Right pneumothorax resulting from an endocardial screw-in atrial lead

Right pneumothorax complicated by an endocardial atrial lead has never been reported. Herein, we report on a small-build 79-year-old Taiwanese woman who suffered from complete AV block and underwent dual-chamber permanent pacemaker implantation. An active fixation screw-in atrial lead was chosen. The procedure was complicated by right pneumothorax associated with atrial perforation. Since simple measurements of the implantation parameters could not be used to predict the occurrence of perforation, great caution should be taken in to avoid overscrewing the atrial lead, and in scrutinizing the penetration depth of the helix of the lead under fluoroscopy.

Expression of the transcription factor lung Krüppel-like factor is regulated by cytokines and correlates with survival of memory T cells in vitro and in vivo

The transcription factor lung Krüppel-like factor (LKLF) is involved in naive T cell survival. Expression of LKLF is rapidly down-regulated upon T cell stimulation, raising the question of whether LKLF is reexpressed after activation, and what factors are required for such reexpression. Furthermore, the expression of LKLF in resting memory cells has not been determined. Here, we use the OT-I TCR transgenic mouse system to address these issues. LKLF was found to be reexpressed following culture of activated CD8 T cells in certain cytokines (IL-2, IL-7) but not others (IL-12) known to influence CTL development. Interestingly, induction of LKLF reexpression corresponded with long-term T cell survival and development of memory T cell phenotype. Furthermore, using OT-I cells stimulated in vivo, we demonstrated that Ag induced rapid LKLF down-regulation and that the factor is expressed by in vivo-derived memory T cells.

Superior vena cava syndrome as a complication of transvenous permanent pacemaker implantation

Venous thrombosis induced by a transvenous permanent pacemaker is a common complication. However, superior vena cava (SVC) syndrome caused by pacemaker leads is only occasionally seen and its prevalence has been estimated to be less than 1 in 1000 pacemaker patients. Herein, we report a Taiwanese patient of high grade AV block, who presented with SVC syndrome 2 years after transvenous permanent pacemaker implantation. This case features fibrotic stenosis of the junction of right brachiocephalic trunk and SVC, and an extensive thrombus formation resulting in complete obliteration of the left brachiocephalic vein. The collateral circulation was so delicate that he still could lead a rather normal life, even if anticoagulant therapy proved to be ineffective from an angiographic point of view.

Transcriptional regulation of T lymphocyte development and function

The development and function of T lymphocytes are regulated tightly by signal transduction pathways that include specific cell-surface receptors, intracellular signaling molecules, and nuclear transcription factors. Since 1988, several families of functionally important T cell transcription factors have been identified. These include the Ikaros, LKLF, and GATA3 zinc-finger proteins; the Ets, CREB/ATF, and NF-kappa B/Rel/NFAT transcription factors; the Stat proteins; and HMG box transcription factors such as LEF1, TCF1, and Sox4. In this review, we summarize our current understanding of the transcriptional regulation of T cell development and function with particular emphasis on the results of recent gene targeting and transgenic experiments. In addition to increasing our understanding of the molecular pathways that regulate T cell development and function, these results have suggested novel targets for genetic and pharmacological manipulation of T cell immunity.

Characterization of atrioventricular nodal reentry with continuous atrioventricular node conduction curve by double atrial extrastimulation

BACKGROUND

Characterization of typical atrioventricular nodal reentrant tachycardia (AVNRT) with continuous AVN conduction (A1A2/A2H2) curves by double atrial extrastimulation (A1A2A3) has never been systematically studied.

METHODS AND RESULTS

This study was composed of 33 patients with typical AVNRT and continuous AVN conduction curves (group 1) and 103 patients with AVNRT and discontinuous AVN conduction curves (group 2). Using A1A2A3 with predefined fast pathway-conducted A2, we examined the effects of slow pathway ablation on the A2A3/A3H3 curves in both groups. In group 1, anterograde AVN effective refractory period (272+/-33 versus 277+/-47 ms, P>0.05) and AVN Wenckebach block cycle length (320+/-45 versus 343+/-59 ms, P>0.05) remained unchanged after ablation. A2H2max was shorter in group 1 than group 2 (237+/-89 versus 395+/-72 ms, P<0.05) at baseline. It shortened in group 2 (395+/-72 versus 221+/-78 ms, P<0.001) but remained unchanged in group 1 (237+/-89 versus 214+/-59 ms, P>0.05) after ablation. A1A2A3 could further disclose discontinuous A2A3/A3H3 curves in 29 patients of group 1. A3H3max shortened in both groups (375+/-81 versus 238+/-82 ms, P<0.001, and 419+/-104 versus 220+/-78 ms, P<0.001, respectively) in a similar fashion. Successful ablation resulted in loss of the left portion of the A2A3/A3H3 curves in the 4 patients of group 1 with continuous A2A3/A3H3 curves.

CONCLUSIONS

Use of A1A2A3 could expose discontinuous A2A3/A3H3 curves in most patients with continuous A1A2/A2H2 curves. Significant shortening of A3H3max after ablation may be indicative of successful elimination of AVNRT.

Transdermal delivery of sodium nonivamide propionate by iontophoresis

The aim of this study was to investigate the transdermal iontophoresis of a newly designed capsaicin derivative, sodium nonivamide propionate (SNP). The iontophoretic permeation of SNP from various pH buffers increased following the decrease of pH values. This trend was consistent with that of sodium nonivamide acetate (SNA) which is another synthetic analogue of capsaicin. However, the iontophoretic permeability of SNP was much lower than that of SNA. SNP was also delivered iontophoretically from hydrogel formulations. It is suggested that ionizable polymers should be avoided for iontophoretic delivery to maintain good penetration capacity of drugs. Both nonionic cellulose polymers of methylcellulose (MC) and hydroxypropyl methylcellulose (HPMC) showed higher iontophoretic flux for SNP than the others did. Furthermore, the flux of SNP leveled off with an increase in the amount of polymers in hydrogel, indicating that the viscosity of vehicles plays an important role in the permeation of SNP. Comparing the various iontophoretic application modes, the discontinuous on/off cyclic mode showed higher penetration capacity than did the continuous mode although they possessed the same electrical energy. Moreover, the desorption time of SNP from skin was approximately 20 min which was longer than that of SNA.

Gender differences in baseline variables, therapies and outcomes in Chinese patients with acute myocardial infarction

We prospectively studied the gender differences of baseline variables, therapies, and outcomes among a cohort of 369 Chinese patients with acute myocardial infarction from 1990 to 1995. There were 277 male and 92 female patients. The male gender had a younger mean (+/-SD) age (61.5+/-10.7 vs. 67.1+/-11.7 years, P<0.0001). Hypercholesterolemia (201.2+/-44.2 vs. 187.5+/-43.7 mg/dl, P=0.0111) and obesity (25.0 vs. 15.9%, P=0.0494) were more prominent in the female. Smoking was more prevalent in the male (78.3 vs. 18.5%, P<0.0001). The male group also had more frequent use of thrombolytic agents (19.1 vs. 9.8%, P=0.0377), beta-blockers (61.7 vs. 47.8%, P=0.0191) and heparin (25.3 vs. 12.0%, P=0.0075); but less use of angiotensin-converting enzyme inhibitors (6.9 vs. 15.2%, P=0.0149). The condition on admission was worse in the female group (Killip classification (1.5+/-0.9 vs. 1.9+/-1.0, P=0.0022), myocardial failure (8.7 vs. 2.9%, P=0.0178) and cardiomegaly (65.2 vs. 53.1%, P=0.0419). During a follow-up duration of 26.4+/-24.1 and 22.9+/-23.9 months respectively, the mortality rate was lower in the male (19.5 vs. 30.4%, P=0.0288). However after adjustment for the effect of age, the differences in Killip classification, myocardial failure, cardiomegaly and mortality became insignificant.

Assessment of messenger RNA of beta 1-->4-N-acetylgalactosaminyl-transferase as a molecular marker for metastatic melanoma

Gangliosides GM2 [GalNAc beta 1-4(NeuAc alpha 2-3)Gal beta 1-4Glc beta 1-1Cer] and GD2 [GalNAc beta 1-4(NeuAc alpha 2-8NeuAc alpha 2-3)Gal beta 1-4Glc beta 1-1Cer] are cell surface tumor-associated antigens and have been demonstrated to be important markers of human malignant melanoma progression. Expression of these glycolipid antigens on melanoma tissues can be assessed by immunohistochemistry or biochemical analysis. These methodologies, however, are not logistically practical or sensitive for testing metastatic melanoma cells in blood or in tissue biopsies. In the present study, we hypothesized that the enzyme involved in GM2 and GD2 synthesis, beta 1-->4-N-acetylgalactosaminyltransferase (beta 1-->4GalNac-T), can be a useful marker for detection of occult metastatic melanoma. A reverse transcription PCR and Southern blot assay to detect beta 1-->4GalNac-T mRNA expression was developed. Beta 1-->4GalNac-T mRNA was detected in all 13 melanoma cell lines tested. Metastatic melanoma of lymph nodes and different organ sites expressed beta 1-->4GalNac-T mRNA at various levels. Detection sensitivity of the reverse transcription PCR assay was 1 ng of total RNA extracted from tumor specimens and approximately 5 melanoma cells in 20 million normal donor peripheral blood lymphocytes. In assessment of blood from 126 melanoma patients, beta 1-->4GalNac-T mRNA was more frequently found in advanced-stage melanomas and in patients showing more aggressive tumor progression. Normal donor blood samples (n = 37) were all negative for beta 1-->4GalNac-T mRNA expression. These results suggest that beta 1-->4GalNac-T mRNA is a promising molecular marker for detecting melanoma cells, characterizing antigen expression, and monitoring tumor progression.

Prognostic implications of p53 overexpression in cutaneous melanoma from sun-exposed and nonexposed sites

BACKGROUND

There is increasing evidence that mutations in the p53 tumor suppressor gene are among the most common genetic alterations in human malignancies. Because ultraviolet light can induce specific p53 mutations and is linked to the development of skin cancers, this study was done to determine the significance of p53 protein (p53p) overexpression in melanomas originating at different cutaneous sites varying in frequency of sunlight exposure.

METHODS

Sixty-three paraffin embedded primary and metastatic melanoma biopsy specimens from 61 patients were deparaffinized and stained with the mouse monoclonal antibody DO-1 to wild-type and mutant p53p. Twenty-eight specimens were from primary tumors and 35 specimens were from lymph node, subcutaneous, or visceral metastases. The chi-square test was used to assess the significance of p53p overexpression, and the Cox proportional hazards model was used to estimate the impact of p53p overexpression on survival.

RESULTS

Of the 61 patients studied, 37 had primary cutaneous melanomas arising on chronically sun-exposed head and neck sites, 12 patients on intermittently exposed extremity sites, and 12 patients on rarely exposed trunk sites. Thirteen of the 63 primary or metastatic specimens (21%) overexpressed p53p. Overexpression of p53p was not related to patient gender or age, anatomic site of the primary tumor, Clark level, or Breslow thickness. However, those patients with p53p positive primary tumors or metastases had significantly better survival than those determined to be negative for p53p overexpression (P = 0.045). The median survival was 152.4 months for p53p positive patients versus 55.7 months for p53p negative patients. The risk ratio of dying from melanoma was 0.32 for patients with tumor specimens overexpressing p53p.

CONCLUSIONS

In this study, p53p overexpression was infrequent in paraffin embedded melanoma specimens and independent of the primary melanoma's anatomic site. Although p53p overexpression was not related to other prognostic features of primary or metastatic lesions, it was associated with a significantly improved survival in this group of melanoma patients.

The LKLF transcription factor is required for normal tunica media formation and blood vessel stabilization during murine embryogenesis

The transcriptional programs that regulate blood vessel formation are largely unknown. In this paper, we examine the role of the zinc finger transcription factor LKLF in murine blood vessel morphogenesis and homeostasis. By in situ hybridization and immunohistochemistry, we show that LKLF is expressed as early as embryonic day 9.5 (E9.5) in vascular endothelial cells throughout the developing mouse embryo. To better understand the function of LKLF, we used homologous recombination in embryonic stem (ES) cells to generate LKLF-deficient (LKLF-/-) mice. Both angiogenesis and vasculogenesis were normal in the LKLF-/- mice. However, LKLF-/- embryos died between E12.5 and E14.5 from severe intra-embryonic and intra-amniotic hemorrhaging. This bleeding disorder was associated with specific defects in blood vessel morphology. Umbilical veins and arteries in the LKLF-/- embryos displayed an abnormally thin tunica media and aneurysmal dilatation before rupturing into the amniotic cavity. Similarly, vascular smooth muscle cells in the aortae from the LKLF-/- animals displayed a cuboidal morphology and failed to organize into a compact tunica media. Consistent with these findings, electron microscopic analyses demonstrated endothelial cell necrosis, significant reductions in the number of vessel-wall pericytes and differentiating smooth muscle cells, and decreased deposition of extracellular matrix in the LKLF-/- vessels. Despite these defects, in situ hybridization demonstrated normal expression of platelet-derived growth factor B, Tie1, Tie2, transforming growth factor beta, and heparin-binding epidermal growth factor in the vasculature of the LKLF-/- embryos. Therefore, LKLF defines a novel transcriptional pathway in which endothelial cells regulate the assembly of the vascular tunica media and concomitant vessel wall stabilization during mammalian embryogenesis.

LKLF: A transcriptional regulator of single-positive T cell quiescence and survival

Mature single-positive (SP) T lymphocytes enter a "resting" state in which they are proliferatively quiescent and relatively resistant to apoptosis. The molecular mechanisms regulating this quiescent phenotype were unknown. Here it was found that the expression of a Kruppel-like zinc finger transcription factor, lung Kruppel-like factor (LKLF), is developmentally induced during the maturation of SP quiescent T cells and rapidly extinguished after SP T cell activation. LKLF-deficient T cells produced by gene targeting had a spontaneously activated phenotype and died in the spleen and lymph nodes from Fas ligand-induced apoptosis. Thus, LKLF is required to program the quiescent state of SP T cells and to maintain their viability in the peripheral lymphoid organs and blood.

Angiotensinogen and angiotensin-I converting enzyme gene polymorphisms and the risk of coronary artery disease in Chinese

The homozygous deletion allele (DD) of the angiotensin-I converting enzyme (ACE) gene and the T235 homozygote of the angiotensinogen (AGT) gene have been reported to be correlated with an increased prevalence of coronary artery disease (CAD) and myocardial infarction (MI). The importance of the DD genotype and T235 homozygote as genetic risk factors for CAD in Chinese remains uncertain. This study included 426 patients who underwent coronary angiography and 180 healthy subjects without clinical evidence of CAD. Coronary angiography identified 268 patients with CAD (CAD group) and 158 patients without CAD. The healthy subjects and patients without angiographic evidence of CAD constituted the control group. Three polymorphisms were studied: an insertion/deletion (I/D) polymorphism of the ACE gene and the T174 M and M235T polymorphisms of the AGT gene. No association was found between any of the three studied polymorphisms and the risk of CAD or MI in Chinese using univariate or multivariate analysis. In multivariate analysis, the relative risks were 1.20 (95% confidence interval = 0.91-1.61, P = 0.20) for the DD genotype, 1.05 (95% CI = 0.82-1.35, P = 0.69) for the T174 homozygote, and 1.19 (95% CI = 0.91-1.55, P = 0.20) for the T235 homozygote. Similarly, no significant difference was found in the frequencies of the DD genotype and the T174 and T235 homozygotes between the control group, the CAD group, the non-MI group, and the MI group when analyzed according to sex, age, or degree of risk. Our data suggest that neither the DD genotype of the ACE I/D polymorphism nor the T174 and T235 homozygotes of the AGT gene confer significant risk for CAD or MI in Chinese.

GATA4 transcription factor is required for ventral morphogenesis and heart tube formation

Previous studies have suggested that the GATA4 transcription factor plays an important role in regulating mammalian cardiac development. In the studies described in this report we have used gene targeting to produce GATA4-deficient mice. Homozygous GATA4-deficient (GATA4-/-) mice died between 8.5 and 10.5 days post coitum (dpc). GATA4-/- embryos displayed severe defects in both rostral-to-caudal and lateral-to-ventral folding, which were reflected in a generalized disruption of the ventral body pattern. This resulted in the defective formation of an organized foregut and anterior intestinal pore, the failure to close both the amniotic cavity and yolk sac, and the uniform lack of a ventral pericardial cavity and heart tube. Analysis of cardiac development in the GATA4-/- mice demonstrated that these embryos developed splanchnic mesoderm, which differentiated into primitive cardiac myocytes that expressed contractile proteins. However, consistent with the observed defect in ventral morphogenesis, these GATA4-/- procardiomyocytes failed to migrate to the ventral midline to form a linear heart tube and instead formed aberrant cardiac structures in the anterior and dorsolateral regions of the embryo. The defect in ventral migration of the GATA4-/- procardiomyocytes was not cell intrinsic because GATA4-/- cardiac myocytes and endocardial cells populated the hearts of GATA4-/- -C57BL/6 chimeric mice. Taken together, these results demonstrated that GATA4 is not essential for the specification of the cardiac cell lineages. However, they define a critical role for GATA4 in regulating the rostral-to-caudal and lateral-to-ventral folding of the embryo that is needed for normal cardiac morphogenesis.

Similar time-dependent recovery property of fast and slow atrioventricular nodal pathways

The purpose of this study was to determine whether fast and slow atrioventricular (AV) nodal pathways have the same recovery property. AV nodal recovery property is studied by delivering atrial extrastimuli coupled to atrial beats and plotting nodal coupling intervals against nodal conduction time. In patients with dual pathways the resultant curves will include a fast to fast (F-F) and a fast to slow (F-S) pathway coupled curves. Although fast pathway recovery property can be represented by the former, slow pathway recovery property requires further assessment by studying slow to slow (S-S) pathways coupled curve. In 9 patients with dual pathways F-F, F-S, S-F, and S-S curves were obtained by pacing protocols. In 8 patients (control) without dual pathways, F-F curve and atrial extrastimuli coupled to a preceding slowly conducted fast pathway beat (also designated as S-F curve) were obtained. (1) The S-S curve had a similar time constant as the F-F curve. (2) Although the S-S curve was markedly shifted upward and leftward from the F-F curve, the degree of leftward and upward shifts of the S-S curve from the F-F curve were both close to the difference of the basic fast and slow pathway conduction time (a constant). (3) Although the effective refractory period of the fast pathway in dual pathway patients was longer than that of the control patients, the slow pathway effective refractory period when corrected was close to that of fast pathway in control patients. These results suggest that the fast and slow AV nodal pathways have a similar time-dependent recovery property.

Anticholinergic overdose induced torsade de pointes successfully treated with verapamil

An 18-year-old schizophrenic female was recently treated after overdosing on trihexyphenidyl, thioridazine and an unknown antidepressant. On presentation to a local hospital, she was cyanotic with dilatated pupils and in acute respiratory failure. She was intubated prior to transfer. While in our Emergency Department, she exhibited occasional premature ventricular contractions which later became intermittent torsade de pointes. As this was an anticholinergic overdose we infused sodium bicarbonate in an attempt to increase protein binding, hoping to decrease the concentration of toxic metabolites. We also tried to suppress the dysrhythmia by infusing magnesium. The potassium level was borderline low so a supplemental infusion was initiated. Defibrillation was attempted. To try to shorten the action potential duration by activating the K+ channel, an isuprel infusion was also attempted. All methods failed. The patient fluctuated between an irregular sinus rhythm with prolonged QT interval and pulseless torsade de pointes for almost 24 hours. At all times, she responded appropriately to pain. Finally we attempted blockade of the calcium channel using verapamil with dramatic results. Each single bolus (0.1 mg/kg) successfully converted the patient back to sinus rhythm for some 15-20 minutes before the torsade recurred. After the initiation of a continuous verapamil infusion (0.005 mg/kg/hr), the patient remained in stable sinus rhythm. Verapamil proved highly effective in this patient with an anticholinergic overdose induced dysrhythmia.

The G1691A mutation of the coagulation factor V gene (factor V Leiden) is rare in Chinese: an analysis of 618 individuals

To understand the allele frequency of the G1691A mutation of the coagulation factor V gene (factor V Leiden) in Chinese, 618 Chinese individuals, including 54 cases with venous thrombosis, were analyzed. Only one case in the control group was heterozygous for the 1691G allele and the 1691A allele. Our data suggest that the factor V Leiden is rare in Chinese.

Comparisons between female and male patients with mitral stenosis

OBJECTIVE

To compare Doppler, echocardiographic, and clinical variables in female and male patients with mitral stenosis.

DESIGN

Observational study in consecutive patients with mitral stenosis of cross sectional and Doppler echocardiographic and clinical variables and a retrospective search for a history of systemic embolism.

SETTING

A medical centre with 3000 beds, serving both urban and rural populations.

PATIENTS

500 consecutive patients with an echocardiographic mitral valve area of 2 cm2 or less. 331 (66.2%) were female and 169 (33.8%) male (mean (SD) ages of 49 (13) and 48 (14) respectively).

MAIN OUTCOME MEASURES

Mitral valve areas by echocardiographic planimetry and Doppler pressure half-time method, peak early diastolic mitral velocity and pressure gradient, echocardiographic score of mitral valve, left atrial end systolic diameter, frequency of left atrial thrombus and smoky echoes as well as various valve lesions detected with Doppler and echocardiography, cardiac rhythm, symptomatic functional class of heart failure, and history of systemic embolism.

RESULTS

The prevalence of significant tricuspid (22% v 9%, P < 0.001) and pulmonary regurgitation (5% v 1%, P = 0.018) was higher in the female patients than in the male patients. Female patients also had a higher peak regurgitant velocity (3.2 (0.7) v 2.9 (0.7) m/s, P = 0.007) and pressure gradient (41 (21) v 36 (19) mm Hg, P = 0.010) across the tricuspid valve. However, the male patients had a higher echocardiographic score (9.7 (2.4) v 7.0 (2.3), P < 0.001) and a smaller Doppler-derived mitral valve area (0.9 (0.4) v 1.0 (0.4) cm2, P = 0.027). There were no differences between the female and the male patients in mitral valve area measured by planimetry, peak early diastolic mitral velocity and pressure gradient, and left atrial end systolic diameter or in the prevalence of atrial fibrillation, left atrial thrombus, left atrial smoky echoes, significant aortic stenosis, aortic regurgitation, or heart failure of New York Heart Association class III or IV.

CONCLUSIONS

Female patients not only had a higher prevalence of mitral stenosis but also had a higher prevalence of associated tricuspid and pulmonary regurgitation along with a higher velocity and gradient of tricuspid regurgitation. The echocardiographic score was higher in male patients, however. These findings suggest that the pathophysiology of mitral stenosis is different in the two sexes and that gender should be taken into account when therapeutic strategies are formulated.

Living biosensors for the management and manipulation of microbial consortia

The increasing interest in microbial ecology has resulted in the creation of new tools for the study of complex microbial interactions. Bioreporter genes are particularly useful because they provide a means of determining gene activity. Most bioreporter genes utilize a biochemical assay requiring destructive sampling of the microbial consortium, but lux bioreporter genes produce visible light when active. The measurement of light is rapid, sensitive, and quantifiable, and background signal is usually absent. The usefulness of lux bioreporters is shown in several examples that demonstrate the unique attributes of this bioreporter. Despite some limitations, bioluminescence has proved to be a useful bioreporter under both laboratory and field conditions. Technological developments are discussed that have the potential to increase the number of bioreporter genes.

Noninvasive predictors of systemic embolism in mitral stenosis. An echocardiographic and clinical study of 500 patients

Few predictors of systemic embolism in patients with mitral stenosis have been identified by noninvasive methods. This study used the most powerful noninvasive diagnostic tool, transthoracic echocardiography, as well as other noninvasive clinical information to look for predictors. Five hundred consecutive patients with a mitral valve area of 2 cm2 or less were studied. They were divided into two groups: group 1 consisted of 143 patients with a history of systemic embolism and group 2 consisted of 357 patients with no history of systemic embolism. Using a stepwise logistic regression on a random subsample of 400 patients, 4 independent predictors were found: the presence of atrial fibrillation (p = 0.003, relative risk [RR] = 2.3, 95% CI = 1.3, 4.2), the absence of significant tricuspid regurgitation (p = 0.008, RR = 2.5, 95% CI = 1.3, 4.9), the absence of aortic regurgitation (p = 0.022, RR = 2.2, 95% CI = 1.1, 4.2), and the presence of left atrial smoky echoes (p = 0.039, RR = 1.7, 95% CI = 1.1, 3.0). When the above model, together with significant interaction terms, was applied to the remaining 100 patients, both the Hosmer-Lemeshow and Brown goodness-of-fit statistics were not significant (p = 0.888 and p = 0.248, respectively), indicating that the fit was adequate and the model was validated. Thus, important noninvasive predictors of systemic embolism in patients with mitral stenosis can easily be obtained. Subgroups of patients with high risk of systemic embolism can be identified. This may refine our therapeutic strategies to prevent the catastrophe of systemic embolism.

Effect of mitral regurgitation and aortic regurgitation on Doppler-derived mitral orifice area in patients with mitral stenosis

Traditional Doppler pressure half-time (T1/2) method (mitral valve area = 220/T1/2) is widely used for evaluating the mitral orifice area in patients with mitral stenosis (MS). However, the effect of mitral regurgitation (MR) and aortic regurgitation (AR) on the calculation of the mitral valve area by this method is still controversial. Therefore, we examined 493 consecutive patients with MS to evaluate the effect of MR and AR on Doppler-derived mitral orifice area. The mitral orifice area planimetered from two-dimensional echocardiogram was used as the standard reference. Excluding 16 patients with either unsatisfactory Doppler or echocardiographic tracings, 477 patients were enrolled in the study. There were 162 males and 315 females with a mean age of 49 years. They were divided into 4 groups: group A, 327 patients with MS but no MR and AR; group B, 68 patients with MS + MR but no AR; group C, 64 patients with MS + AR but no MR; group D, 18 patients with MS + MR + AR. The differences between echo and Doppler area were 0.02 +/- 0.02 cm2 (mean +/- SE), p = 0.220, in group A; 0.13 +/- 0.04 cm2, p = 0.004, in group B; 0.11 +/- 0.05 cm2, p = 0.026 in group C; and 0.31 +/- 0.08 cm2, p = 0.001, in group D. Thus, in patients with MS, the associated MR or AR may invalidate the pressure half-time method for the derivation of mitral valve area.

Diagnostic use of metoclopramide in hypertension caused by pheochromocytoma

We studied 5-mg metoclopramide provocation in six pheochromocytomatous patients with different tumor locations, varying secretory patterns and large tumor sizes (> 12 g or equivalently) and in 14 patients with essential hypertension as part of diagnostic work-up, usually after screening with vanillylmandelic acid assay by the colorimetric method. Antihypertensive medication continued in three and five patients, respectively. Despite similar basal blood pressures patients with pheochromocytomas developed more prominent pressor responses in five of six patients than the nonpheochromocytomatous patients (P < 0.01), most (10) of the latter with negligible pressor responses. Basal plasma catecholamines were higher in each of the pheochromocytomatous patients of different secretory patterns. Further rises after provocation were seen in all pheochromocytomatous patients except one with early pressor response, and also in one nonpheochromocytomatous patient. All tests were well tolerated. Thus, we concluded that the metoclopramide test based upon joint pressor response and plasma catecholamine response can be safely used in the diagnosis of pheochromocytoma. A less stringent protocol including a short drug-off preparatory period may be a warranted compromise between feasibility and diagnostic accuracy.

Imaging of multiple coronary artery fistulas to right ventricle by transthoracic and transesophageal echocardiography

A 20-year-old woman presented with extremely rare multiple coronary artery fistulas with left circumflex and right coronary arteries as the feeding vessels and two distinct sites of drainage into the posterior wall of the right ventricle near the apex in close proximity. The large left fistula was well depicted by transthoracic echocardiography, whereas the transesophageal approach better delineated part of the smaller right fistula.