. Multidisciplinary decision making in these high-risk patients can make good long-term outcomes in CABG.
    General Thoracic and Cardiovascular Surgery 12/2013;
  • JACC. Cardiovascular imaging 12/2013; 6(12):1347-1349. · 14.29 Impact Factor
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    ABSTRACT: The present study aimed to develop a comprehensive clinical risk score for vasospastic angina (VSA) patients. Previous studies demonstrated various prognostic factors of future adverse events in VSA patients. However, to apply these prognostic factors in clinical practice, the assessment of their accumulation in individual patients is important. The patient database of the multicenter registry study by the Japanese Coronary Spasm Association (JCSA) (n=1,429; median 66 years; median follow-up of 32 months) was utilized for score derivation. Multivariable Cox proportional hazard model selected 7 predictors of major adverse cardiac events (MACE). The integer score was assigned to each predictors proportional to their respective adjusted hazard ratio; history of out-of-hospital cardiac arrest (4 points), smoking, angina at rest alone, organic coronary stenosis, multivessel spasm (2 points each), ST-elevation during angina and β-blocker use (1 point each). According to the total score in individual patients, 3 risk strata were defined; low (score 0-2, n=598), intermediate (score 3-5, n=639) and high (score 6 or more, n=192). The incidence of MACE in the low-, intermediate- and high-risk patients were 2.5%, 7.0% and 13.0%, respectively (P<0.001). Cox model for MACE between the 3 risk strata also showed prognostic utility of the scoring system in various clinical subgroups. The average prediction rate of the scoring system in the internal training and validation sets were 86.6% and 86.5%, respectively. We developed a novel scoring system, the JCSA risk score, which may provide the comprehensive risk assessment and prognostic stratification for VSA patients.
    Journal of the American College of Cardiology 07/2013; · 14.09 Impact Factor
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    ABSTRACT: We present a case of prosthetic valve endocarditis, which was caused by a rare etiological agent, Streptococcus constellatus. In our case, transesophageal echocardiography showed a large and broad abscess formation throughout the patient's aortic prosthetic valve ring and left atrium. Despite specific intravenous antibiotic therapy, the infection was uncontrollable, and the patient underwent surgical treatment. The pathogen rarely causes endocarditis, but it is known to have a strong potential to form abscess, and therefore its infection may be more serious than other Streptococcus species. Our case seems to be the first report of surgical treatment of PVE caused by S. constellatus. As in our case, transesophageal echocardiography is useful for the detection of vegetation and abscess, and early cardiac surgery may be a more appropriate therapeutic approach for endocarditis caused by S. constellatus.
    Heart & lung: the journal of critical care 07/2013; · 1.04 Impact Factor
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    ABSTRACT: BACKGROUND: Acute Stanford type A aortic dissection (AAD) with coronary involvement is associated with high mortality. However, coronary involvement is not always successfully visualized by computed tomography and two-dimensional (2D) transesophageal echocardiography (TEE). The aim of this study was to test the hypothesis that three-dimensional (3D) TEE can detect coronary involvement in patients with AAD. METHODS: Fifty-one consecutive patients with AAD who underwent intraoperative TEE using an iE33 system during emergency surgery were enrolled. Using computed tomographic images, conventional 2D transesophageal echocardiographic images, and a 3D transesophageal echocardiographic data set, the status of coronary ostia was evaluated and classified into four types-branching from true lumen, branching from false lumen, dissection, and unclear-and these results were compared with operative findings. RESULTS: In six patients, coronary involvement was diagnosed operatively by surgeons. They comprised dissection at three left coronary ostia and branching from false lumen at three right coronary ostia. All six cases were successfully detected by both 2D TEE and 3D TEE before instituting cardiopulmonary bypass. However, in 45 patients (90 ostia) confirmed operatively as having no coronary involvement, 69 ostia by computed tomography (36 in the left and 33 in the right coronary artery) and 16 ostia by 2D TEE (four in the left and 12 in the right coronary artery) were evaluated as unclear coronary involvement. On the other hand, 3D TEE clearly depicted no coronary involvement in all but one (right coronary ostium) of the unclear cases. CONCLUSIONS: Three-dimensional TEE reduced the number of cases evaluated as unclear coronary involvement by computed tomography and 2D TEE. In patients with AAD, 3D TEE allows evaluation of the status of coronary ostia in the operating room.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 06/2013; · 2.98 Impact Factor
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    ABSTRACT: BACKGROUND: Traditional 3-dimensional echocardiography (3DE) with volumetric scanning technique requires several heart cycles for full-volume acquisition and complicated manual contouring of left ventricular (LV) endocardium. The new real-time 3DE (RT3DE) system allows acquisition of an instantaneous full-volume dataset in a single heart cycle and automated measurement of LV volume by the algorithm software. However, it has not been evaluated adequately whether automated measurement by RT3DE has better agreement with cardiac magnetic resonance imaging (CMR) than 2-dimensional echocardiography (2DE) with CMR. PURPOSE: This study aimed to evaluate the accuracy of automated measurement of LV volume using RT3DE compared with 2DE and CMR. METHODS AND RESULTS: Forty-four consecutive patients who underwent RT3DE, 2DE, and CMR were evaluated in this study. The feasibility of automated measurement by RT3DE was 93.2% and the mean operation time was 6min. LV volume and ejection fraction (EF) from semi-automated measurement [end-diastolic volume: r=0.96, limits of agreement (LOA) -30.5 to 39.3ml; end-systolic volume: r=0.97, LOA -22.6 to 32.7ml; EF: r=0.90, LOA -16.1 to 14.2%, respectively] had better agreement with CMR than those from 2DE (r=0.87, LOA -50.5 to 72.2ml; r=0.93, LOA -34.1 to 65.2ml; r=0.89, LOA -20.9 to 10.0%, respectively). CONCLUSION: Semi-automated measurement by RT3DE has better agreement with CMR than 2DE in LV volume and EF. In addition, it is simple to operate and acceptable in feasibility for the clinical setting although there may be room for further learning required to incorporate small hypertrophic LV into the automated algorithm software.
    Journal of Cardiology 03/2013; · 2.30 Impact Factor
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    ABSTRACT: Background: Accumulating evidence has demonstrated the gender differences in the clinical characteristics and outcomes of patients with ischemic heart disease. However, it remains to be elucidated whether it is also the case for vasospastic angina (VSA). Methods and Results: We enrolled a total of 1,429 VSA patients (male/female, 1090/339; median age 66 years) in our nationwide multicenter registry by the Japanese Coronary Spasm Association. As compared with male patients, female patients were characterized by older age (median 69 vs. 66 years), lower incidence of smoking (20% vs. 72%) and less significant organic stenosis (9% vs. 16%) (all P=0.001). Multivariate analysis demonstrated that the predictors of major adverse cardiac events (MACE) were considerably different by genders; women were more associated with age and electrical abnormalities, whereas men with structural abnormalities. Overall 5-year MACE-free survival was comparable between both genders. However, when the patients were divided into 3 groups by age [young (<50 years), middle-aged (50-64 years) and elderly (≥65 years)], the survival was significantly lower in the young female group (young 82%, middle-aged 92%, elderly 96%, P<0.01), where a significant interaction was noted between age and smoking. In contrast, the survival was comparable among the 3 age groups of male patients. Conclusions: These results indicate that there are gender differences in the characteristics and outcomes of Japanese VSA patients, suggesting the importance of gender-specific management of the disorder.
    Circulation Journal 01/2013; · 3.58 Impact Factor
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    ABSTRACT: Background Recently, post-exercise diastolic stunning (PES) has been reported as a new clinical marker of induced ischemia. Velocity vector imaging (VVI) has been developed to visualize regional wall motion abnormalities based on vectors detected by the tissue tracking technique, which has the potential to visualize PES. Thus, the aim of this study was to evaluate the usefulness of PES detection by VVI as an objective marker of ischemia compared to stress thallium-201 (Tl-201) single photon emission computed tomography (SPECT). Methods We studied consecutive patients who were scheduled to undergo exercise stress Tl-201 SPECT for the diagnosis of ischemic heart disease. Transthoracic echocardiography was recorded digitally before and 20 min after exercise for Tl-201 SPECT, and the data were used subsequently for VVI analysis. We defined PES regions as those with new abnormal vectors observed during isovolumic relaxation. Results After excluding 14 patients with old myocardial infarction and/or atrial fibrillation, echocardiograms suitable for VVI analysis were obtained from 62 of 65 patients (feasibility, 95 %; 44 men; mean age, 64 ± 11 years). SPECT revealed induced ischemia in 20 patients, whereas VVI identified PES in 18 patients. VVI detected inducible ischemia with 85 % sensitivity and 98 % specificity compared to SPECT. Conclusions VVI detection of PES is a new clinical tool for induced ischemia. Regional diastolic wall motion abnormalities following induced ischemia can be noninvasively detected by VVI.
    Journal of Echocardiography 01/2013; 11(2).
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    ABSTRACT: In Japan, there has been virtually no study in a population large enough to definitively demonstrate a relationship between the preoperative clinical features and postoperative outcomes in patients undergoing abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the preoperative variables that significantly predict postoperative mortality after emergency or elective repair in Japanese patients with infrarenal AAA. In this retrospective cohort study, we assessed significant predictors of postoperative mortality in 1055 consecutive patients undergoing emergency (n = 186) or elective repair (n = 869) of an infrarenal AAA at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). Using logistic regression analysis, anemia (hemoglobin <9 g/dl), shock (systolic blood pressure <80 mmHg), and hypocholesterolemia (total cholesterol <120 mg/dl) were found to be independent preoperative predictors of 30-day mortality after emergency repair for ruptured AAA. The hazard ratio (HR) (95 % confidence interval) for these three predictors was 5.96 (1.70-20.84), 8.48 (1.47-49.02), and 7.31 (1.96-27.35), respectively. In the elective repair cases, no significant preoperative predictor of postoperative mortality could be identified either within or beyond 30 days of surgery. Hypocholesterolemia, anemia, and shock were found to be independent preoperative predictors of a postoperative high mortality rate in Japanese patients undergoing emergency repair for ruptured infrarenal AAA.
    Heart and Vessels 12/2012; · 2.13 Impact Factor
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    ABSTRACT: Late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR) can predict ventricular arrhythmia and poor prognosis in hypertrophic cardiomyopathy (HCM) patients. Although myocardial T2-high signal has been reported to appear within LGE in those patients, its clinical significance remains unclear. We investigated the relationship between the T2-high signal and nonsustained ventricular tachycardia (NSVT) in HCM patients. Eighty-one HCM patients who underwent Holter ECG and CMR including T2-weighted and LGE imaging were retrospectively recruited. They were divided into NSVT-positive and NSVT-negative groups. We compared the clinical and CMR characteristics between both of the groups, and assessed predictors of NSVT with multivariate analysis. Myocardial T2-high signal was observed in 15/81 (18.5 %) patients. Each T2-high signal was localized within LGE. Significantly in the NSVT-positive group, the prevalence of atrial fibrillation [5/17 (29.4 %) vs. 2/64 (3.1 %), p = 0.0006] and T2-high signal [9/17 (52.9 %) vs. 6/64 (9.4 %), p < 0.0001] and the left ventricular (LV) end-systolic volume index (32.2 ± 15.9 ml/m(2) vs. 23.3 ± 14.9 ml/m(2), p = 0.034) and the number of segments with LGE (5.8 ± 3.3 vs. 2.7 ± 2.7, p < 0.0001) was increased, and the LV ejection fraction (54.8 ± 10.9 % vs. 65.1 ± 10.6 %, p = 0.0007) was decreased, compared to the NSVT-negative group. On multivariate analysis, the presence of atrial fibrillation (OR 29.49, p = 0.0025) and DM (OR 7.36, p = 0.0455) and T2-high signal (OR 14.96, p = 0.0014) and reduced LV ejection fraction (OR 0.93, p = 0.0222) were significantly associated with NSVT. The presence of myocardial T2-high signal is a significant independent predictor of NSVT in HCM patients.
    Heart and Vessels 10/2012; · 2.13 Impact Factor
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    ABSTRACT: AimsProvocation tests of coronary artery spasm are useful for the diagnosis of vasospastic angina (VSA). However, these tests are thought to have a potential risk of arrhythmic complications, including ventricular tachycardia (VT), ventricular fibrillation (VF), and brady-arrhythmias. We aimed to elucidate the safety and the clinical implications of the spasm provocation tests in the nationwide multicentre registry study by the Japanese Coronary Spasm Association.Methods and resultsA total of 1244 VSA patients (M/F, 938/306; median 66 years) who underwent the spasm provocation tests were enrolled from 47 institutes. The primary endpoint was defined as major adverse cardiac events (MACEs). The provocation tests were performed with either acetylcholine (ACh, 57%) or ergonovine (40%). During the provocation tests, VT/VF and brady-arrhythmias developed at a rate of 3.2 and 2.7%, respectively. Overall incidence of arrhythmic complications was 6.8%, a comparable incidence of those during spontaneous angina attack (7.0%). Multivariable logistic regression analysis demonstrated that diffuse right coronary artery spasm (P < 0.01) and the use of ACh (P < 0.05) had a significant correlation with provocation-related VT/VF. During the median follow-up of 32 months, 69 patients (5.5%) reached the primary endpoint. The multivariable Cox proportional hazard model revealed that mixed (focal plus diffuse) type multivessel spasm had an important association with MACEs (adjusted hazard ratio, 2.84; 95% confidence interval, 1.34-6.03; P < 0.01), whereas provocation-related arrhythmias did not.Conclusion The spasm provocation tests have an acceptable level of safety and the evaluation of spasm type may provide useful information for the risk prediction of VSA patients.
    European Heart Journal 07/2012; · 14.72 Impact Factor

Publication Stats

851 Citations
352.58 Total Impact Points

Institutions

  • 2000–2014
    • Sakakibara Heart Institute
      Фучу, Tōkyō, Japan
  • 2013
    • Tokyobay UrayasuIchikawa Medical Center
      Urayasu, Tōkyō, Japan
  • 2001–2012
    • The University of Tokyo
      • Faculty & Graduate School of Medicine
      Tokyo, Tokyo-to, Japan
  • 2005–2010
    • Tokyo Women's Medical University
      • Department of Cardiology
      Tokyo, Tokyo-to, Japan
  • 2004–2009
    • Kyoto University
      • Department of Cardiovascular Medicine
      Kyoto, Kyoto-fu, Japan
  • 2003
    • National Cerebral and Cardiovascular Center
      • Department of Cardiovascular Medicine
      Ōsaka-shi, Osaka-fu, Japan
    • Osaka Police Hospital
      Ōsaka, Ōsaka, Japan
  • 1996
    • Tokyo Junshin Women's College
      • Department of Cardiovascular Surgery
      Edo, Tōkyō, Japan