The coronavirus disease 2019 (COVID-19) pandemic has changed the lives of healthcare professionals, especially vulnerable physicians such as young or female cardiologists. In Japan, they are facing the fear of not only infection but also weak and unstable employment, difficulties in medical practice and training anxiety, implications for research and studying abroad, as well as worsened mental health issues due to social isolation. Conversely, some positive aspects are seen through the holding of remote meetings and conferences. Here, we suggest a new working style for cardiologists, as well as offer solutions to the medical employment problems that have been taken place in Japan.

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SummaryThe morphological determinants of left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) are not completely understood. We aimed to identify the anatomical risks of the obstruction using echocardiography.Fifty patients with untreated HCM were classified into two groups: those with LVOT pressure gradient (LVOTPG) !30 mmHg (obstructive HCM [HOCM] group) and those with LVOTPG < 30 mmHg (HNCM group). The echocardiographic morphological variables were analyzed to determine whether they were predictive of LVOT obstruction. Systolic anterior motions of the mitral valve were observed in 100% of patients in the HOCM group but only in 58% in the HNCM group. There were no significant differences in wall thickness, end-systolic LV dimension (LVDs), or LVOT diameter between the two groups. However, HOCM subjects had a shorter distance from papillary muscles to the inter-ventricular septum (5.97 ± 2.3 versus 9.20 ± 1.9 mm, respectively, P < 0.0001) and a longer anterior mitral leaflet (AML) length (24.7 ± 5.8 versus 20.1 ± 5.4 mm, respectively, P < 0.01) compared to the HNCM group. The AML length/LVDs ratio was significantly higher in the HOCM group compared to the HNCM group (1.02 ± 0.34 versus 0.78 ± 0.26, P < 0.01), and an LVOT obstruction was predicted with an area under the curve of 0.71 (P < 0.05). Multiple linear regression revealed that only the AML length/LVDs ratio was independently associated with LVOTPG (P < 0.01).The AML length/LVDs ratio has a significant predictive value for LVOT obstruction and a strong relationship with LVOTPGs. The AML length/LVDs ratio determines the anatomical risk of LVOT obstruction in HCM.(Int Heart J Advance Publication)

Infective endocarditis (IE) associated with atrial septal defect (ASD) is extremely rare. However, tricuspid regurgitation (TR) secondary to right ventricular overload is a potential cause of IE, and once it occurs, the development of a paradoxical embolism may lead to fatal complications. We herein report the case of a 50-year-old woman who was admitted due to a persistent fever resistant to antibiotics. Echocardiography showed secundum ASD, moderate TR and a mobile vegetation measuring 15×10 mm attached to the tricuspid valve. Given the risk of developing a paradoxical embolism, urgent surgery was successfully performed.

A 75-year-old male with a left atrial (LA) mass was referred to our hospital. The patient had been healthy until 5 months prior, when dyspnea on exertion developed. A chest radiograph showed mild enlargement of the cardiac silhouette. An ECG showed sinus rhythm with P mitrale ( Figure 1A). Transthoracic echocardiography (TTE) revealed a 5.4×3.9-cm hypoechoic tumor that had prolapsed through the mitral valve causing left ventricular inflow obstruction ( Figure 1B; Movie I in the online-only Data Supplement). The tumor appeared to be soft with smooth surface and had a stalk originating from the interatrial septum. Transesophageal echocardiography (TEE) revealed dynamic smoke-like echoes, indicative of spontaneous echo contrast, inside the tumor ( Figure 1C; Movie I in the online-only Data Supplement). M-mode showed multiple echoes and unique tumor behavior with subtle motion, in which the tumor rebounded into LA cavity twice during systole, producing an M-shaped signal ( Figure 1D; Movie II in the online-only Data Supplement). These echocardiographic findings implied that the inside of tumor was filled with liquid, rather than clotted blood, giving it a blood-balloon-like appearance. Moreover, color Doppler revealed afferent flow entering the tumor ( Figure 2A) and efferent flow draining from the tumor ( Figure 2C). Both flows occurred predominantly during diastole (Figure 2B and 2D; Movie III in the online-only Data Supplement), suggestive of blood supply from the coronary artery. Enhanced chest CT confirmed the tumor prolapse and the entry jet into the tumor ( Figure 3A). On MRI, the mass was well defined and encapsulated with a homogeneous internal structure, but it did not include a solid lesion ( Figure 3B and 3C). Echocardiography, CT, and MRI showed no evidence of tumor invasion, such as inhomogeneity or thickness of the interatrial septum, or tumor extension into other chambers. Coronary angiography demonstrated the blood spurting and staining of the entire tumor, with filling from the left ventricular branch of the right coronary artery ( Figure 3D). Interestingly, the tumor staining lasted for 30 s despite halting coronary injection of contrast medium (Movie IV in the online-only Data Supplement). Preoperatively, we suspected that this was an LA myxoma with intratumoral hemorrhage. The differential diagnosis of intracardiac cystic masses includes bronchial cysts, hydatid cyst, thrombus, cystic tumor of the atrioventricular node, intracardiac varices, closed interatrial septum aneurysm, and endocardial blood cyst.The tumor was removed urgently. The broad attachment of the tumor to interatrial septum required a biatrial approach for tumor excision with pericardial patch reconstruction. An left ventricular branch of right coronary artery was ligated. Intraoperatively, the tumor was soft, with a thin wall that ruptured during tumor excision ( Figure 4A and 4B), revealing the presence of liquid blood. As expected, we found a pinhole entrance for coronary flow into the tumor ( Figure 4B and 4C). Histologically...