Kenichiro Suwa

Background: A thrombus in the sinus of Valsalva (SOV) with a native aortic valve is a rare aetiology of type 2 myocardial infarction. To the best of our knowledge, no previous report has evaluated blood flow dynamics in the SOV of a patient who experienced an SOV thrombus. Case summary: A 72-year-old woman presented to our hospital with chest pain. Based on electrocardiogram and echocardiography findings, she was diagnosed with ST-elevation acute coronary syndrome (ACS) due to left main trunk (LMT) occlusion. Emergency coronary angiography revealed embolization in the distal left anterior descending artery. Her symptoms improved after catheter engagement in the LMT. Echocardiography revealed an abnormal mass (20 × 20 mm) in the left coronary cusp, which appeared to intermittently occlude the LMT. Emergency surgical removal revealed that the thrombus was adherent to the aortic wall at the left SOV. Histopathological examination confirmed a fresh red thrombus. The patient was discharged on warfarin 13 days postoperatively. Time-resolved three-dimensional cine phase-contrast magnetic resonance imaging (4D-flow MRI) was performed to assess blood flow. She was subsequently diagnosed with antiphospholipid syndrome. Discussion: 4D-flow MRI showed reduced blood flow velocity in the left SOV compared with the other sinuses, without evidence of excessive wall shear stress. These findings may represent a ‘second hit’ of antiphospholipid syndrome. Further investigation is warranted to elucidate the mechanisms underlying SOV thrombosis. It is important to consider SOV thrombus as an aetiology of ACS, even in patients without history of thrombosis or prior aortic valve surgery.

Introduction: The relationship between myocardial lipid metabolism and disease phenotypes, genetic variation, and prognostic factors in patients with hypertrophic cardiomyopathy (HCM) remains largely unexplored. This study aimed to clarify how metabolic remodelling relates to disease phenotypes in HCM. We used desorption electrospray ionization imaging mass spectrometry (DESI-IMS) to compare myocardial lipid signatures in patients who required septal reduction therapy (SRT) and those who did not. Methods: In this prospective study, patients with HCM undergoing either right-ventricular biopsy or surgical septal myectomy were enrolled. Frozen 10 µm sections were analysed using DESI-IMS, and mass spectra were compared with volcano plots after signal-intensity normalization. Candidate ions showing |log2 fold change| ≥ 1 and P < .05 were annotated using the Human Metabolome Database. Results: Overall, 61 patients were analysed (34 [55.7%] were female; mean age 64.5 ± 15.9 years). Of these, 43 (70.5%) had obstructive HCM and 20 underwent SRT (SRT, n = 20; non-SRT, n = 41). The SRT group displayed a 3.3-fold higher signal for m/z 463.23, identified as testosterone glucuronide (P < .001). SRT remained the only predictor of elevated testosterone-glucuronide intensity in confirmatory regression (β = 1.991, P = .004), even after adjusting for age at diagnosis and the presence of hypertension, which significantly differed in baseline characteristics between the SRT and non-SRT groups. Conclusion: DESI-IMS revealed selective accumulation of testosterone glucuronide in hypertrophied myocardium from patients needing SRT, suggesting that androgen-linked metabolic remodelling plays a role in advanced obstructive physiology in HCM.

Objective: To investigate the relationship between a quality of life (QOL) score and clinical parameters in patients with hypertrophic cardiomyopathy (HCM). Design: A multicentre cross-sectional study. Setting: We analysed data from the Searching for Atrial Fibrillation and Early Recruitment of Heart Failure in HCM registry, collected between 2018 and 2023. Participants: Patients with HCM (n=499) aged ≥18 years from 12 institutions (Shizuoka Prefecture, Japan) were consecutively enrolled. Outcome measures: Clinical parameters, along with data from a short form of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), were collected. The association between each clinical parameter and the KCCQ-12 score was analysed. Clinical parameters with a significant univariable association (p2 of 0.48. In this model, the PSQI (standardised coefficient −0.39; p<0.001), history of sustained ventricular tachycardia or fibrillation, history of atrial fibrillation (−0.23; p<0.001), female sex (−0.19; p=0.035), systolic blood pressure (0.17; p=0.040), lateral E/e prime (−0.17; p=0.049) and A wave (−0.14, p=0.049) were independently associated with the KCCQ-12 score with high relative importance. Conclusions: In patients with HCM, we investigated the association between the KCCQ-12 score and various clinical parameters. PSQI, as well as known heart failure-related clinical parameters, was significantly associated with the KCCQ-12 score. Visualising the associations of various clinical parameters with the KCCQ-12 score will help physicians to consider factors linked to the decline in QOL in patients with HCM.

Background: A detailed evaluation of hemodynamics, supportive morphology, and deformation may help uncover the pathophysiology of hypertrophic obstructive cardiomyopathy (HOCM) and the changes wrought by alcohol septal ablation (ASA). Purpose: To investigate the global cardiac volume, myocardial deformation, and hemodynamic characteristics before and during long‐term follow‐up after ASA in patients with HOCM. Study Type: Retrospective. Subjects: Twenty‐three patients (68.1 ± 8.6 years, 21.7% male) with HOCM who underwent MRI before and after ASA. Field Strength/Sequence: A 3T, Two‐dimensional fast imaging employing steady‐state acquisition, inversion recovery‐prepared fast gradient echo sequences, and cine and time‐resolved three‐dimensional cine phase‐contrast (4D flow) MRI. Assessment: Global left ventricular (LV) volume by cine, peak strain, and strain rate by myocardial feature‐tracking MRI, and hemodynamic characteristics by 4D flow MRI. Statistical Tests: Paired t ‐test and Wilcoxon signed–rank test compared normally and nonnormally distributed data, respectively. Chi‐squared or Fisher's exact tests were used to compare categorical data, as appropriate. Pearson's or Spearman's correlation coefficient evaluated the correlations. Statistical significance was set at q ≤ 0.10 or p < 0.05. Results: In LV long‐axis images, the global radial strain increased significantly (16.6% ± 5.8% vs. 20.1% ± 6.8%), whereas the global longitudinal strain decreased significantly after ASA (−10.5% ± 3.2% vs. −12.1% ± 3.5%). The diastolic LV anterior vortex area increased significantly after ASA (2256.1 [703.6, 4038.4] vs. 3826.1 [1914.3, 4820.1] mm ² ). Multiplication of the LV end‐diastolic volume index, global circumferential strain, and diastolic radial peak strain rate in LV long‐axis images revealed a significant correlation with the diastolic LV anterior vortex area (Rs = 0.43). Data Conclusions: Feature‐tracking and 4D flow MRI revealed improved systolic and diastolic LV function during long‐term follow‐up after ASA. The diastolic LV vortex was associated with the combined parameters of LV volume and deformation. Comprehensive cardiac MRI may help understand the beneficial effects of ASA. Evidence Level: 3. Technical Efficacy: Stage 5.

The effect of balloon pulmonary angioplasty (BPA) on hemodynamics in chronic thromboembolic pulmonary hypertension (CTEPH), assessed using time-resolved three-dimensional cine phase-contrast cardiac magnetic resonance (4D flow CMR), remains unclear. Therefore, the present study aimed to investigate the hemodynamic features of the pulmonary artery (PA) before and after BPA and the diagnostic performance of 4D flow CMR-derived hemodynamics before BPA to predict the achievement of mean pulmonary artery pressure (mPAP) < 30 mmHg after BPA. Twenty-one patients with CTEPH who underwent 4D flow CMR before and after BPA were retrospectively enrolled. Regarding 4D flow CMR, the analysis included peak flow volume and velocity at the main PA and peak systolic wall shear stress (WSS). Seventeen patients achieved a mPAP < 30 mmHg after BPA. Peak flow velocity at the main PA (262.8 ± 52.3 mm/s vs. 298.5 ± 68.3 mm/s, p = 0.015) and peak WSS (0.97 ± 0.26 Pa vs. 1.13 ± 0.37 Pa, p = 0.044) both increased after BPA compared to their values before BPA. Receiver operating characteristic analysis was performed to predict mPAP ≥ 30 mmHg after BPA based on peak flow velocity and peak WSS before BPA. The analysis revealed an area under the curve of 0.926 (p < 0.001) for peak flow velocity before BPA (sensitivity, 0.765; specificity, 0.750; cut-off, < 251 mm/s) and 0.971 (p < 0.001) for peak WSS before BPA (sensitivity, 0.882; specificity, 1.00; cut-off, < 0.89 Pa). Based on the study results, 4D flow CMR imaging showed improvement in hemodynamics after BPA. Furthermore, peak flow velocity and peak WSS were useful metrics for predicting the achievement of catheter-based BPA goal of mPAP < 30 mmHg with a better prognosis.