Hyperventilation-induced simultaneous multivessel coronary spasm in patients with variant angina: an echocardiographic and arteriographic study

Left ventricular wall motion abnormalities during an attack of coronary spasm induced by hyperventilation were examined with use of two-dimensional echocardiography in 27 patients with variant angina. Transient abnormal wall motion (asynergy) confined to one coronary artery region was found in 18 of the 27 patients and transient abnormal motion extending over more than one coronary artery region in the remaining 9 patients. Spasm of more than one major coronary artery was demonstrated separately by coronary arteriography during an attack induced by injection of acetylcholine or ergonovine in seven of the nine patients who manifested asynergy in more than one coronary artery region. In one patient, spasm was demonstrated in one major coronary artery, and the other coronary arteries were severely stenosed or occluded organically. In the remaining patient, acetylcholine was not injected into both arteries; however, the attack was sometimes associated with ST segment elevation in the anterior leads and at other times in the inferior leads. Therefore, simultaneous multivessel coronary spasm seems to have occurred in eight of the nine patients who exhibited asynergy in more than one coronary artery region. The 8 patients with simultaneous multivessel coronary spasm had a higher degree and longer duration of ST segment elevation and a higher incidence of arrhythmias during the attack induced by hyperventilation than did the 19 patients with single vessel coronary spasm, and all of them had no significant organic stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Suppression of exercise-induced angina by magnesium sulfate in patients with variant angina

The effects of intravenous magnesium on exercise-induced angina were examined in 15 patients with variant angina and in 13 patients with stable effort angina and were compared with those of placebo. Symptom-limited bicycle exercise and thallium-201 myocardial scintigraphy were performed after intravenous administration of 0.27 mmol/kg body weight of magnesium sulfate and after placebo on different days. In all patients, serum magnesium levels after administration of magnesium sulfate were about twofold higher than levels after placebo. Exercise-induced angina associated with transient ST segment elevation occurred in 11 patients with variant angina receiving placebo and in only 2 of these patients receiving magnesium (p less than 0.005). On the other hand, exercise-induced angina was not suppressed by magnesium in any patient with stable effort angina. In these patients there was no significant difference in exercise duration after administration of placebo versus after administration of magnesium. The size of the perfusion defect as measured by thallium-201 scintigraphy was significantly less in patients with variant angina receiving magnesium than that in those receiving placebo (p less than 0.001), whereas it was not significantly different in patients with stable effort angina receiving placebo versus magnesium. In conclusion, exercise-induced angina is suppressed by intravenous magnesium in patients with variant angina but not in patients with stable effort angina. This beneficial effect of magnesium in patients with variant angina is most likely due to improvement of regional myocardial blood flow by suppression of coronary artery spasm.

Effects of intracoronary injection of acetylcholine on coronary arterial hemodynamics and diameter

To examine the effects of intracoronary injection of acetylcholine on coronary blood flow and on coronary arterial diameter in humans, acetylcholine was injected into the left coronary artery in 32 adult patients (21 men and 11 women with a mean age of 54 years, range 37 to 65) with normal or almost normal coronary arteriographic findings. Patients with angina pectoris, myocardial infarction and severe cardiac diseases were excluded. Temporary right ventricular pacing was set at a rate of 60 beats/min to prevent transient bradyarrhythmias during intracoronary injection of acetylcholine. Measurements of coronary sinus blood flow and coronary vascular resistance and quantification of coronary arterial diameters using a computer-assisted technique were performed before and after each injection of 20, 50 and 100 micrograms of acetylcholine. Significant increase in coronary sinus blood flow and significant decrease in coronary vascular resistance occurred after intracoronary injection of acetylcholine. In contrast, mean diameter of normal epicardial coronary artery tended to decrease and that of irregular epicardial coronary artery decreased significantly after intracoronary injection of acetylcholine. Intracoronary injection of acetylcholine increases coronary blood flow, suggesting vasodilation in the coronary arteriolar bed, while it induces vasoconstriction in most of epicardial coronary arteries in adult humans.

Entrainment of idiopathic ventricular tachycardia of left ventricular origin with evidence for reentry with an area of slow conduction and effect of verapamil

Recurrent sustained ventricular tachycardia (VT) with QRS morphology of the right bundle branch block and left axis deviation was studied in 4 patients without any underlying heart diseases. The mean VT rate was 155 beats/min and the endocardial catheter mapping during VT showed the earliest activation site at the left ventricular lateral wall near the apex. In all patients, rapid pacing from the right ventricular outflow tract during VT resulted in constant fusion beats except for the last entrained beat (thus VT was entrained), while pacing from the right ventricular apex and from the earliest activation site failed to demonstrate entrainment. During entrainment from the right ventricular outflow tract (mean pacing rate 168 beats/min), conduction intervals from the pacing site to the earliest activation site (St-A interval) and to the right ventricular apex (St-B interval) were measured in 3 patients. The St-A intervals were 400, 410 and 440 ms and the St-B intervals were 80, 70 and 90 ms, respectively. A small dose of verapamil (1.0 mg) was administered during VT, which resulted in a decrease of VT rate by a mean of 23 beats/min. During entrainment from the right ventricular outflow tract the St-A interval was prolonged in all 3 patients while the St-B interval remained the same. In conclusion, the mechanism of this VT was best explained by reentry with an area of slow conduction. Verapamil slowed the rate of VT by prolonging conduction within the area of slow conduction. Tachycardia entrainment makes possible a selective examination of antiarrhythmic drug effect on the area of slow conduction within the reentry circuit of VT.

Sensitivity and specificity of intracoronary injection of acetylcholine for the induction of coronary artery spasm

Intracoronary injection of acetylcholine has been shown to induce coronary spasm in patients with variant angina. To examine its sensitivity and specificity, incremental doses of acetylcholine (20, 50 and 100 micrograms into the left coronary artery and 20 and 50 micrograms into the right coronary artery) were injected into the coronary artery or arteries in 70 patients with variant angina (Group 1) (mean age 57 years) and 93 patients without variant angina or angina at rest (Group 2) (mean age 54 years). Forty patients of the latter group had atypical chest pain, 16 cardiomyopathy, 14 arrhythmia, 11 valvular disease, 7 stable effort angina due to advanced coronary artery disease, 3 congenital heart disease and 2 hypertension. A temporary cardiac pacemaker set at 40 to 50 beats/min was positioned in the right ventricle. Coronary spasm was defined as total occlusion or severe vasoconstriction associated with chest pain or ischemic ST changes on the electrocardiogram or both. In Group 1, acetylcholine induced spasm in 63 (90%) of the 70 patients in the artery or arteries predicted to be responsible for spontaneous attacks. In Group 2, acetylcholine induced coronary spasm only in one patient with effort angina and advanced coronary artery disease although lesser degrees of vasoconstriction (less than or equal to 75% of the luminal diameter) occurred in most patients after acetylcholine (specificity of acetylcholine thus was 99%). In conclusion, intracoronary injection of acetylcholine is sensitive and reliable for the induction of coronary spasm.

Ascending and descending projections of the nucleus reticularis gigantocellularis in the cat demonstrated by the anterograde neural tracer, Phaseolus vulgaris leucoagglutinin (PHA-L)

Ascending and descending projections of the nucleus reticularis gigantocellularis (NRGc) were studied in the cat by the anterograde tracer, Phaseolus vulgaris leucoagglutinin. Ascending fibers from the left or the right NRGc coursed through the bilateral medial reticular formation and some of them reached the diencephalon. In the brainstem, PHA-L-labeled fibers and their terminals were observed in the medial reticular formation, the cranial motor nuclei (III, IV, V, VI, VII, XII), the vestibular complex, the LC complex, the raphe nuclei, the periaqueductal gray, the red nucleus, the Edinger-Westphal nucleus and the interstitial nucleus of Cajal. In the diencephalon, they were observed in the dorsal thalamus and the hypothalamic regions. In the caudal medulla, labeled fibers and their terminals were observed in the nucleus prepositus hypoglossi, the nucleus intercalatus and the inferior olive. Descending axons from the NRGc coursed bilaterally through the ventral and ventrolateral funiculi as far caudal as the upper thoracic cord. Single axon collaterals arising from the descending axons gave off terminal fibers to the left or the right gray matter. Their terminals were located in laminae V-X, mainly in laminae VII and VIII. In lamina IX, they were distributed mainly in the medial portion. A few fibers originating from the descending axons ipsilateral to the PHA-L injection side coursed through the anterior or posterior commissure, and ended in laminae VI, VII and VIII. The functional implications of these findings are discussed in relation to the behavioral state control and the generalized motor inhibition.

The effects of intracerebroventricular administration of adrenergic agonists and antagonists on adrenaline secretion from the adrenal medulla in stressed conscious rats

The effects of intracerebroventricular (i.c.v.) administration of adrenergic agonists and antagonists on the increase in serum adrenaline (Ad) induced by immobilization stress were examined in unanesthetized, unrestrained rats. The serum Ad of rats showed a significant linear increase as time elapsed after the induction of immobilization stress. This immobilization stress-induced increase was inhibited by the i.c.v. administration of a small amount of noradrenaline (NA) and phenylephrine. Isoproterenol and clonidine failed to inhibit the immobilization stress-induced increase. The inhibition of the immobilization stress-induced increase by i.c.v. administration of NA was antagonized by pretreatment with phentolamine and prazosin, but not by pretreatment with yohimbine and propranolol. These results suggested that NA administered via an i.c.v. route may inhibit the stress-induced increase in adrenomedullary Ad secretion by an action on the central alpha 1-adrenoceptor.

Use of cyclophosphamide and total lymphoid irradiation combined with cyclosporine in bone marrow transplantation for transfused severe aplastic anemia

Between February 1984 and August 1987, 10 patients with severe aplastic anemia were treated with bone marrow transplantation from HLA-identical sibling donors after preparation with cyclophosphamide (CY) 200 mg/kg and total lymphoid irradiation (TLI) 750 cGy. Ages ranged from 5 to 28 years (median 14 years). All patients were previously transfused. Median number of transfusions was 16 (range, 3-886). For post-transplant immunosuppression all patients were given cyclosporine and the last three patients received additional immunosuppression with short-term methotrexate. All patients had initial engraftment and survived for more than 3-46 months after transplantation. One patient developed significant acute graft-versus-host disease (GVHD) and three of nine recipients who survived more than 100 days developed chronic GVHD. One male patient who had received 21 transfusions from his marrow donor before transplantation suffered from persistent granulocytopenia. Otherwise all have Karnofsky performance scores of 90-100%. Although the number of patients is small, it appears that allogeneic bone marrow transplantation with the regimen of CY + TLI for preparation combined with cyclosporine (+ short-term methotrexate) for post-transplant immunosuppression is a promising modality for treatment of previously transfused patients with severe aplastic anemia.

[Hypertrophic cardiomyopathy with left ventricular dilatation]

There is increasing interest in the notion that some patients with hypertrophic cardiomyopathy (HCM) progress to morphological and functional manifestations similar to those of dilated cardiomyopathy (DCM). From 165 consecutive patients with HCM, 20 patients with left ventricular dilatation (left ventricular end-diastolic diameter greater than or equal to 50 mm) were selected and designated as dilated HCM. The diagnosis of HCM was established in these patients either by detection of the classical form of HCM in family members, with 2-dimensional echocardiographic evidence of asymmetric septal hypertrophy (ASH; septal thickness greater than or equal to 15 mm and a ratio of septal to posterior wall thickness greater than or equal to 1.3); or by demonstrating myocardial fiber disarray in autopsy or biopsy samples. The clinical manifestations of these patients with dilated HCM were then compared with those of other forms of HCM without left ventricular dilatation; 1) 40 patients with hypertrophic obstructive cardiomyopathy (HOCM) who had resting intraventricular pressure gradients of 20 mmHg or more, 2) 80 patients with non-obstructive HCM, each of whom had ASH of the entire ventricular septum (typical ASH), and 3) 25 non-obstructive patients whose hypertrophy was localized to the apical region of the ventricular septum (apical ASH). Patients having apical hypertrophy with a spade-like configuration on the left ventriculogram were excluded from the study. Compared with HOCM and typical ASH groups, the patients with dilated HCM had family histories of significantly more frequent HCM and less frequent hypertension. The patients with dilated HCM also had significantly less fractional shortening (FS), decreased interventricular septal thickness, greater left ventricular end-diastolic pressure (LVEDP), and left ventricular dilatation. During the follow-up period (average: 3.5 years), seven patients (35%) with dilated HCM died; five from congestive heart failure (CHF), one suddenly, and one three days following mitral valve replacement. The other five patients had CHF at the time of their follow-up examination. The patients with apical ASH had clinical features similar to those of dilated HCM; a higher familial frequency, less marked septal hypertrophy, and higher LVEDP. They tended to develop left ventricular dilatation, associated with reduced fractional shortening, although left ventricular diameter at end-diastole did not exceed 50 mm. These findings suggested that dilated HCM is not a rare condition. It is observed in 12% of consecutive patients with HCM.(ABSTRACT TRUNCATED AT 400 WORDS)

Monoclonal antibodies that detect different antigenic determinants of the same human osteosarcoma-associated antigen

Monoclonal antibodies (MoAbs) against human osteosarcoma cells were obtained by the fusion of NS/1 mouse myeloma cells with spleen cells from the human osteosarcoma cell line-immunized BALB/c mice. Two hybrid clones were established and designated as 2H10 and 2D3. Both MoAbs reacted strongly with all osteosarcoma tissues but not with other bone and soft tissue tumors such as chondrosarcoma, malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, and rhabdomyosarcoma. In addition, neither MoAb reacted with tumor cell lines and tissues obtained from other cancers. Immunohistochemical analysis demonstrated that 2H10 and 2D3 reacted with endothelial cells in sarcoma tissues, but not with those of other tumors and normal tissues. 2H10 also reacted with cells on the basal layer of epidermis of the skin. 2H10- and 2D3-defined antigen has an approximate molecular weight of 75,000 under nonreducing and reducing conditions, indicating that the antigen has a single chain structure and there is no intramolecular disulfide bond. 2H10- and 2D3-defined antigen has a pI value between 5.5 and 6.2. Sequential immunoprecipitation analysis clearly demonstrated that 2H10 and 2D3 recognized the same antigen molecule. However, further analysis suggested the possibility that 2H10 and 2D3 MoAbs recognized the different antigenic determinants on the same antigen molecule.

Determination of gamma-aminobutyric acid and associated amino acids in mouse brain by liquid chromatography

A rapid method is described for the analysis of amino acids containing in mouse brain by high performance liquid chromatography equipped with a fluorescence detector. Pre-column o-phthalaldehyde-2-mercaptoethanol derivatives of the amino acids were injected onto an ODS C-18 column. 5-Amino-n-valeric acid, a non-endogenous amino acid, was used as an internal standard. Separation and elution of amino acid derivatives were achieved by varying the ratio of organic phase by a step gradient. Significant increases in gamma-aminobutyric acid, glutamine and glycine levels in the brain were detected 2 h after injection of 800 mg/kg valproic acid (VPA). A high dose administration of VPA was correlated with Reye's syndrome.

Multivessel coronary spasm in patients with variant angina: a study with intracoronary injection of acetylcholine

Multivessel coronary spasm has been described but its incidence in patients with variant angina still remains unclear. Thirty-three patients with variant angina were studied during coronary angiographic examination with selective intracoronary injection of acetylcholine (ACh). In all but three patients, the location of ischemia during attack was determined by the electrocardiographic findings, by exercise 201Tl myocardial scintigraphy, and by two-dimensional echocardiography during a hyperventilation test, and the coronary artery (or arteries) responsible for the attack was predicted before the study. ACh induced spasm of at least one coronary artery in all but one patient. ACh induced spasm of both the left and right coronary arteries (i.e., multivessel coronary spasm) in 24 patients: in two of the four patients who were predicted to have spasm of the left coronary artery, in six of the 11 predicted to have spasm of the right coronary artery, in 13 of the 15 predicted to have spasm of both the left and right coronary arteries, and in three of the three in whom coronary artery responsible for attack had not been predicted. This ACh-induced spasm of the left and right coronary arteries occurred separately and no patients showed hemodynamic instability during attack. In one patient in whom multivessel coronary spasm had been predicted and ACh failed to induice coronary spasm, ergonovine maleate (0.2 mg) induced spasm of both the left and right coronary arteries simultaneously, resulting in severe prolonged hypotension. Nineteen of the 25 patients in whom multivessel coronary spasm was documented showed angiographically normal or nearly normal coronary arteries after administration of nitroglycerin.(ABSTRACT TRUNCATED AT 250 WORDS)

High serum iron in human parvovirus-induced aplastic crisis in iron deficiency anemia

Recent study has shown that the human parvovirus (HPV) is a causative agent of aplastic crisis in hemolytic anemias. In subjects without shortened red blood cell life span, HPV is not associated with symptomatic anemia. A case of iron deficiency anemia revealed by HPV linked to erythroblastopenia is described in a child. On admission, the serum iron was not decreased and other blood chemistry tests were also not consistent with the diagnosis of iron deficiency anemia. Abrupt cessation of erythropoiesis induced by HPV infection appeared to prolong plasma iron clearance, which elevated serum iron concentration.

Bone marrow transplantation for hepatitis-associated aplastic anemia

Five patients with hepatitis-associated aplastic anemia were transplanted with HLA-identical, mixed lymphocyte culture-compatible sibling marrow. One patient who had suffered from severe chronic graft-versus-host disease died from intracranial bleeding at 42 months following the transplant. The other four patients are surviving from 15 to 54 months after transplant with a median follow-up of 21 months. Previous hepatic damage from viral hepatitis and liver function abnormalities existing at the time of grafting do not appear to increase the risk of hepatic venocclusive disease or the side effects of ciclosporin in patients with hepatitis-associated aplastic anemia.

Transient left atrial mobile thrombus in acute myocardial infarction--a case report

The authors report a fifty-year-old woman with acute inferior myocardial infarction in whom left atrial mobile thrombus was found by echocardiography. They believe this to be the first echocardiographic documentation of such a thrombus after acute myocardial infarction. The combination of the stagnant flow in the left atrium due to atrial ischemia, the low output state due to left ventricular dysfunction, and the hemoconcentric tendency from use of diuretics might have played a role in the present thrombus formation. The thrombus was safely lysed without complication after intravenous urokinase.