Published Papers - Kusunose Kenya

Left ventricular mass influences relationship between filling pressure and early-diastolic ratio of inflow velocity to mitral annular velocity (E/e′)

Masahiro Nakabachi, Satoshi Yamada, Hiroyuki Iwano, Taichi Hayashi, Kazunori Okada, Kenya Kusunose, Kiyotaka Watanabe, Tomoko Ishizu, Kazuaki Wakami, Hirotsugu Yamada, Kaoru Dohi, Yoshihiro Seo, Nobuyuki Ohte, Chikara Shimizu, Taisei Mikami

Circulation Journal ( Japanese Circulation Society )  82 ( 3 ) 732 - 738   2018 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Background: Early-diastolic mitral annular velocity (e′) and the ratio of early-diastolic left ventricular (LV) inflow velocity (E) to e′ (E/e′) have been widely used as indexes of LV relaxation and filling pressure, respectively. However, many recent studies have demonstrated that they are not reliable in various clinical settings. We thus investigated the factors influencing these echocardiographic parameters in a multicenter study. Methods and Results: The study group comprised 69 patients, referred for cardiac catheterization, and enrolled in 5 university hospitals. Time constant (τ) and LV mean diastolic pressure (LVMDP) were measured using a micromanometer-tipped catheter. Although e′ only weakly correlated with τ (r=−0.35, P&lt 0.01), E/e′ modestly correlated with LVMDP (r=0.48, P&lt 0.001). Multivariable analysis revealed that hypertension (β=−0.33, P&lt 0.01) and LV ejection fraction (LVEF) (β=0.44, P&lt 0.001) were the independent determinants of e′, and LV mass index (LVMI) (β=0.37, P&lt 0.001) and LVMDP (β=0.47, P&lt 0.001) were those of E/e′. Additionally, E/e′ significantly correlated with LVMDP in patients with normal LVMI (r=0.74, P&lt 0.001) but not in those with increased LVMI. Conclusions: The coincidence of hypertension and LVEF affected the relationship between LV relaxation and e′, whereas LVMI altered the relationship between LV filling pressure and E/e′. Thus, clinical conditions associated with an increase in LVMI, such as LV hypertrophy and LV dilatation, should be considered when estimating the filling pressure from E/e′.

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Activated Factor X Signaling Pathway via Protease-Activated Receptor-2 is a Novel Therapeutic Target to Prevent Atrial Fibrillation

Soeki Takeshi, Matsuura Tomomi, Fukuda Daiju, Uematsu Etsuko, Tobiume Takeshi, Hara Tomoya, Kusunose Kenya, Ise Takayuki, Yamaguchi Koji, Yagi Shusuke, Yamada Hirotsugu, Wakatsuki Tetsuzo, Sata Masataka

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Preserved Endothelial Function and Suppressed Local Coagulative and Inflammatory Response After Biodegradable Polymer SES Implantation Compared to Durable Polymer SES

Yamaguchi Koji, Wakatsuki Tetsuzo, Kawabata Yutaka, Ito Hiroyuki, Matsuura Tomomi, Ise Takayuki, Kusunose Kenya, Tobiume Takeshi, Yagi Shusuke, Yamada Hirotsugu, Soeki Takeshi, Sata Masataka

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Preload Stress Echocardiography Predicts Outcomes in Patients With Preserved Ejection Fraction and Low Gradient Aortic Stenosis

Kusunose Kenya, Yamada Hirotsugu, Nishio Susumu, Torii Yuta, Hirata Yukina, Seno Hiromitsu, Saijo Yoshihito, Ise Takayuki, Yamaguchi Koji, Yagi Shusuke, Soeki Takeshi, Wakatsuki Tetsuzo, Sata Masataka

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Local Epicardial Adipose Tissue Thickness in Left Anterior Descending Artery Provides a New Prediction Model for Coronary Artery Disease

Maimaituxun Gulinu, Shimabukuro Michio, Hirata Yukina, Iwase Takashi, Takao Shoichiro, Matsuura Tomomi, Ise Takayuki, Kusunose Kenya, Tobiume Takeshi, Yamaguchi Koji, Yagi Shusuke, Fukuda Daiju, Yamada Hirotsugu, Soeki Takeshi, Wakatsuki Tetsuzo, Harada Masafumi, Sata Masataka

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Epicardial Adipose Tissue Produces Proinflammatory Cytokines and Influences the Pathogenesis of Atrial Fibrillation

Soeki Takeshi, Matsuura Tomomi, Uematsu Etsuko, Tobiume Takeshi, Kusunose Kenya, Ise Takayuki, Yamaguchi Koji, Yagi Shusuke, Fukuda Daiju, Yamada Hirotsugu, Wakatsuki Tetsuzo, Sata Masataka

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Direct Slow Pathway Capture: A New Electrophysiological Method of Catheter Ablation for Atrioventricular Nodal Reentrant Tachycardia

Matsuura Tomomi, Tobiume Takeshi, Takeshi Soeki, Kato Ritsushi, Hara Motoki, Ise Takayuki, Kusunose Kenya, Yamaguchi Koji, Yagi Shusuke, Yamada Hirotsugu, Wakatsuki Tetsuzo, Sata Masataka, Matsumoto Kazuo

CIRCULATION   136   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

Edoxaban improves acute venous thromboembolism while preserving protein C and protein S levels

山? 宙, 八木 秀介, Y Torii, R Amano, Y Oomichi, T Sangawa, 福田 大受, 門田 宗之, 伊勢 孝之, R Ueno, 原 知也, 楠瀬 賢也, 松浦 朋美, 飛梅 威, 山口 浩司, 山田 博胤, 添木 武, 若槻 哲三, 赤池 雅史, 佐田 政隆

Journal of Cardiology   Vol.71 ( No.3 ) 305 - 309   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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It is well known that warfarin inhibits the synthesis of vitamin K-dependent anticoagulants, including thrombin, protein C and S, and factor Xa, leading, paradoxically, to an initial hypercoagulable state. Edoxaban, a direct inhibitor of activated factor X is widely used for the treatment of acute venous thromboembolism (VTE). However, the effect of edoxaban on circulating coagulation factors, in patients with acute VTE, remains unknown. We enrolled 57 patients with acute VTE with/without pulmonary embolism treated with edoxaban (n=37) or warfarin (n=20) in a clinical setting. Before treatment and 2 weeks after treatment, we evaluated thrombotic burden using ultrasound or computed tomography angiography. We also evaluated thrombin generation, represented by prothrombin fragment F1+2; thrombus degradation, represented by D-dimer; and levels of anticoagulants, including protein C, protein S, and antithrombin III. Both edoxaban and warfarin treatment improved thrombotic burden and decreased prothrombin fragment F1+2, and D-dimer. Edoxaban treatment preserved protein C and protein S levels. In contrast, warfarin decreased protein C and protein S levels. Neither treatment affected antithrombin III. Edoxaban improves VTE while preserving protein C and protein S levels, thereby indicating that edoxaban improves thrombotic burden while maintaining levels of anticoagulants.

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Predictors of Mortality in Patients With Severe Ischemic Cardiomyopathy Undergoing Surgical Mitral Valve Intervention

Kenya Kusunose, Nancy A. Obuchowski, Marc Gillinov, Zoran B. Popovic, Scott D. Flamm, Brian P. Griffin, Deborah H. Kwon

JOURNAL OF THE AMERICAN HEART ASSOCIATION ( WILEY )  6 ( 11 ) e007163 - e007163   2017.11 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Background-Ischemic mitral regurgitation is associated with substantial risk of death. Although surgical mitral valve intervention (MVi) may improve symptoms, it has not been shown to improve survival. The aim of this study was to identify predictors of mortality in patients with ischemic mitral regurgitation and MVi. Methods and Results-We evaluated 117 consecutive patients (age, 65 +/- 10 years) with advanced ischemic cardiomyopathy who underwent cardiac magnetic resonance and subsequent MVi between January 1, 2002 and January 1, 2012. Cardiac magnetic resonance was used to assess left ventricular remodeling and myocardial scarring. The effective regurgitant orifice area was calculated from the proximal isovelocity surface area by echocardiography. There were 43 deaths (37%) during follow-up (median, 62 months). On multivariable analysis, age >= 70 years (P=0.013), diabetes mellitus (P=0.001), dyslipidemia (P=0.012), papillary muscle scar (P=0.010), incomplete revascularization (P=0.001), and total scar %xeffective regurgitant orifice area >= 0.20 cm(2) (P=0.005) were each independently associated with all-cause mortality. Although patients with effective regurgitant orifice area <0.2 cm(2) at baseline demonstrated an increased hazard ratio of 3.3 for every 10% increase in scar, the hazard ratio increased to 9 for every 10% increase in scar in those with baseline effective regurgitant orifice area >= 0.20 cm(2). Mortality also was significantly higher in patients with incomplete revascularization compared with those with vascularized viable myocardium (61% versus 28%; P<0.001). Conclusions-Increased total scar burden and the presence of incomplete revascularization are powerful predictors of mortality in patients with advanced ischemic cardiomyopathy undergoing MVi. Viability assessment with cardiac magnetic resonance imaging can identify which patients with ischemic mitral regurgitation are at highest risk for mortality after surgical MVi.

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症例検討:妊婦に発症した脳梗塞の1例

細川 忍, 戸根 沙織, Naoko Matsui, Kenya Kusunose, Kumiko Kagawa, 山上 圭, 廣島 裕也, 田村 洋人

The Journal of the Japanese Society of Internal Medicine   Vol.106 ( No.10 ) 2265 - 2272   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (bulletin of university, research institution)

Echocardiographic Epicardial Adipose Tissue Thickness Is Associated with Symptomatic Coronary Vasospasm during Provocative Testing

Susumu Nishio, Kenya Kusunose, Hirotsugu Yamada, Yukina Hirata, Takayuki Ise, Koji Yamaguchi, Shusuke Yagi, Takeshi Soeki, Tetsuzo Wakatsuki, Michio Shimabukuro, Masataka Sata

Journal of the American Society of Echocardiography ( Mosby Inc. )  30 ( 10 ) 1021 - 1027.e1   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Background Epicardial adipose tissue (EAT) is the ectopic visceral fat surrounding the heart, which plays an important role in atherosclerosis of the coronary arteries via endothelial damage. Several studies have also suggested that vasospasm with angina (VSA) causes endothelial dysfunction in the coronary arteries. The aim of this study was to evaluate the thickness of EAT in the anterior interventricular groove (EAT-AIG) using echocardiography in patients who had no obstructive coronary artery disease and were suspected of having VSA. Methods Sixty-five patients who underwent intracoronary acetylcholine provocation testing for clinical indications were prospectively enrolled. VSA was diagnosed by coronary artery stenosis increase of &gt 90% and the presentation of chest pain with ischemic changes on electrocardiography. Results Subjects were divided into two groups, with and without significant coronary spasm (VSA group, 30 patients non-VSA group, 35 patients), consistent with acetylcholine provocation testing. EAT-AIG thickness was significantly greater in the VSA group than in the non-VSA group (8.2 ± 2.7 vs 6.1 ± 2.5 mm, P =.002). By receiver operating characteristic analysis, EAT-AIG thickness had a high C statistic (area under the curve = 0.81, P &lt .001) after adjustment for conventional risk factors (smoking, diabetes mellitus, and dyslipidemia). EAT-AIG thickness had incremental diagnostic value over other conventional risk factors (area under the curve = 0.81 vs 0.64, P for comparison =.020). Conclusions EAT-AIG thickness, which is noninvasively and easily measured using transthoracic echocardiography, can be one of multiple clinical variables associated with VSA.

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RV Myocardial Strain During Pre-Load Augmentation Is Associated With Exercise Capacity in Patients With Chronic HF

Kenya Kusunose, Hirotsugu Yamada, Susumu Nishio, Ayumi Ishii, Yukina Hirata, Hiromitsu Seno, Yoshihito Saijo, Takayuki Ise, Koji Yamaguchi, Shusuke Yagi, Takeshi Soeki, Tetsuzo Wakatsuki, Masataka Sata

JACC: Cardiovascular Imaging ( Elsevier Inc. )  10 ( 10 ) 1240 - 1249   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Objectives The aim of this study was to assess the relationship between right ventricular (RV) function during pre-load augmentation and exercise tolerance. Background Peak oxygen uptake (VO2) is a strong predictor of mortality in chronic heart failure. Cardiac function during pre-load augmentation is an important part of the phenomenon in the evaluation of exercise capacity. Methods We prospectively performed echocardiographic studies in 68 chronic heart failure patients with cardiopulmonary exercise testing (mean age 60 ± 12 years 69% male). After resting evaluations, echocardiographic parameters were repeated during leg positive pressure (LPP). Exercise capacity was assessed by peak VO2 in all patients (left ventricular ejection fraction: 43 ± 15%). Results Patients with severely reduced exercise capacity (peak VO2 &lt 14 ml/kg/min) had significantly lower stroke volume index, left ventricular global longitudinal strain and RV strain and higher filling pressure (E/e’ and pulmonary arterial systolic pressure) than the remainder. Stroke volume index (β = 0.49), global longitudinal strain (β = −0.61), E/e’ (β = −0.32), pulmonary arterial systolic pressure (β = −0.57), and RV strain (β = −0.66) during LPP were independently correlated to peak VO2 (all p &lt 0.01). RV strain during LPP was the most powerful predictor in identifying patients with severely reduced exercise capacity (cut off value: −17% sensitivity: 81% specificity: 88% areas under the curve: 0.88 p &lt 0.001) compared with other variables including resting parameters. Conclusions RV strain during pre-load augmentation correlated independently to peak VO2 and was a powerful predictor in identifying patients with severely reduced exercise capacity.

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Preload Stress Echocardiography Predicts Outcomes in Patients with Preserved Ejection Fraction and Low-Gradient Aortic Stenosis

Kenya Kusunose, Hirotsugu Yamada, Susumu Nishio, Yuta Torii, Yukina Hirata, Hiromitsu Seno, Yoshihito Saijo, Takayuki Ise, Koji Yamaguchi, Shusuke Yagi, Takeshi Soeki, Tetsuzo Wakatsuki, Masataka Sata

Circulation: Cardiovascular Imaging ( Lippincott Williams and Wilkins )  10 ( 10 )   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Background-The projected aortic valve area (AVAproj) at a normal transvalvular flow rate using dobutamine is helpful to determine the actual severity of aortic stenosis (AS) and to predict risk of adverse events in low-gradient AS cases with unclear surgical indication. Our study aimed to identify the independent and incremental value of preload stress echocardiography-derived AVAproj to predict outcomes in patients with preserved ejection fraction and low-gradient AS. Methods and Results-We prospectively performed echocardiographic studies in 79 patients with low-gradient AS (age, 77±7 years 30% men) with preload stress echocardiography using leg positive pressure. AVAproj was calculated using AVA and transvalvular flow rate at baseline and during leg positive pressure. The primary end point was the decision for aortic valve surgery or cardiac death. During a median period of 19 months, 23 patients had the decision for aortic valve surgery, and none died during follow-up. In a stepwise multivariable analysis, indexed AVAproj (AVAiproj hazard ratio, 2.00 per 0.1 cm2/m2 decrease 95% confidence interval, 1.36-2.96 P&lt 0.001) was associated with the primary end point. Using a receiver operating characteristic curve analysis, the best cutoff value of AVAiproj for predicting cardiac events was &lt 0.72 cm2/m2. By incorporating AVAiproj into AVAi at baseline, continuous net reclassification index for cardiac events was 0.48 (P=0.04). Conclusions-In patients with low-gradient AS, indexed AVAproj derived from preload stress echocardiography can be useful to predict risk of adverse events. The present article should be considered as a proof of concept study, and we think that larger multicenter studies are warranted.

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Canagliflozin reduces epicardial fat in patients with type 2 diabetes mellitus

Shusuke Yagi, Yukina Hirata, Takayuki Ise, Kenya Kusunose, Hirotsugu Yamada, Daiju Fukuda, Hotimah Masdan Salim, Gulinu Maimaituxun, Susumu Nishio, Yuriko Takagawa, Saori Hama, Tomomi Matsuura, Koji Yamaguchi, Takeshi Tobiume, Takeshi Soeki, Tetsuzo Wakatsuki, Ken-ichi Aihara, Masashi Akaike, Michio Shimabukuro, Masataka Sata

DIABETOLOGY & METABOLIC SYNDROME ( BIOMED CENTRAL LTD )  9   78 - 78   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Background: It is unknown whether canagliflozin, a selective sodium glucose co-transporter 2 inhibitor, reduces epicardial adipose tissue (EAT) thickness, which is associated with insulin resistance and is a risk factor for coronary artery disease. Methods and results: We administered 100 mg of canagliflozin for 6 months to 13 patients with type 2 diabetes mellitus. We evaluated glycemic control, visceral adipose tissue (VAT) area and subcutaneous adipose tissue (SAT) area, and skeletal muscle mass by using impedance methods, and EAT thickness by using echocardiography. Canagliflozin treatment for 6 months decreased hemoglobin A1c level from 7.1 +/- 0.5% to 6.7 +/- 0.6% (P < 0.05) and decreased EAT thickness from 9.3 +/- 2.5 to 7.3 +/- 2.0 mm (P < 0.001), along with a trend of decreasing VAT and SAT area. No association was found between any of these changes. Conclusion: Canagliflozin reduced EAT thickness in patients with type 2 diabetes mellitus independent of its effect on lowering blood glucose, suggesting that canagliflozin may have an effect in preventing cardiovascular events in these patients (UMIN000021327).

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RV Myocardial Strain During Pre-Load Augmentation Is Associated With Exercise Capacity in Patients With Chronic HF

Kenya Kusunose, Hirotsugu Yamada, Susumu Nishio, Ayumi Ishii, Yukina Hirata, Hiromitsu Seno, Yoshihito Saijo, Takayuki Ise, Koji Yamaguchi, Shusuke Yagi, Takeshi Soeki, Tetsuzo Wakatsuki, Masataka Sata

JACC-CARDIOVASCULAR IMAGING ( ELSEVIER SCIENCE INC )  10 ( 10 ) 1240 - 1249   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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OBJECTIVES The aim of this study was to assess the relationship between right ventricular (RV) function during pre-load augmentation and exercise tolerance. BACKGROUND Peak oxygen uptake (VO2) is a strong predictor of mortality in chronic heart failure. Cardiac function during pre-load augmentation is an important part of the phenomenon in the evaluation of exercise capacity. METHODS We prospectively performed echocardiographic studies in 68 chronic heart failure patients with cardiopulmonary exercise testing (mean age 60 +/- 12 years; 69% male). After resting evaluations, echocardiographic parameters were repeated during leg positive pressure (LPP). Exercise capacity was assessed by peak VO2 in all patients (left ventricular ejection fraction: 43 +/- 15%). RESULTS Patients with severely reduced exercise capacity (peak VO2 < 14 ml/kg/min) had significantly lower stroke volume index, left ventricular global longitudinal strain and RV strain and higher filling pressure (E/e' and pulmonary arterial systolic pressure) than the remainder. Stroke volume index (beta = 0.49), global longitudinal strain (beta = -0.61), E/e' (beta = -0.32), pulmonary arterial systolic pressure (beta = -0.57), and RV strain (beta = -0.66) during LPP were independently correlated to peak VO2 (all p < 0.01). RV strain during LPP was the most powerful predictor in identifying patients with severely reduced exercise capacity (cut off value: -17%; sensitivity: 81%; specificity: 88%; areas under the curve: 0.88; p < 0.001) compared with other variables including resting parameters. CONCLUSIONS RV strain during pre-load augmentation correlated independently to peak V(O)2 and was a powerful predictor in identifying patients with severely reduced exercise capacity. (C) 2017 by the American College of Cardiology Foundation.

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Preload Stress Echocardiography Predicts Outcomes in Patients With Preserved Ejection Fraction and Low-Gradient Aortic Stenosis.

Kusunose K, Yamada H, Nishio S, Torii Y, Hirata Y, Seno H, Saijo Y, Ise T, Yamaguchi K, Yagi S, Soeki T, Wakatsuki T, Sata M

Circulation. Cardiovascular imaging   10 ( 10 )   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

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Low Serum Levels of Eicosapentaenoic Acid and Docosahexaenoic Acid are Risk Factors for Cardiogenic Syncope in Patients with Brugada Syndrome.

Yagi S, Soeki T, Aihara KI, Fukuda D, Ise T, Kadota M, Bando S, Matsuura T, Tobiume T, Yamaguchi K, Kusunose K, Yamada H, Wakatsuki T, Shimabukuro M, Akaike M, Sata M

International heart journal   58 ( 5 ) 720 - 723   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

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Improved Exercise Capacity After Cardiac Rehabilitation Is Associated with Reduced Visceral Fat in Patients with Chronic Heart Failure.

Takagawa Y, Yagi S, Ise T, Ishii A, Nishikawa K, Fukuda D, Kusunose K, Matsuura T, Tobiume T, Yamaguchi K, Yamada H, Soeki T, Wakatsuki T, Shimabukuro M, Katoh S, Aihara KI, Akaike M, Sata M

International heart journal   58 ( 5 ) 746 - 751   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

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Echocardiographic Epicardial Adipose Tissue Thickness Is Associated with Symptomatic Coronary Vasospasm during Provocative Testing.

Nishio S, Kusunose K, Yamada H, Hirata Y, Ise T, Yamaguchi K, Yagi S, Soeki T, Wakatsuki T, Shimabukuro M, Sata M

Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography   30 ( 10 ) 1021 - 1027.e1   2017.10 [ Peer Review Accepted ]

Type of publication: Research paper (other science council materials etc.)

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Improved exercise capacity after cardiac rehabilitation is associated with reduced visceral fat in patients with chronic heart failure

Yuriko Takagawa, Shusuke Yagi, Takayuki Ise, Ayumi Ishii, Koji Nishikawa, Daiju Fukuda, Kenya Kusunose, Tomomi Matsuura, Takeshi Tobiume, Koji Yamaguchi, Hirotsugu Yamada, Takeshi Soeki, Tetsuzo Wakatsuki, Michio Shimabukuro, Shinsuke Katoh, Ken-ichi Aihara, Masashi Akaike, Masataka Sata

International Heart Journal ( International Heart Journal Association )  58 ( 5 ) 746 - 751   2017.09 [ Peer Review Accepted ]

Type of publication: Research paper (scientific journal)

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Participation in a comprehensive cardiac rehabilitation (CR) program has been shown to reduce mortality and improve exercise capacity and symptoms in patients with chronic heart failure (CHF). Reduced exercise capacity leads to a concomitant reduction of skeletal muscle mass and accumulation of body fat. However, it is currently unknown whether CR reduces visceral adipose tissue (VAT) and/or subcutaneous abdominal adipose tissue (SAT) in patients with CHF. In addition, the body composition associated with improved exercise capacity after CR in patients with CHF has not been previously studied. Nineteen CHF patients who were categorized as NYHA functional class II or III and had received optimal medical treatment including a CR program for 5 months were enrolled in this study. The CR program significantly increased peak VO2 and reduced B-type natriuretic peptide. In addition, fat and body composition analysis showed reductions in the visceral fat tissue (VAT) area, subcutaneous abdominal adipose tissue (SAT) area, body weight, and total fat weight after CR. There were no changes in total water weight and total muscle weight. Single regression analysis revealed that the amelioration of reduced exercise capacity seen after CR is associated with reduced VAT area but not with SAT area or body weight. In conclusion, CR reduces VAT and improves exercise capacity in patients with CHF. This suggests that reducing VAT is important for CR to be most effective in the treatment of CHF.

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