[Cardiac amyloidosis]

In our experience, QS pattern of poor R wave progression and atrio-ventricular block of varying degrees on electrocardiogram, cardiomegaly with pleural effusion on chest X-ray film, left ventricular wall thickening, pericardial effusion and findings suggesting left ventricular diastolic dysfunction on echocardiogram and increased right ventricular end-diastolic pressure in cardiac catheterization were frequently observed in patients with cardiac amyloidosis. Though none of these findings are specific, we should suspect cardiac amyloidosis as a possibility when some of these signs are observed in patients with chronic cardiac failure of unknown etiology. Left ventricular mass obtained from echocardiography could be useful predictive parameter of prognosis in patients with cardiac amyloidosis.

Prognostic benefit in cytoreductive surgery for curatively unresectable hepatocellular carcinoma - comparison to transcatheter arterial chemoembolization

As a strategy for treating advanced hepatocellular carcinoma (HCC), cytoreductive surgery was studied comparing to transcatheter arterial chemoembolization (TACE). Patients who had curatively unresectable intrahepatic multiple HCC with the main tumor 30 mm or more in size were selected for this study. The patients were classified into two groups; i) cytoreductive surgery group (CRS group): 28 patients in whom the main tumor was resected but other cancer nodules remained in the remnant liver, ii) TACE group: 25 patients at Child A grade who underwent TACE, and in whom it was also evaluated retrospectively that the main tumor had been resectable. The cumulative 5-year survival rate was significantly higher in CRS (48.7%) than TACE (17.1%) group. Multivariate analysis revealed that performing cytoreductive surgery was a significant and independent factor to prolong survival. However, 6 of 28 patients died within one year of surgery. Residual tumor thrombus, and the absence or non-effectiveness of adjuvant therapy were significant high risk factors for postoperative death within one year. Conclusively, cytoreductive surgery contributes to a significant lengthening of survival in patients with advanced HCC. To reduce the risk of early postoperative death, the importance of postoperative adjuvant therapy is also recognized.

Palmaz-Schatz stent for hepatic artery stenosis during hepatic arterial infusion chemotherapy

Hepatic arterial infusion chemotherapy using an implantable port system was performed on a 40 year-old man with advanced hepatocellular carcinoma. When the in-dwelling catheter was inserted into the common hepatic artery (CHA), intimal dissection occurred as a result of the catheterization causing severe stenosis. On day 55 after intimal dissection, an in-dwelling Palmaz-Schatz stent was inserted after percutaneous transluminal angioplasty (PTA). CHA blood flow was shown to have improved on Digital subtraction angiography (DSA) and Doppler ultrasound after the in-dwelling Palmaz-Schatz stent. Thus a partial response was shown. The DSA from the implantable port system showed adequate patency 6 months after. This is the first report describing the usefulness of a Palmaz-Schatz stent for the severe stenosis of the CHA caused by the technique of catheterization.

Evaluation of curability and prediction of prognosis after surgical treatment for hepatocellular carcinoma by lens culinaris agglutinin-reactive alpha-fetoprotein

The clinical significance of serum lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3), which can distinguish between hepatocellular carcinoma and hepatitis by detecting a sugar chain micro heterogeneity, was evaluated for its possible ability to recognize previously undetectable residual tumors, and for increasing the accuracy of prognosis after surgical treatment for hepatocellular carcinoma. Serum lens culinaris agglutinin-reactive alpha-fetoprotein was measured pre- and post-operatively in 130 patients who underwent curative surgical treatment for hepatocellular carcinoma. The preoperative AFP-L3 positive rate was 35.4%. AFP-L3 remained positive postoperatively in 28 of the 46 preoperative AFP-L3 positive patients, and converted to positive in 4 of the 84 preoperative AFP-L3 negative patients. Regardless to preoperative AFP-L3, the postoperative AFP-L3 positive patients had a poorer recurrence-free rate (p<0.0001). The postoperative L3 positive patients had a high incidence of recurrence due to metastasis, but did not have recurrence due to multicentric origin. Multivariate analysis revealed that AFP-L3 (p<0.0001) was the most independently significant factor for predicting survival after surgery among several conventional prognostic factors. Thus, AFP-L3 is a valuable marker for evaluation of curability of surgical treatment and for improving the accuracy of prognosis.

[Assessment of localized hypertrophy in the basal part of the interventricular septum in the elderly]

The basal part of the interventricular septum (IVS) is known to show different hypertrophic features from those observed in the other parts of the left ventricular wall. These are considered to reflect physiological changes that occur with normal aging. However, these changes have not been carefully evaluated, and their clinical significance has not been defined. We assessed these changes echocardiographically. The subjects were patients at least 70 years of age in whom localized hypertrophy in the basal part of the IVS was seen during the whole cardiac cycle on echocardiography. The prevalence was 6.3% among 96 consecutively studied patients. All 6 patients had a history of hypertension. Echocardiographic findings were as follows: 1) the left atrium was mildly or moderately dilated, 2) there was no evidence of either dilatation or narrowing of the left ventricular cavity, 3) the left ventricular wall motion appeared normal and indices of systolic function were within normal limits in all subjects except one who had a history of myocardial infarction, 4) the angle formed by the aorta and the IVS averaged 106.7 degrees (range: 95 to 120 degrees), 5) Doppler examination showed increases in the ratio of the peak flow velocity during atrial systole to the peak flow velocity early in diastole, and 6) prolongation of the deceleration time of the flow velocity early in diastole. The last of these findings suggested left ventricular diastolic dysfunction, but peak flow velocity at the left ventricular outflow tract was normal. There was no evidence of stenosis of the left ventricular outflow tract. Localized hypertrophy in the basal part of the IVS in elderly patients could be a type of cardiac hypertrophy caused by hypertension. On echocardiography, the basal part of the IVS seemed to protrude toward the left ventricular cavity, but there was no evidence of stenosis in the left ventricular outflow tract.

Heart failure in 3 patients with acromegaly: echocardiographic assessment

We evaluated 3 patients with acromegaly who developed heart failure. Heart failure appeared to be due to acromegalic cardiomyopathy in 2 patients who did not have hypertension or evidence of coronary artery disease, and it was possibly due to acromegalic cardiomyopathy combined with familiar hypertrophic cardiomyopathy in 1 patient. The common echocardiographic findings in the present three cases were: 1) enlargement of the left atrium, 2) markedly dilated left ventricular cavity with diffuse hypokinesis, 3) decrease of indices of the left ventricular systolic function, and 4) no evidence of left ventricular hypertrophy. Echocardiographic findings in acromegaly with congestive heart failure resemble those of idiopathic dilated cardiomyopathy.

Beneficial effects of mechanical reperfusion therapy on left ventricular remodeling and late outcome following myocardial infarction

The long-term relative benefits of thrombolysis and mechanical reperfusion therapy following acute myocardial infarction (AMI) have not been established. The purpose of this study was to compare left ventricular function, left ventricular remodeling and late outcome after AMI for different reperfusion therapies. Thirty consecutive patients suffering their first anterior wall myocardial infarction with coronary stenoses limited to the left anterior descending coronary artery were studied. They included 10 patients who underwent intracoronary thrombolysis (ICT), 10 who underwent PTCA and 10 who underwent noninterventional medical treatment. All patients underwent coronary angiography (CAG) during the acute phase of AMI and also during the follow-up period, and left ventriculography during the follow-up period and clinical follow-up was performed (mean clinical follow-up period: 53 +/- 31 months). No significant difference in global ejection fraction was noted among the groups, although the end-diastolic volume index (EDVI) in the PTCA group (79.4 +/- 17.5 ml/m2) was significantly smaller than in the noninterventional (106.1 +/- 25.1 ml/m2) and ICT (107.9 +/- 28.3 ml/m2) group (p < 0.05). The regional wall motion index (RWMI) for the anterior region in the PTCA group (-2.7 +/- 0.8) was greater (p < 0.05) than in the noninterventional (-3.4 +/- 0.6) and ICT (-3.3 +/- 0.6) groups. A significant linear correlation was found between EDVI and % diameter stenosis and also between RWMI and % diameter stenosis following reperfusion (p = 0.01). There was no difference in the incidence of cardiac death, nonfatal reinfarction, bypass surgery or congestive heart failure among the groups. Disturbed left ventricular regional wall motion and remodeling benefit most from angioplasty because of prompt restoration of adequate blood flow. However, there was no difference in late outcomes following AMI among the three groups.

[Preoperative evaluation of the limitation of hepatic resection using 99mTc-GSA (galactosyl human serum albumin) scintigraphy]

Preoperative evaluation of the operative indication of hepatic resection using the parameters obtained by 99mTc-GSA scintigraphy has been done. In particular, the accurate evaluation of the postoperative hepatic functional reserve essentially depends on these parameters. In the present study, a preoperative evaluation of postoperative hepatic functional reserve using 99mTc-GSA scintigraphy was performed in our operated cases retrospectively.

PATIENTS AND METHODS

Thirty-eight patients who underwent hepatic resection were studied on 99mTc-GSA scintigraphy before and after operation. These patients were divided into two groups. Group A; had no postoperative complications (n = 31). Group B; had some postoperative complications (n = 7). Preoperative parameters of 99mTc-GSA liver scintigraphy (HH15, LU15) were calculated from the activities of liver and cardiac ROIs at 5 and 15 minutes after injection. The resection ratio (RR) was obtained by comparing the liver volumes which were calculated from the pre- and postoperative SPECT studies. The resectability indices (Res) were as follows: Res (LU15) = LU15 x (100-RR(%)/100, Res (HH15) = (1/HH15) x (100-RR (%)/100.

RESULTS

There were statistically significant differences in the distribution of Res between A and B groups (p = 0.002, Mann-Whitney test). The values of Res, of which half of patients have complication, were 1.10 (Res (HH15)) and 16.4 (Res (LU15)).

CONCLUSION

The resectability indices using 99mTc-GSA liver scintigraphy are useful for the preoperative evaluation of the limitation of hepatic resection.

Plasmapheresis in the treatment of rapidly progressive glomerulonephritis

The present study was carried out to examine the efficacy of plasma exchange in patients with rapidly progressive glomerulonephritis (RPGN). Seventeen patients with RPGN were treated with plasmapheresis as adjunct to immunosuppressive therapy. Of these, 4 had antiglomerular basement membrane (GBM) antibody-mediated glomerulonephritis (GN), 8 had immune-complex GN (5 SLE, 2 HSP, 1 cryoblobulinemia), 5 had pauci-immune GN (3 peripheral antineutrophil cytoplasmic antibody [P-ANCA], 1 cytoplasmic antineutrophil cytoplasmic antibody [C-ANCA], 1 other). Treatment of 10 of these patients with plasmapheresis within the first month of disease onset resulted in a stable renal function for a period extending from 1 to 3 years, except in 2 patients who had high baseline levels of serum creatinine. In the remaining patients, 2 were treated with hemodialysis 6 years later at the end of follow-up. We conclude that plasmapheresis, when used in combination with immunosuppressive drugs, is beneficial, leading to improved renal function.

[Successful direct percutaneous transluminal coronary angioplasty in a 91-year-old male with acute myocardial infarction complicating cardiogenic shock]

A 91-year-old male patient was admitted to hospital with acute myocardial infarction complicating cardiogenic shock. An emergency coronary arteriogram showed 99% stenosis at the mid-section of the right coronary artery, and in order to achieve an early recovery direct percutaneous transluminal angioplasty (PTCA) was performed through the brachial artery using a 6 french catheter. The lesion was successfully dilated up to 25% residual stenosis. Hypointention had been sustained during the admission; however, it gradually improved and he was discharged on the 31st hospital day. He has been followed up for 6 months after discharge at the out-patient clinic and has not recurrent ischemic episodes. According to other reports on the use of direct PTCA in the elderly, the postdischarge mortality rate is lower than that with medical therapy or thrombolysis. When cardiogenic shock occurs even in the elderly, direct PTCA should be selected as the first choice of treatment.

A randomized trial of aspirin versus cilostazol therapy after successful coronary stent implantation

Percutaneous transluminal coronary angioplasty (PTCA) is widely used to treat patients with ischemic heart disease, but the procedure involves a number of problems, including acute coronary occlusion and restenosis. Although stents have proved useful for preventing post-PTCA restenosis, especially elastic recoil during the acute phase, no method has yet been established to prevent restenosis caused by vascular smooth muscle cell proliferation in the late phase. Cilostazol selectively inhibits the 3'5'-cyclic-nucleotide phosphodiesterase (PDE) III (cyclic guanosine monophosphate-inhibited PDE) of the cyclic adenosine monophosphate PDE family; it also has antithrombotic and vasodilating effects, as well as an inhibitory effect on vascular smooth muscle cell proliferation through PDE III inhibition. From November 1995 to March 1997, the usefulness of cilostazol versus aspirin in preventing subacute thrombosis and restenosis was studied in 70 patients (55 men and 15 women; 82 total lesions) who had undergone successful elective Palmaz-Schatz stent implantation. Patients were randomly allocated to receive aspirin 81 mg/d (40 patients with 45 lesions) or cilostazol 200 mg/d (30 patients with 37 lesions) alone. There was no difference in patients or angiographic characteristics between these groups. No subacute thrombosis, acute complications (ie, death, emergent coronary artery bypass grafting, or hemorrhagic complications), or drug side effects were found in the cilostazol group. The minimal lumen diameter (mean +/- SD) at follow-up was 1.89 +/- 1.08 mm in the aspirin group (41 lesions, 5.63 +/- 1.74 months after stent implantation) and 2.34 +/- 0.74 mm in the cilostazol group (35 lesions, 5.14 +/- 1.91 months after stent implantation), revealing statistically significant dilatation in the cilostazol group. The restenosis rate was 26.8% in the aspirin group, compared with 8.6% in the cilostazol group; this difference was statistically significant. Administration of cilostazol alone after the implantation of intracoronary Palmaz-Schatz stents was useful for the prevention of subacute thrombosis and restenosis.

Influence of exercise on QT dispersion in ischemic heart disease

QT dispersion (QTd: maximum QT interval-minimum QT interval) is associated with severe cardiac arrhythmia and with abnormal ventricular repolarization. We investigated the influence of exercise on QTd in patients with ischemic heart disease. On standard 12-lead electrocardiograms, QTd was measured before and after treadmill exercise in 7 normal subjects, 17 patients with effort angina pectoris (and > or = 75% stenosis on coronary arteriography), and 33 patients with old myocardial infarction. Bazett's formula was used to obtain the corrected QTd (QTcd). The pre-exercise resting QTcd was 45.9 +/- 10.6, 44.3 +/- 15.2, and 74.8 +/- 28.1 msec in the respective groups, being significantly greater in the infarct group (p < 0.05). The QTcd at 5 min after exercise was respectively 49.3 +/- 9.0, 58.8 +/- 19.9, and 75.4 +/- 30.9 msec (p = 0.0347, infarct vs. controls). The difference in QTcd was significant for the angina group before and after physical exercise (p = 0.0003). There was a significant increase of QTcd after exercise in the angina group whether or not the patients were receiving beta-blockers. The infarct patients without beta-blocker therapy showed an increase of QTcd after exercise, while those receiving beta-blockers showed a decrease. The post-exercise difference between these subgroups was significant (p = 0.0351).

CONCLUSIONS

QTcd was significantly increased by exercise in the angina group, possibly reflecting impaired repolarization due to ischemia. Inhibition of the increase in QTd by beta-blockers suggested a possible preventive effect on severe arrhythmias due to nonhomogeneous ventricular repolarization.

[Benefit of monitoring the level of blood flecainide acetate in an elderly patient with ventricular premature contractions]

A 67-year-old woman without organic heart, disease had symptomatic ventricular premature contractions. Because class Ia, Ib and IV antiarrhythmic drugs did not prevent the premature contractions, the patient was treated with flecainide acetate at a dose of 50 mg t.i.d. Adverse reactions were noted. After measurement of the blood drug level, the dose was reduced to 50 mg b.i.d. The adverse reactions disappeared, and the arrhythmia was controlled. Flecainide acetate has a relatively long blood elimination half-life and a narrow safety margin. When some antiarrhythmic drugs are used in elderly patients, blood drug level monitoring is useful in preventing adverse reactions and in designing appropriate therapy.

[Examination of scanning technique for lung cancer screening with helical CT]

As a new application of helical CT scanning we evaluated the parameters for lung cancer screening with an extremely low doses and large helical pitch. On the phantom studies, the image quality obtained with the low dose parameter was not inferior to that of the usual screening technique but artifacts were increased with the large helical pitch. A scanning technique using 120 kv, 40-60mA, 10mmth, 20mm/ sec, and a reconstruction pitch of 2 was used for lung cancer screening (screening parameters) (50 cases), and comparison was made between the detectability of the screening parameters and the routine parameters (120 kv, 200mA, 10mmth, 10-13mm/sec, and a reconstruction pitch of 1-1.3). Detectability with the screening parameters was as follows: nodular lesions (< 5mm in size: 76%. 5-10mm: 90-93% 10mm < 100%), linear lesions: 94-95%, infiltrations: 93-100%. There were no false negative lesions, when the reconstruction pitch of the screening parameters was changed from 1 to 0.25. In conclusion, reconstruction pitch had the most influence on lesion detectability.

[Usefulness of continuous arterial infusion chemotherapy for post operative multiple recurrence and residual hepatocellular carcinoma]

Twenty five patients with postoperative multiple recurrence and residual hepatocellular carcinoma received continuous arterial infusion of CDDP and 5-FU via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days as one course, and 4 courses were basally administered. The efficacy rate was 60%, and there were 7 (28%) CR (complete response) cases. The survival rate was 76.0% for 1 year and 36.5% for 3 years, which is a favorable result considering their advanced stage. Thus, this treatment seemed to be effective for multiple hepatocellular carcinoma.

Assessment of posterior aortic wall motion using echocardiogram in patients with atrial fibrillation

BACKGROUND AND HYPOTHESIS

Noninvasive evaluation of left ventricular (LV) diastolic function was performed on 12 patients with atrial fibrillation (AF) using posterior aortic wall echocardiogram and a parameter for determining the optimal heart rate in patients with chronic atrial fibrillation was considered.

METHODS

Subjects were divided into two groups; one with no underlying cardiac disease (AF only group; n = 7) and the other with dilated cardiomyopathy (DCM group; n = 5). Left atrial emptying index (LAEI) obtained from the posterior aortic wall echocardiogram was used as the parameter of LV diastolic function, and R-R interval-LAEI relation and minimum R-R interval showing LAEI = 1.0 were investigated and compared between the two groups.

RESULTS

There was a good correlation between R-R interval and LAEI until LAEI of 1.0 was obtained in all patients. Slope of the regression line was significantly steeper in the AF only group than in the DCM group, and minimum R-R interval showing LAEI = 1.0 was significantly shorter in the AF only group.

CONCLUSION

Assessment of R-R interval-LAEI relation was useful for the noninvasive evaluation of LV diastolic function, and this parameter could be used for clinical application to determine the optimal heart rate in atrial fibrillation.

[The study of continuous arterial infusion chemotherapy with CDDP and 5-FU in patients with hepatocellular carcinoma]

Between Feb. 1992 and April in 1995, 22 patients with hepatocellular carcinoma (10, recurrence; 12, unresectable) received continuous arterial infusion of CDDP and 5-FU via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days as one course, and 4 courses were basally administered. Patients were divided into 2 groups (6 hours group and 24 hours group) according to the duration of the administration of 5-FU. There were no differences in efficacy rate between the 2 groups (6 hours group, 64%; 24 hours group, 62.5%), but CR (complete response) cases appeared in only the 6 hours group. There were no severe side effects in the 2 groups, but systemic side effects appeared in 6 hours group more often than in 24 hours group. Only in the 24 hours group, 2 patients had the narrowing and obstruction of hepatic artery which was suggested to be caused by intimal injury due to continuous administration of 5-FU. Continuous arterial infusion chemotherapy with CDDP and 5-FU seemed to be effective. Further study on adequate time and volume of administration including pharmacokinetics is needed to enhance the clinical effectiveness of continuous arterial infusion of CDDP and 5-FU.

[CT finding of right diaphragmatic rupture due to blunt trauma--subhepatic hemothorax]

Owing to the poor detectability of the anatomic location of diaphragm on the parallel plane of computed tomography (CT), capability of CT to predict traumatic ruptured diaphragm has been debated in several reports. A specific hematoma (subhepatic hemothorax) adjacent to the posterior attachment of the right diaphragm was identified on CT. The finding originated from herniated liver that migrated to the posterior thoracic wall as a result of gravity, to separate the hemothorax in the supine position. This was surgically proven in two patients after blunt traumatic accident. The finding is useful in predicting right diaphragmatic rupture on CT study. The formation of subhepatic hemothorax, its differential diagnosis and a brief review of diaphragmatic rupture are discussed.

A case of right atrial mobile thrombus complicating multiple pulmonary emboli

Right atrial thrombi are usually immobile. However, a mobile type mimicking a cardiac tumor, especially myxoma, has been described on rare occasions. We report here a case of atrial thrombus which was mobile in the cardiac chambers. A 29-year-old male was admitted because of exertional dyspnea. On admission, his echocardiogram showed an abnormal mass in the right atrium with a stalk attached to the interatrial septum. It decreased in size on the next day. On the fourth day of admission, it moved to the right ventricle. Multiple pulmonary emboli were revealed by the lung perfusion scintigram. Two days after the administration of intravenous urokinase, the abnormal mass in the cardiac chambers was no longer seen on the echocardiogram. This was a rare case of mobile atrial thrombus associated with multiple pulmonary emboli. Thrombolytic therapy appeared to be effective in this case.

Müllerian duct cyst: ultrasonographic and computed tomographic spectrum

A Müllerian duct cyst (MDC) is the persistent remnant of the Müllerian duct. Reports of symptomatic cases are rare, signs and symptoms include perineal pain, dysuria, infertility, hematuria and genital inflammation. The prevalence of MDC has been previously reported as 4% of newborns and 1% in adult males. Herein we report six cases encountered in the past year. Our detection percentage was 1% and is compatible with the reported values. The imaging evaluation of symptomatic and asymptomatic patients with MDC is discussed as well as the apparent discrepancy between the number of previously reported cases and the reported prevalence.

[A case of myelolipoma originating from bilateral adrenal glands; a comparison of CT and pathological findings]

We experienced a case of bilateral retroperitoneal tumor incidentally on CT which was carried out on suspicion of either cholelithiasis or choledocholithiasis. In company with other radiologic studies, US, angiography etc. we were able to make a correct diagnosis of adrenal myelolipoma preoperatively. Among these studies, CT coincided well with the structure of pathological findings and is thus the most powerful method for the diagnosis of myelolipoma. The case was discussed in addition to the studies of other literatures.