A case of insufficient sleep syndrome

All night polysomnographic evaluation (PSG) soon after admission and at the late period of admission revealed an atypically high sleep efficiency and a prolonged total sleep time. Sleep onset latency and distribution of REM and NREM sleep stages were like those of normal sleepers. On REM latency, while it was remarkably reduced (25.0 min) soon after admission and sleep onset REM period (SOREMP) was found, at the late period of admission it was prolonged and SOREMP was not found. Giving multiple sleep latency test with polysomnography, soon after admission subjective excessive daytime sleepiness had already improved and mean sleep latency (13.2 min) was within normal range. However, SOREMP appeared twice in five tests. We considered that the appearance at the early period of admission was the result of REM pressure growing.

In vitro and in vivo evidence for high frequency of I-Ab-reactive CD4+ T cells in HLA-DQ or HLA-DRA transgenic mice lacking endogenous MHC class I and/or class II expression

Although T cells are educated to recognize foreign antigenic peptides in the context of self MHC molecules during their development in the thymus, peripheral T cells also recognize allo- and xeno-MHC molecules. The lower frequency of xeno-MHC-reactive T cells than that of allo-MHC-reactive T cells is often explained by the difference in the degree of homology between xeno- or allo-MHC and self MHC molecules, as well as by the species barrier of the molecules involved in immune recognition. To distinguish these two possibilities, we estimated the frequency of I-Ab-reactive CD4+ T cells selected by HLA-DQ or DR alpha E beta b molecules, using HLA-DQ6 and HLA-DRA transgenic C57BL/6 (B6) mice lacking endogenous MHC class I and/or class II molecules (DQ6A0/0 and DR alpha 30A0/0 beta 20/0). CD4+ lymph node T cells from DQ6A0/0 and DR alpha 30A0/0 beta 20/0 showed the strong proliferative response to I-Ab molecules. In addition, DQ6A0/0 and DR alpha 30A0/0 beta 20/0 rejected the skin graft from mice expressing I-Ab molecules irrespective of MHC class I expression, indicating that the CD4+ T cells recognizing I-Ab molecules are directly involved in this rejection. The estimated frequency of I-Ab-reactive CD4(+)CD8- thymocytes in DR alpha 30A0/0 beta 20/0 and DQ6A0/0 was comparable with that observed in the MHC class II-disparate strains. Our findings thus indicate that CD4+ T cells selected to mature on xeno-MHC class II molecules such as HLA-DQ6 or DR alpha E beta b, when these molecules are expressed in mice, recognize I-Ab molecules as allo-MHC class II, despite the less structural homology.

In vitro and in vivo evidence for high frequency of I-Ab-reactive CD4+ T cells in HLA-DQ or HLA-DRA transgenic mice lacking endogenous MHC class I and/or class II expression

Although T cells are educated to recognize foreign antigenic peptides in the context of self MHC molecules during their development in the thymus, peripheral T cells also recognize allo- and xeno-MHC molecules. The lower frequency of xeno-MHC-reactive T cells than that of allo-MHC-reactive T cells is often explained by the difference in the degree of homology between xeno- or allo-MHC and self MHC molecules, as well as by the species barrier of the molecules involved in immune recognition. To distinguish these two possibilities, we estimated the frequency of I-Ab-reactive CD4+ T cells selected by HLA-DQ or DR alpha E beta b molecules, using HLA-DQ6 and HLA-DRA transgenic C57BL/6 (B6) mice lacking endogenous MHC class I and/or class II molecules (DQ6A0/0 and DR alpha 30A0/0 beta 20/0). CD4+ lymph node T cells from DQ6A0/0 and DR alpha 30A0/0 beta 20/0 showed the strong proliferative response to I-Ab molecules. In addition, DQ6A0/0 and DR alpha 30A0/0 beta 20/0 rejected the skin graft from mice expressing I-Ab molecules irrespective of MHC class I expression, indicating that the CD4+ T cells recognizing I-Ab molecules are directly involved in this rejection. The estimated frequency of I-Ab-reactive CD4(+)CD8- thymocytes in DR alpha 30A0/0 beta 20/0 and DQ6A0/0 was comparable with that observed in the MHC class II-disparate strains. Our findings thus indicate that CD4+ T cells selected to mature on xeno-MHC class II molecules such as HLA-DQ6 or DR alpha E beta b, when these molecules are expressed in mice, recognize I-Ab molecules as allo-MHC class II, despite the less structural homology.

Localised thrombus in the distal aortic arch: its aetiology analysed by three-dimensional mould model of the thoracic aorta

Isolated thrombus of the thoracic aorta without aneurysmal change or dissection is a relatively rare event. A case presenting with aortic thrombus and successive distal embolism is reported herein and the aetiology of the thrombus of the distal aortic arch is analysed by a three dimensional aortic model. A 61-year-old man suffered acute ischaemia in his right leg on January 26, 1994. Enhanced computed tomography (CT) showed a localized thrombus in the distal aortic arch expanding towards the descending aorta, and partial infarction of the left kidney and the spleen. Angiography demonstrated abrupt occlusion of the right superficial femoral artery. Immediate anticoagulation with heparin and coumadin was administered, and the thrombus in the aorta disappeared following 1 month of this medical treatment, leaving the renal and splenic infarction unchanged. The unresolved occlusion of the superficial femoral artery and the popliteal artery was treated with a bypass from the right superficial femoral artery to the peroneal artery using a reversed saphenous vein graft. The mould model of the thoracic aorta was reconstructed from CT, and the thrombus was found to be at the most distal and medial site of the lesser curvature of the aortic arch. This specific location is referred mostly as the site for thrombus formation in the literature. The case is reported briefly and the risk of this specific region of the thoracic aorta for thrombus formation is discussed using this mold model.

Positive and negative CD4+ thymocyte selection by a single MHC class II/peptide ligand affected by its expression level in the thymus

The central event in thymic selection of T cells bearing alpha beta TCRs is their interaction with self-peptides bound to self-MHC molecules. With the use of transgenic mouse lines expressing a single peptide/MHC class II complex, we show that CD4+ T cells with the preferential usage of particular TCR V(alpha)s and V(beta)s were selected to mature on this complex in lines with the lower expression, whereas such CD4+ T cells were eliminated in the thymus in a line with the relatively high expression. When a low expressing line was crossed with a high expressing line, the frequency of CD4+ T cells selected by this complex markedly decreased. Thus, these results suggest that a single peptide/MHC class II complex, being affected by its cell surface density in the thymus, can serve as both positively and negatively selecting ligand in vivo.

[Two cases of annulo-aortic ectasia with type A aortic dissection reconstructed by reimplantation of the aortic valve]

We performed aortic valve sparing operation in two cases of annulo-aortic ectasia combined with Type A aortic dissection. Marfan syndrome was found in one case and the dissection was acutely evolving in another case. The aortic valves were observed as normal configuration in both cases and then reimplanted within the synthetic grafts along with the David's procedure. No aortic regurgitation was found in the acute case but slight regurgitation was checked out in the Marfan case at the discharge. The aortic valve preserving operation for annulo-aortic ectasia was considered much effective in cases with aortic dissection in order to expect the thrombolization in the pseudo lumen.

Delayed manifestation of aortic stenosis after blunt abdominal trauma: report of a case

Delayed manifestation of aortic stenosis caused by abdominal blunt trauma is rare. We report herein the case of a 67-year-old man who was taken to a nearby hospital after being crushed between a heavy truck and a wall. An emergency laparotomy was performed, revealing only a mesenteric tear which was repaired. He was discharged after an uneventful postoperative course; however, 1 month later he began to experience intermittent claudication, and presented to our hospital in December 1994, 1 year after the first operation. Angiography and enhanced computed tomography (CT) demonstrated infrarenal abdominal aortic dilatation with distal stenosis. Both the dilated and stenotic lesions were resected and bypass surgery ws performed. Pathologic examination demonstrated that the intima had been lacerated circumferentially and everted distally, causing the aortic stenosis. To our knowledge, this is the first case of the delayed manifestation of traumatic aortic stenosis to be documented in Japan. The etiology of this rare complication of blunt trauma is described in this report.

Requirement of calcium influx for hydrolytic action of membrane phospholipids by cytosolic phospholipase A2 rather than mitogen-activated protein kinase activation in Fc epsilon RI-stimulated rat peritoneal mast cells

The mechanism by which cytosolic phospholipase A2 (cPLA2) is not responsible for eicosanoid production in rat peritoneal mast cells upon antigen stimulation [Ishimoto et al. (1996) J. Biochem. 120, 616-623] was investigated in the mast cells stimulated by cross-linking of the IgE receptor or with thapsigargin. Stimulation with thapsigargin, but not with antigen, resulted in apparent lysophosphatidylcholine (lysoPC) formation. Antigen stimulation significantly increased the activities of mitogen-activated protein (MAP) kinase and cPLA2. These activities were further potentiated by phorbol ester. The antigen elicited a rapid and transient increase in intracellular Ca2+ concentration, while thapsigargin produced a slow and sustained increase. Furthermore, a combination of antigen and thapsigargin rapidly increased and prolonged the intracellular Ca2+ concentration. Under these conditions, lysoPC was apparently generated, whereas it was not in response to antigen alone. These results suggest that a prolonged increase in the intracellular Ca2+ concentration is required for cPLA2 to associate with membranes, thus leading to hydrolysis of membrane phospholipids by the enzyme.

Importance of the phospholipase D-initiated sequential pathway for arachidonic acid release and prostaglandin D2 generation by rat peritoneal mast cells

The association of prostaglandin D2 (PGD2) production as well as arachidonic acid release with the phospholipase D (PLD)-linked mechanism was studied in rat peritoneal mast cells. Stimulation of mast cells with cross-linking of the high-affinity Fc receptor for IgE caused increases in the release of arachidonic acid and PGD2, which are suppressed almost completely by ethanol or RHC 80267, a diacylglycerol lipase inhibitor. Ethanol did not influence inositol phosphate release in response to an antigen. An increase in diacylglycerol, that is inhibited by propranolol, was observed, with a peak within 1 min. Antigen stimulation induced little production of lysophosphatidylcholine, while ionomycin as a control markedly induced the production. However, the phospholipase A2 (PLA2) activity in the cytosol of antigen-stimulated cells increased to the level in ionomycin-stimulated cells. The addition of the ADP-ribosylation factor-containing fraction prepared from bovine brain, that is known to specifically activate PLD, to permeabilized mast cells in the presence of GTP gamma S, apparently increased arachidonic acid and PGD2 release, but not in the presence of ethanol. Furthermore, arachidonic acid release by an antigen was enhanced by melittin, that activates PLA2, but PGD2 production was not. These results suggest that antigen-stimulated PGD2 production as well as arachidonic acid release are strongly associated with the sequential PLD-linked pathway.

Effects of enalapril on left ventricular mass and diastolic function in essential hypertension: special reference to duration of hypertension

Using M-mode and pulsed Doppler echocardiography, the effects of enalapril on left ventricular (LV) hypertrophy and diastolic dysfunction in essential hypertension and the relation between improvement in these two parameters and duration of hypertension were evaluated. The subjects, 30 previously untreated hypertensive patients, were divided into nonhypertrophy (18 patients) and hypertrophy (12 patients) groups. All patients received enalapril at a daily dose of 5 to 10 mg for 6 months. Left ventricular mass by M-mode echocardiography and LV inflow (LVIF) velocity by transthoracic pulsed Doppler echocardiography were measured before and after enalapril therapy. In the nonhypertrophy group, enalapril significantly increased peak early diastolic LVIF (E) velocity (P < .05), slightly lowered peak atrial systolic LVIF (A) velocity, significantly decreased their ratio (A/E) (P < .01), and significantly shortened both the deceleration time, from the peak of the early diastolic wave, and isovolumic relaxation time (P < .05 and P < .01, respectively). In the hypertrophy group, enalapril significantly increased E (P < .05), slightly lowered A, significantly decreased A/E (P < .05), slightly shortened the deceleration time and isovolumic relaxation time, and slightly decreased LV mass. The administration of enalapril correlated significantly and positively with the duration of hypertension and the rates of change in A/E and LV mass in all of the hypertensive patients (P < .01 and P < .05, respectively). These results suggest that long-term administration of enalapril to hypertensive patients improves LV diastolic hemodynamics regardless of the presence or absence of LV hypertrophy and that the effects are most remarkable in patients with the shortest duration of hypertension.

Effect of berbamine on cytosolic phospholipase A2 activation in rabbit platelets

The effect of berbamine, a biscoclaurine alkaloid, on cytosolic phospholipase A2 activation in rabbit platelets was investigated. Berbamine inhibited arachidonic acid liberation induced by thrombin but not that by ionomycin. The alkaloid did not affect thrombin-stimulated Ca2+ mobilization. Ca(2+)-dependent translocation of cytosolic phospholipase A2 to membranes, or the activity of partially purified cytosolic phospholipase A2. Furthermore, berbamine had no effect on the thrombin-elicited increase in cytosolic phospholipase A2 activity. However, berbamine suppressed arachidonic acid liberation in platelets stimulated with GTP-binding protein activators. Although incubation of platelet membranes with a GTP analogue decreased the islet-activating protein-catalyzed ADP-ribosylation of an approximately 40 kDa protein in the membranes, pretreatment of the membranes with berbamine did not influence the decrease in ADP-ribosylation. These results suggest that berbamine may impair GTP-binding protein-mediated activation of cytosolic phospholipase A2, probably without influencing the enzyme translocation to membranes or the increase in the enzyme activity, and thus may cause the suppression of thrombin-induced arachidonic acid liberation.

Contribution of phospholipases A2 and D to arachidonic acid liberation and prostaglandin D2 formation with increase in intracellular Ca2+ concentration in rat peritoneal mast cells

The contribution of phospholipases A2 (PLA2) and D (PLD) activation to arachidonic acid liberation and prostaglandin D2 (PGD2) formation was studied in stimulated rat peritoneal mast cells. Stimulation of the cells with ionomycin induced time-dependent and Ca(2+)-concentration-dependent increase in arachidonic acid liberation and PGD2 formation, and the Ca(2+)-dependent increase was especially remarkable at extracellular Ca2+ concentration higher than 200 microM. Staurosporine did not induce any effect on the arachidonic acid liberation, indicating that protein kinase C is not involved in the liberation. Addition of ethanol to the cells decreased the ionomycin-stimulated arachidonic acid liberation to 40% of the control, while it decreased the PGD2 formation almost completely, with the increase in phosphatidylethanol formation. Propranolol, a phosphatidate phosphohydrolase inhibitor, caused similar effects. p-Bromophenacyl bromide, a PLA2 inhibitor, inhibited partially the arachidonic acid liberation. The inhibition of the liberation by combination of p-bromophenacyl bromide and ethanol was additive and reached approximately 90%. Under the conditions used p-bromophenacyl bromide did not influence significantly the PLD activity assessed by the phosphatidylethanol formation. Histamine release was decreased by ethanol treatment to 35% of the control. These results suggest that more than half of the total arachidonic acid liberation is mediated by the sequential pathway of PLD/phosphatidate phosphohydrolase/diacylglycerol lipase and more than half of histamine release is also dependent on PLD activation, while the PGD2 formation is fully mediated by the pathway. PLA2 also contributes to arachidonic acid liberation but to a lower extent.

Selective infiltration of B cells committed to the production of monoreactive rheumatoid factor in synovial tissue of patients with rheumatoid arthritis

B cells were directly cloned using EBV transformation fron the synovial tissue of patients with rheumatoid arthritis (RA), the objective being to investigate the B cell repertoire at the site of inflammation. The frequency of clones producing antibodies with rheumatoid factor (RF) activity was approximately 10% in those from the RA synovial tissue. Similar percentages of B cell clones from the peripheral blood of both RA patients and healthy controls also produced RF. However, almost all of these clones from the peripheral blood produced RF reactive not only with rabbit IgG or human IgG Fc but also with several other antigens (polyreactive). Only one of 654 clones (0.15%) from the RA peripheral blood produced RF specific to rabbit IgG or human IgG Fc (monoreactive). On the other hand, the frequency of clones producing monoreactive RF was approximately 30 times higher in RA synovial tissue. Furthermore, these B cells were activated in vivo to produce antibodies, since monoreactive RF was spontaneously produced from synovial tissue cells without the addition of B cell stimulators. No clones producing monoreactive RF were obtained from the synovial tissue of patients with osteoarthritis. These results suggest selective infiltration and/or proliferation of B cells committed to the production of monoreactive RF in RA synovial tissue.

Enhancement of phospholipase A2 activation by phosphatidic acid endogenously formed through phospholipase D action in rat peritoneal mast cell

Contribution of phosphatidic acid (PA) generated by activated phospholipase (PL) D to PLA2 activation was studied in rat peritoneal mast cells. Exogenous didecanoyl PA induced arachidonate liberation in the permeabilized cells which was inhibited by p-bromophenacyl bromide. Upon exposure of the cells to ethanol in a high enough concentration to prevent PA formation, A23187-induced arachidonate liberation was suppressed by 50% and the rest was completely inhibited by p-bromophenacyl bromide. In contrast, propranolol, which enhanced PA accumulation, significantly increased the arachidonate liberation. These results suggest that A23187-induced PLA2 activation may be potentiated, at least in part, by PA generated through PLD action.

Role of superoxide dismutase in resistance of Porphyromonas gingivalis to killing by polymorphonuclear leukocytes

Porphyromonas gingivalis in which the synthesis of superoxide dismutase (SOD) was induced by nitrate or by aeration was rendered resistant to killing by polymorphonuclear leukocytes. SOD purified from either anaerobically maintained or aerated cells also inhibited bacterial killing when added exogenously, and no difference between the effects of the two SODs was observed. These results suggest that SOD may form part of a defense mechanism that helps protect P. gingivalis against killing by polymorphonuclear leukocytes.

Induction of signet ring cell carcinomas in X-irradiated hypocatalasemic mice (C3H/Cbs)

The stomach region of hypocatalasemic mice of both sexes was X-irradiated once with a dose of 20 Gy. Thirteen months after the irradiation, 3 out of 13 (20%) males and 2 out of 9 (15%) females were observed to have developed signet ring cell carcinomas in the glandular stomach. This finding was statistically significant (P less than 0.01 in males and P less than 0.05 in females) compared to a total absence of similar tumors in the non-irradiated controls. Local invasion of malignant tumors into muscle and subserosal layers was observed, but no metastatic tumors were found in distant organs.

Epidermolysis bullosa atrophicans generalisata mitis--report of a case with renal dysfunction

A male adult epidermolysis bullosa atrophicans generalisata mitis (EBAGM) patient with renal dysfunction is described. The abnormal urological findings were improved together and healing of the generalized skin erosions occurred. To our best knowledge, he is the 3rd EBAGM patient with urological abnormalities in the world.

[Diastolic right ventricular hemodynamics in right ventricular overloads assessed by pulsed Doppler echocardiography]

To assess right ventricular (RV) filling dynamics, RV inflow velocity patterns of pulsed Doppler echocardiograms and jugular pulse tracings were analyzed in 59 patients with various types of RV overloads and in 20 normal subjects. The patients were classified as (1) RV volume overload group (RVVO) consisting of 25 patients with atrial septal defect (ASD) without pulmonary hypertension (PH), (2) RV pressure overload group consisting of 26 patients including 12 with primary pulmonary hypertension (PPH), eight with mitral stenosis, three with pulmonary stenosis and three with cor pulmonale, and (3) RV volume and pressure overload group consisting of eight patients with ASD and PH. The acceleration time (AT), deceleration time (DT) and the A/D ratio were measured from the RV inflow velocity patterns, and v-y interval and the y/H ratio were measured from jugular pulse tracings. The results were as follows: 1. AT was significantly prolonged in groups with pressure overload as well as pressure and volume overload compared with that of the normal controls. 2. DT was significantly prolonged in all overload groups compared with that of the normal controls except for PPH, and was particularly prolonged in the group with pressure overload. 3. The A/D ratio was significantly increased in all overload groups, particularly in the groups with pressure overload. 4. In patients with volume overloads, the v-y interval was longer and the y/H ratio was higher than in the normal controls. RVVO shifted to the right and superiorly. The reverse was true in the pressure overload group, and the high ratios were observed in the remainder. 5. In 12 patients with ASD evaluated pre- and postoperatively, AT, DT and the A/D ratio were restored to normal after surgery. These findings suggest that RV volume overload was characterized not only by increased inflow velocity during the rapid filling period, but prolongation of this period and compensatory increase of atrial inflow velocity. However, the pressure overload group had disturbed rapid filling and a decrease in end-diastolic RV compliance. The group with both pressure and volume overloads was between the two. In conclusion, the mode of RV filling in patients with RV overload showed various patterns depending on the type of overload. The RV inflow velocity pattern recorded by pulsed Doppler echocardiography is of use in discriminating these varieties.

[Statistical survey of malignant skin tumors during the first five years of cases treated at the Dermatological Clinic of Shimane Medical University Hospital]

A statistical survey of malignant skin tumors has been carried out involving the outpatients seen at the Dermatological Clinic of Shimane Medical University Hospital during the period between October, 1979 and October, 1984. Out of 9,702 patients seen, 51 were found to have a malignant skin tumor or, statistically, 0.53% of all patients. The number and type of the malignant skin tumor were as follows: squamous cell carcinoma, 16; basal cell epithelioma, 7; Bowen's disease, 6; Paget's disease, 1; a metastatic carcinoma of the skin, 4; a malignant melanoma, 5; a malignant lymphoma, 10; leukemia, 1 and a multicentric reticulohistiocytoma, 1. reticulohistiocytoma, 1.

[Mode of left ventricular diastolic filling in hypertrophic cardiomyopathy as studied by pulsed Doppler echocardiography and multigated blood pool scan]

The clinical significance of the mode of left ventricular (LV) diastolic filling in hypertrophic cardiomyopathy was studied by the LV inflow velocity patterns (LVIF) of pulsed Doppler echocardiography and LV early diastolic filling rates (V2) of radionuclide (RI) angiography. The relationship between the deceleration time (DT) obtained from LVIF and the V2 was evaluated in 34 patients with nonobstructive hypertrophic cardiomyopathy (HCM) and in nine with obstructive hypertrophic cardiomyopathy (HOCM), and the results were compared with those of 10 patients with dilated cardiomyopathy (DCM), of two with restrictive cardiomyopathy (RCM), and of 19 normal subjects. HCM was subdivided into the following groups according to V1-DT relationships: Group 1 with prolonged DT and decreased V1, Group 2 with normal or short DT and normal V1, and Group 3 with normal or short DT and decreased V1. There were significant negative correlations between V2 and DT in Groups 1 and 2 of HCM, normal and HOCM. However, there were significant positive correlations in Group 3 of HCM, DCM and RCM. Nearly all patients in Group 3 had decreased LV ejection fraction and % fractional shortening, distinct B-B' step formation of the mitral valve echogram, and huge A wave of the apexcardiogram. These findings suggested that the LV rapid filling interval gradually became shorter because the LV contraction is decreased as myocardial fibrosis develops in HCM, and that we must pay attention to the diagnosis of such abnormalities, similar to those of DCM or RCM.

[Primary pericardial malignant mesothelioma associated with constrictive pericarditis: a case report]

A case of primary pericardial malignant mesothelioma was presented, which initially had a relatively large quantity of pericardial fluid, followed by constrictive pericarditis. The patient was a 43-year-old woman whose chief complaint was dyspnea and admitted to our hospital in March, 1984. Because of a relatively large quantity of pericardial fluid was observed. In April, drainage of the fluid and pericardiotomy were performed with marked relief of symptoms. She was discharged, but her dyspnea recurred in August, and she was readmitted. After the second admission, the chest radiograph showed a cardiothoracic ratio of 62%, and her electrocardiogram showed low voltage. A pericardial knock was recorded, and the timing of this sound coincided with that of the peak of the early distolic wave of the mitral flow velocity pattern. A jugular pulse tracing showed a deep and sharp y descent. The diastolic pressure curve of the right ventricle revealed a dip and plateau pattern. The echocardiographic finding was characterized by abnormal systolic motion and an early diastolic dip of the interventricular septum, multiple abnormal echoes and thickening of the pericardium, and an abnormal mass echo in the left atrial cavity. Based on the above examinations, pericardiotomy was performed, but the tumor was not entirely resected. The histological diagnosis was malignant mesothelioma.

[Apical mid-diastolic rumble in hypertrophic cardiomyopathy: a pulsed Doppler echocardiographic study]

To investigate the mechanism of an apical mid-diastolic rumble in hypertrophic cardiomyopathy (HCM), we recorded left ventricular (LV) inflow velocity patterns using pulsed Doppler echocardiography and apexcardiography for 10 HCM patients with rumble and 20 HCM patients without rumble. Controls consist of 17 normal subjects, three patients with complete atrioventricular block and two patients with artificial right ventricular pacemakers. The LV inflow velocity profiles were analyzed in terms of acceleration time (AT) and deceleration time (DT) of the rapid filling wave, and the ratio of peak velocity of the atrial contraction wave to that of the rapid filling wave (A/D ratio). The results were as follows: The apical mid-diastolic murmur in HCM had a crescendo-decrescendo character mainly of medium frequency, and increased in intensity after the inhalation of amyl nitrite. All patients with rumble had asymmetric septal hypertrophy and the five of these had LV outflow obstruction. In six of the 10 patients with rumble, mild mitral regurgitation was detected. In HCM with rumble, the AT tended to be shorter than that of HCM without rumble, but it was significantly longer than the AT of normal subjects. In HCM with rumble, the DT was significantly shorter than that of HCM without rumble, but it was significantly longer than the DT of normal subjects. There was no significant difference in the A/D ratio between the HCM with rumble and the normal subjects, but the A/H ratio of the apexcardiogram was significantly increased in HCM with rumble as compared with those of HCM without rumble and of the normal subjects. The LV dimension was significantly decreased in HCM with rumble as compared with those of HCM without rumble and the normal subjects. Peak negative VCF was significantly decreased in HCM with rumble as compared with that of HCM without rumble. But there was no significant difference in this parameter between HCM with rumble and the normal subjects. In simultaneous recordings of apical mid-diastolic rumble and LV inflow velocity patterns, the rumble appeared to start after the beginning of the diastolic rapid filling wave and to stop before or at the end of the diastolic rapid filling wave. In patients with complete atrioventricular block and with artificial right ventricular pacemakers, the apical mid-diastolic rumble appeared when the P wave was during the rapid filling phase of the left ventricle.(ABSTRACT TRUNCATED AT 400 WORDS)

[Left ventricular function in patients with right ventricular overload evaluated by exercise echocardiography: comparison of pulmonary hypertension and atrial septal defects]

To evaluate left ventricular function in patients (pts) with right ventricular overload, exercise echocardiographic studies using a bicycle ergometer were performed for seven pts with pulmonary hypertension (PH), two with cor pulmonale (CP) and 16 with atrial septal defects (ASD), and the results were compared with those of 10 (control I) and 27 (control II) normal persons. These subjects were categorized in two study groups; study I consisting of PH, CP and control group I with an exercise workload of 25 watts for 3 min; and study II consisting of ASD and control group II with an exercise workload of 50 watts for 3 min. The results were as follows: M-mode echocardiography revealed that: During exercise, the stroke volume (SV) was increased with a significant decrease of left ventricular end-systolic dimension (LVDs), but without a change in left ventricular end-diastolic dimension (LVDd) in control groups I and II, with a marked increase of LVDd and a slight decrease of LVDs in the ASD group. By contrast, the SV in the PH group tended to decrease during exercise with a slight decrease of LVDd, but without a significant change in LVDs. Right ventricular dimension (RVD) was significantly increased during exercise in the PH group, but was decreased in the ASD group. In control groups I and II, RVD did not change during exercise. In ASD, and control groups I and II, the peak velocity of circumferential fiber shortening (Vcf) was increased during exercise, and the peak negative Vcf was significantly decreased. However, these parameters exhibited impaired responses during exercise in the PH group. Abnormal interventricular septal (IVS) motion at rest tended to become normal during exercise in 12 of 16 pts with ASD. In all pts with PH, however, IVS motion did not change substantially during exercise. There were similar parameter responses between the PH and CP groups. Two-dimensional echocardiography showed that: The left ventricular short-axis view demonstrated a diastolic left ventricular configuration which changed from oblique to relatively circular orientation during exercise in the ASD group. In four of five pts with PH, the diastolic configuration of the left ventricle was oblique because of a loss of the normal curvature of the IVS at rest and during exercise. The diastolic left ventricular configuration improved during exercise in only one pt with PH, with slightly elevated pulmonary arterial systolic pressure as in the ASD group.(ABSTRACT TRUNCATED AT 400 WORDS)

[Left ventricular diastolic filling patterns in hypertrophic cardiomyopathy and myocardial infarction: studies by pulsed doppler echocardiography and multi-gated blood pool scans]

Relationship between various parameters of the left ventricular inflow velocity patterns by pulsed Doppler echocardiography and the early diastolic mean filling rate (V1) by multi-gated blood pool scans was evaluated. The materials consist of 26 patients with hypertrophic cardiomyopathy (HCM), 24 with old myocardial infarction (MI), seven with hypertensive heart disease (HHD), seven with dilated cardiomyopathy (DCM), seven with ischemic heart disease (IHD), and 16 normal subjects (N). The results were as follows: 1. Acceleration time (AT) and deceleration time (DT) were significantly prolonged in HCM (120 +/- 20 msec, 147 +/- 23 msec), MI (102 +/- 17 msec, 124 +/- 21 msec), HHD (105 +/- 11 msec, 141 +/- 17 msec) and IHD (111 +/- 16 msec, 122 +/- 20 msec) compared with those of normals (89 +/- 20 msec, 106 +/- 18 msec). 2. V1 was significantly decreased in HCM (1.14 +/- 0.28 sec-1), MI (0.68 +/- 0.24 sec-1), HHD (0.73 +/- 0.12 sec-1), DCM (0.67 +/- 0.30 sec-1) and IHD (1.03 +/- 0.29 sec-1) compared with that of normals (1.48 +/- 0.28 sec-1). 3. There were significant negative correlations between V1 and AT or DT in HCM, IHD with slightly impaired diastolic filling and normals. However, there were significant positive correlations between V1 and AT or DT in MI and DCM. These findings suggested that left ventricular diastolic filling is impaired in both HCM and MI, and that DT-V1 relationship is useful for differentiating HCM characterized by the "chamber stiffness" from MI characterized by the "myocardial stiffness".

[Mechanism of an early diastolic posterior motion of the interventricular septum in patients with mitral stenosis: with special reference to left ventricular inflow velocity pattern]

The mechanism of an early diastolic posterior motion of the interventricular septum (IVS) was investigated by means of M-mode, two-dimensional and pulsed Doppler echocardiographies in 53 patients with pure mitral stenosis (MS). Velocity patterns of the blood flow at the inflow tract of the left ventricle (LVIT) were classified into three types as previously reported (cf. Fig.3). The results obtained were as follows: The mitral valve orifice area (MVA) was significantly smaller in patients with type III of the LVIT flow velocity pattern than in patients with type I (p less than 0.001). An amplitude ("a") of the posterior IVS motion in systole (P1) was significantly diminished in type III (4.2 +/- 1.1 mm) than in type I (6.6 +/- 1.5 mm) (p less than 0.001). An amplitude ("b") of the posterior IVS motion in early diastole (P3) showed a significant increase in type III (7.5 +/- 1.2 mm) than in type I (5.2 +/- 1.5 mm) (p less than 0.001). Difference of the amplitude between P1 and P3 ("a-b") was significantly greater in type III (-3.4 +/- 1.1 mm) than in type I (1.4 +/- 0.9 mm) (p less than 0.0001). MVA was correlated statistically with "a" (r = 0.58, p less than 0.001), "b" (r = -0.38, p less than 0.01) and "a-b" (r = 0.80, p less than 0.0001). Deformity of the left ventricular cavity due to the flattened IVS in early diastole was observed in severe MS with an augmented septal P3 dip. A case of severe MS with type III velocity pattern and an augmented P3 dip showed type II velocity pattern and a decreased P3 dip after the attack of acute myocardial infarction. These findings suggested a close relationship between type III of the LVIT flow velocity pattern and the prominent septal P3 dip. The importance of diastolic suction of the left ventricle in producing an early diastolic posterior motion of IVS (P3) was discussed.

[Phase analysis of mitral regurgitation in mitral valve prolapse: comparison of pulsed Doppler echocardiography with phonocardiography]

The clinical implication of the timing of mitral regurgitation (MR) in mitral valve prolapse (MVP) was investigated by comparison of the phonocardiographic patterns of the regurgitant murmur with either prolapsing phase of the mitral valve determined by two-dimensional echocardiography (TDE) or regurgitant flow patterns by pulsed Doppler echocardiography (PDE). A total of 23 patients (pts) with MVP was classified into five subsets on the basis of the phonocardiographic findings: six pts with a pansystolic murmur, seven with a late systolic murmur, two with an early systolic murmur, three with only a click(s) and five with a angiotensin II-induced regurgitant murmur (provocative MR). A comparative study between the regurgitant murmur and regurgitant flow patterns was also made in 10 pts with MR due to other etiology (four pts of rheumatic MR, three of ruptured chordae tendineae and three of papillary muscle dysfunction). MR was detected at or just above the mitral orifice using a combined system of the PDE and TDE from a transcutaneous approach. The results obtained were as follows: Phase of MR detected by PDE coincided well in timing with a regurgitant murmur recorded on the phonocardiogram (PCG) except one patient. In four of five pts with provocative MR, abnormal Doppler signals indicating MR were detected even at rest and these coincided temporally with a newly developed regurgitant murmur by provocation. Phase of MR detected by PDE was not synchronous with prolapse of the mitral leaflets examined by TDE in five out of 23 pts, suggesting that MR does not necessarily occur in accordance with mitral prolapse. Regurgitant flow patterns examined by PDE in 30 pts including 10 pts of MR due to other etiology were either a widely dispersed dot pattern or a narrow banded reverse flow pattern. Pts with a loud systolic regurgitant murmur (Levine 3/6 or greater) tended to show a widely dispersed dot pattern, and pts with a soft systolic regurgitant murmur (less than Levine 2/6) showed a narrow banded reverse flow pattern. In conclusion, PDE seems to be more sensitive than PCG for the detection of MR in MVP, and PDE may serve to the qualitative as well as quantitative evaluation of MR in MVP.

[Evaluation of left ventricular function in patients with atrial septal defect by exercise echocardiography]

In order to evaluate left ventricular function in atrial septal defect (ASD), 12 cases with ASD, 18 postoperative cases of ASD and 27 normal controls were examined by means of exercise echocardiography using supine bicycle ergometer (50 watts and 3 min). M-mode echocardiograms and left ventricular (LV) short-axis views by two-dimensional echocardiography were subjected to the observation. M-mode echocardiographic studies: ASD group showed an increased stroke dimension (SD) during exercise mainly due to a marked increase of left ventricular end-diastolic dimension ( LVDd ) and a slight decrease of left ventricular end-systolic dimension ( LVDs ). Postoperative ASD group showed an increased SD during exercise mainly due to a marked decrease of LVDs and a slight decrease of LVDd . On the other hand, in normal control group exercise increased SD only by a significant decrease of LVDs . Right ventricular dimension was decreased during exercise in ASD group, but did not change significantly in postoperative ASD and normal control groups. During exercise in ASD group, peak velocity of circumferential fiber shortening (VCF) was increased most markedly, and negative peak VCF was decreased most strikingly. Eight of 12 patients with ASD who showed abnormal interventricular septal motion demonstrated remarkable improvement of the motion during exercise. Two-dimensional echocardiographic studies: Left ventricular short-axis views demonstrated that the shape of the left ventricular cavity changed from flattened to more circular configuration during exercise at end- and early-diastole in ASD group. The shape of the left ventricular cavity at late-systole did not change significantly during exercise in this group. In postoperative ASD group, the left ventricular short-axis view demonstrated circular configuration of the left ventricle at end-diastole both in rest and during exercise. The shape of the left ventricular cavity did not change by exercise. It was concluded that in ASD group cardiac output is increased during exercise by decreasing a left to right shunt at the atrial level and increasing left ventricular filling rate. Therefore, the left ventricular function was found to be good in ASD.