Siderotic nodules in the spleen: MR imaging of portal hypertension

The authors retrospectively evaluated magnetic resonance (MR) images obtained at 1.5 T in 233 patients with portal hypertension and 91 subjects without it and pathologic findings in four resected spleens (one normal). Multiple, tiny (3-8 mm in diameter), low-intensity spots in the spleen were observed in 21 of 233 patients. Among the imaging studies performed in these 21 patients, the spots were seen on five of 14 T1-weighted images, 11 of 20 proton density images, and 12 of 20 T2-weighted images obtained with spin-echo techniques and on 14 of 14 fast-scan images obtained with gradient-echo rephasing. MR images in the 91 subjects did not show such lesions. MR images of the three spleens resected from patients with portal hypertension showed the low-intensity spots, which corresponded to siderotic nodules found at pathologic analysis. Despite limited pathologic confirmation, siderotic nodules (so-called Gamna-Gandy nodules) are considered the most likely cause of multiple low-intensity spots in the spleen.

Purification and characterization of a T lymphocyte-derived differentiation-inducing factor for human promyelocytic cell line (HL-60) and its relationship to lymphotoxin

The human T cell leukemia virus type I (HTLV-I)-transformed T lymphocyte cell line MT-2 constitutively produces differentiation-inducing factor (DIF) for the human promyelocytic leukemia cell line HL-60. Purification and characterization of DIF derived from MT-2 were performed here to identify T cell-derived DIF. DIF was purified from conditioned medium of the MT-2 cell culture with serum-free medium by utilizing the sequential chromatographies of anion-exchange (mono-Q) column, gel filtration (superose-12) column, and hydrophobic (phenyl 5PW) column and finally the sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). In the SDS-PAGE, one major band with a molecular weight of 56,000 and one minor band with 15,000 were stained with Coomassie Brilliant Blue and both showed DIF activity after extraction from gels. DIF had an isoelectric point of 5.8. In all purification steps, DIF activity for HL-60 and cytotoxic activity to the sublines of mouse L-929 were not able to be separated. Further, DIF was neutralized by antibody against lymphotoxin (LT) but not by antibody against tumor necrosis factor. These results indicate that the major DIF activity derived from MT-2 is LT.

[Adrenocortical carcinoma with Cushing syndrome: report of a case]

We report a 45-year-old female with left adrenocortical carcinoma resulting in Cushing syndrome. She visited the 3rd Department of Internal Medicine, Kanazawa University Hospital with complaints of moon face, amenorrhea and hypertension. A diagnosis of left adrenal tumor with Cushing syndrome was made and she was transferred to our clinic. Left thoracoabdominal adrenalectomy was performed. The histologic report was compatible with adrenocortical carcinoma with no invasion into adjunctive tissues. She is now on endocrinologic study and is being administered 1,1-dichloro-2-[o-chlorophenyl]-2[p-chlorophenyl] ethane. There is no evidence of local recurrence or remote metastasis.

Chondromyxoid fibroma of the mastoid invading the occipital bone

We describe a case of chondromyxoid fibroma of the mastoid bone extending along the occipital bone in a 48-year-old man. The presence of this tumor was heralded solely by aural fullness caused by otitis media with effusion. The tumor arose from the mastoid cavity, eroding the entire petrous portion, and invading the foramen magnum and jugular foramen. The occurrence of this tumor is exceedingly rare, and, to our knowledge, this is only the second article in the literature that describes a chondromyxoid fibroma of the mastoid region. The clinical appearance of this tumor and its light- and electron-microscopic findings are presented with reference to other articles.

Tetraethylammonium induced coronary spasm in isolated perfused rabbit heart: a hypothesis for the mechanism of coronary spasm

The vasoactive effect of tetraethylammonium, which is known to reduce potassium conductance of the membrane of arterial smooth muscle cells, was tested on large epicardial coronary arteries in isolated perfused rabbit hearts. These hearts were perfused selectively through the right and left coronary arteries. Left coronary angiography was performed using Krebs-Henseleit solution containing phenolsulfonphthalein under constant pressure, and the epicardial electrogram was recorded. In 59 of 114 hearts 30 mmol.litre-1 tetraethylammonium induced severe constriction of the left epicardial coronary artery, which was associated with electrocardiographic ST segment elevation in some cases. The induced spasm was prevented by diltiazem (200 nmol.litre-1), glyceryl trinitrate (2 mumol.litre-1), or nicorandil (10 mumol.litre-1), but not by phentolamine (1 mumol.litre-1) or atropine (1 mumol.litre-1). In hearts in which tetraethylammonium did not induce spasm, subsequent addition of ergonovine (100 nmol.litre-1) or alkalinisation of the perfusate (pH 7.65-7.70) provoked spasm. The tetraethylammonium induced spasm resembled the coronary spasm seen in patients with variant angina and was a reproducible in vitro model of coronary spasm. These observations support the hypothesis that the primary defect in patients with coronary spasm is decreased potassium permeability of the membrane of coronary arterial smooth muscle cells.

Properties of Plasma Membrane Isolated from Chilling-Sensitive Etiolated Seedlings of Vigna radiata L

Plasma membrane was isolated in a uniform population and with a high purity from chilling-sensitive etiolated young seedlings of Vigna radiata (mung bean) utilizing an aqueous two polymer phase separation system and subsequent sucrose density gradient. The isolated plasma membrane was associated with vanadate-sensitive and KNO(3)-insensitive ATPase. The ATPase has high specificities both for substrate and Mg(2+) ion with optimum pH at 6.5. It was slightly stimulated by monovalent anions, especially Cl(-). Proton ionophores such as gramicidin D and carbonyl cyanide p-trifluoromethoxyphenylhydrazone did not stimulate the enzyme activity. The ATPase is apparently latent and highly stimulated by the addition of detergents such as Triton X-100. A maximum stimulation was achieved by the addition of 0.02% Triton X-100. After treatment with proteinase K in an isotonic buffer solution, the enzyme activity was less affected, whereas the peptides were specifically digested. Based on these facts, the isolated plasma membrane vesicles appear to be tightly sealed and in a right-side-out orientation. The plasma membrane ATPase had two inflection points at higher (18.9 degrees C) and lower (6.7 degrees C) temperatures on the Arrhenius plots of the activity. The lower inflection temperature apparently coincided with that of the anisotropy parameter of embedded 1,6-diphenyl-1,3,5-hexatriene, indicating that the membrane bound ATPase activity was affected by a phase transition of membrane lipids and/or temperature-dependent conformational changes in the enzyme molecules per se. Considering the fact that the plant material used here is highly sensitive to chilling temperatures and injured severely by exposure to temperatures below 5 degrees C for a relatively short period, the thermotropic properties of membrane molecules are considered to be involved in the mechanism of chilling injury.

Isolation and Characterization of Tonoplast from Chilling-Sensitive Etiolated Seedlings of Vigna radiata L

Tonoplasts were isolated in a high purity from etiolated young seedlings of Vigna radiata L. (mung bean) utilizing a sucrose density gradient system. The excised hypocotyls were homogenized in a sorbitol-buffer system and the 3,600 to 156,000g pellets obtained after the differential centrifugations were suspended in a sorbitol medium and loaded on a linear sucrose density gradient. After centrifugation at 89,000g for 2 hours, tonoplasts were banded at the sample load/sucrose interface. Assessed by electron microscopy and marker enzymes, the purity and the quantity were found to be sufficient for biochemical and biophysical analyses. The tonoplasts were associated with NO(3) (-)-sensitive and vana-date-insensitive ATPase. The tonoplast ATPase was stimulated by proton ionophores such as carbonyl cyanide p-trifluoromethoxyphenyl-hydrazone and gramicidin D, suggesting a proton-pumping enzyme. In the presence of ATP and Mg(2+), a proton gradient was formed in the isolated tonoplast vesicles as assessed by fluorescence quenching of quinacrine. The tonoplasts contained several kinds of mannosylated or glycosylated glycoproteins and a major protein (65 kilodaltons) which was unique to the membranes.

[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)

[Phono- and echocardiographic studies of the genesis of mitral valve prolapse in patients with funnel chest]

Two-dimensional echocardiograms (2-DE) and phonocardiograms (PCG) were used to clarify the genesis of mitral valve prolapse (MVP) and mitral regurgitation (MR) in 44 patients with funnel chest. These patients were categorized in three groups on the basis of the fronto-sagittal index (FSI) as determined from chest radiographs; 17 as mild, 15 as moderate and 12 as severe funnel chest. Their ages ranged from 5 to 65 years and averaged 24 years. MVP was diagnosed using the long-axis view of the 2-DE, and MR was diagnosed phonocardiographically including provocative test using angiotensin II. The results were as follows: In 44 patients with funnel chest, 20 (45%) had MVP and 15 (34%) had MR, respectively. The incidence of MVP increased directly in proportion to the severity of index, but the incidence of MR did not. In the short-axis view of the left ventricle at the level of the papillary muscles, there was more marked flattening of the interventricular septum than of the left ventricular posterior wall, resulting in deformity of the left ventricular geometry. A distortion index (DI) was used to quantify the degree of distortion of left ventricular shape, calculated as follows: DI = (R-r)/r, where R and r were radii of the curvatures of the interventricular septum and the left ventricular posterior wall, respectively. The DI in end-diastole (DId) and end-systole (DIs) increased in proportion to the severity of funnel chest. Patients were subdivided into four groups on the basis of DId. Incidence of MVP increased in proportion to the degree of distortion of the left ventricular shape. There was, however, no significant difference in the incidence of MR among the four groups. Patients were subdivided; one group of 13 under 14 years of age; another, 31 over 15 years old. The incidence was much higher in the latter than the former, but the incidence of MVP increased in proportion to the severity of funnel chest in both groups. MR was complicated by MR in nearly all cases in the latter group, but none had MR in the former. The DI of patients, whose FSI improved with surgery, apparently improved in addition to the disappearance and/or improvement of their MVP and MR. However, patients whose FSI did not improve with surgery showed little change in DI and persistence of MVP and/or MR.(ABSTRACT TRUNCATED AT 400 WORDS)

Distribution of capillary nonperfusion in early-stage diabetic retinopathy

Using composite super-wide fluorescein angiography, 152 eyes with nonproliferative diabetic retinopathy were evaluated for capillary nonperfusion. Four basic types of eyes were distinguished according to the location of capillary nonperfusion: peripheral type 4 eyes, midperipheral type 93 eyes, central type 40 eyes and generalized type 15 eyes. The rate of enlargement of nonperfused area was more rapid in peripheral type, midperipheral type, central type and the generalized type in the ascending order. Eyes belonging to midperipheral and central types evolved into other, usually generalized type during the course of observation. There is a positive correlation between the initial site of occurrence of capillary nonperfusion and its progression in nonproliferative diabetic retinopathy. A proper recognition of the typing is claimed to be of prognostic value.

[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)

[Noninvasive studies of dynamic left ventricular outflow obstruction in patients with sigmoid septum]

In order to evaluate the clinical significance of the markedly protruding interventricular septum into the left ventricular (LV) cavity (sigmoid septum), we performed non-invasive studies including amyl nitrite (AN) inhalation in 21 patients (pts) with two-dimensional echocardiographic (2DE) documentations. LV outflow tract (LVOT) obstruction was determined by the presence at least three of the following findings at rest or during AN inhalation: 1) a loud apical ejection systolic murmur (ESM), 2) a midsystolic dip in the carotid pulse, 3) systolic anterior motion (SAM) of the mitral valve (MV) or chordae tendineae, and 4) systolic semiclosure of the aortic valve (AV). The 21 pts were subdivided into six pts (group I) with resting (two pts) or provocative (four) obstruction, and 15 pts (group II) without obstruction. Their ages ranged from 40 to 85 years with an average of 65. No pt had evidence of hypertrophic cardiomyopathy. Results were as follows: In five pts of group I a long ESM with a mid-systolic peak was recorded near the apex. After AN inhalation, this murmur was markedly intensified. On the contrary, all pts of group II had a short and early systolic murmur, which was not markedly intensified by AN. In contrast to group II, group I pts had a significantly smaller LV end-diastolic dimension, a smaller LVOT dimension, higher percent thickening of the LV posterior wall, higher fractional shortening and decreased aorto septal angle (the angle between the anterior aortic wall and the interventricular septum by 2DE). On 2DE, each pt of group I showed significant narrowing between the protruded septum and the hypercontractile LV posterior wall with the papillary muscle. Anteriorly shifted chordae tendineae noted as the SAM on the M-mode echocardiogram might also play an important role on the genesis of obstruction. The signs of LVOT obstruction at rest disappeared following oral administration of propranolol in two pts of group I. These observations suggested that LVOT obstruction might occur in some pts with sigmoid septum and the hypercontractile state, and that a systolic murmur observed in this condition should be differentiated from a functional murmur in the aged or a systolic murmur in hypertrophic obstructive cardiomyopathy.

[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.

Characteristics of non-sustained ventricular tachycardia detected by ambulatory electrocardiography

We analyzed non-sustained ventricular tachycardia (VT) observed during ambulatory electrocardiographic (ECG) monitoring in 21 subjects. The rate of VT was 160.7 +/- 2.3 beats/min and showed a moderate positive correlation (r = 0.61, p less than 0.01) with the preceding heart rate (81.8 +/- 1.0 beats/min). The prematurity index of VT was 1.118 +/- 0.015 and showed a moderate inverse correlation with the rate of VT (r = -0.64, p less than 0.01). The vulnerability index was 0.713 +/- 0.009. These indices of prematurity showed a wide distribution and the prematurity of ventricular ectopic beats may not be so significant as previously documented. The incidence of VT was higher in the morning and the evening and was reduced by sleep. The most frequent type of VT (25-/day) was observed only in patients with VT predominantly occurring during the day. We have therefore postulated that these diurnal variations in the frequency of VT may have important therapeutic and prognostic implications. In this study, we used the classification of VT based on the focus, the diurnal variation and the frequency of the tachycardia. Ambulatory ECG monitoring is useful in distinguishing the various types of VT and it is important to separate the various types of VT into several subgroups in order to classify grade the severity of VT.

Vectorcardiographic and epicardial activation studies on experimentally-induced subdivision block of the left bundle branch

The functional significance of the septal Purkinje network (SEP) in the left ventricular conduction system was examined by measuring changes of the activation sequence and vectorcardiogram (VCG) after inducing experimental blocks of the left anterior subdivision (LA) and the SEP. A discrete block of the SEP (10 dogs) resulted in a slight delay of the epicardial activation in the apical area. In lead of the McFee system of VCG, the antero-posterior ratio was increased significantly, and in 3 of 10 cases (30%) major QRS loops were deviated anteriorly on the horizontal plane. In the discrete block of the LA (10 dogs), epicardial mapping revealed a slight activation delay in the anterior basal area. There were no significant changes on VCG, except for a superior and leftward deviation of the terminal QRS vector. In the combined block of the LA + SEP (9 dogs), an activation delay of the greater area and magnitude was observed from the anterior basal area to the apical area, and the direction of the maximum QRS vector on the frontal plane showed a significant displacement to the left and superiorly. These results suggest that the SEP block itself may produce an electrocardiographic change and that this network also plays an important role in the so-called hemiblock, producing axis changes on the frontal plane of a VCG, in association with the blocks of the left anterior and posterior subdivisions.

[Pulsed Doppler echocardiographic observation of right and left ventricular inflow velocity patterns in various types of arrhythmia, with special reference to the mechanism of atrioventricular regurgitation]

To investigate the possibility for detection of atrio-ventricular (A-V) regurgitation in arrhythmias non-invasively, we recorded velocity patterns of blood flow at the inflow tract of the right (RVI) and left ventricles (LVI), and at the outflow tract of the left ventricle (LVO) by pulsed Doppler echocardiography in 32 patients with various types of arrhythmia. They were six cases with supraventricular premature contraction (SVPC), 13 with ventricular premature contraction (VPC), two with second degree A-V block, five with complete A-V block and six with artificial right ventricular pacemaker. The following results were obtained. In SVPC, peak velocity of the preceding early diastolic flow of RVI and LVI was related to the coupling interval. A crucial ectopic atrial contraction occurring at the early diastole augmented right or left ventricular filling by summation of the two kinds of ventricular filling. Peak velocity of the early diastolic flow at RVI and LVI was decreased after SVPC compared with that of normal sinus rhythm. A reverse flow was not observed in RVI or LVI velocity pattern in these cases. In VPC, peak velocity of the preceding early diastolic flow at RVI and LVI was related to the coupling interval. An effective early diastolic flow was not observed when coupling interval was short. A systolic A-V reverse flow was detected in six of eight cases of VPC with compensatory pause. In these six cases, M-mode and two-dimensional echograms showed patterns of tricuspid and/or mitral valve prolapse and systolic "bulging" of the left ventricular posterior wall. Peak velocity of the blood flow at LVO was decreased in VPCs with short coupling intervals, but it was increased markedly in the next beat after compensatory pause (post-extrasystolic potentiation). Velocity pattern of a blood flow at RVI and LVI showed two types of reverse flow patterns in all cases with complete A-V block or with artificial right ventricular pacemaker; a) systolic reverse flow in beats with P wave superimposed on QRS complex or ST segment, and b) diastolic reverse flow in beats with markedly prolonged P-R intervals. Diastolic tricuspid regurgitation was demonstrated by contrast echography at the level of the tricuspid valve orifice, and diastolic mitral regurgitation by left cineventriculography. The clinical implication of pulsed Doppler echocardiography to detect A-V regurgitation during systole and diastole was discussed in various types of arrhythmia.

[Pulsed Doppler echocardiographic assessment of diastolic left ventricular hemodynamics in hypertrophic cardiomyopathy: relationship between the mode of left ventricular filling and the distribution of left ventricular hypertrophy]

In order to clarify left ventricular relaxation and filling in different types of hypertrophic cardiomyopathy (HCM), velocity patterns of blood flow at the inflow tract of the left ventricle (LV) were recorded by pulsed Doppler echocardiography and compared with those of normal subjects (26 cases). Forty-one patients with HCM were classified into the following 4 groups according to the distribution of LV hypertrophy and the evidence of cavity obstruction of the LV; with asymmetric septal hypertrophy (ASH: 15 patients), apical hypertrophy (APH: 10), diffuse hypertrophy ( DIH : five) and obstruction of the LV cavity (HOCM: 11). The HOCM group consisted of five cases of ASH type and six of APH or DIH type. Acceleration time (AT), deceleration time (DT) and the A/D ratio were measured on the pulsed Doppler echocardiogram. The M-mode echogram of the LV was recorded and subsequently digitized to obtain peak LV filling rate. The results were as follows: AT was significantly prolonged in 4 groups of HCM compared with that of the normal subjects. But there was no significant difference in AT among various HCM groups. DT was markedly prolonged in 4 groups of HCM compared with that of the normal subjects, but DT was significantly shortened in the ASH group compared with that of the APH or HOCM group. DT of the HOCM group was divided into the following 2 types according to the duration; normal or slightly prolonged DT (three cases) and markedly prolonged DT (eight). The former group belonged to the ASH type of LV hypertrophy in all cases, and two of them showed a third heart sound. An apical diastolic murmur was recorded in four patients of the ASH group, and six of the HOCM (five cases with ASH type and one with APH type). The A/D ratio was significantly increased in 4 groups of HCM compared with that of the normal subjects. But there was no significant difference among HCM groups. Diastolic descent rate (DDR) of the mitral valve echogram was significantly reduced in 4 groups of HCM compared with that of the normal subjects, particularly in the ASH and HOCM groups. DDR was roughly correlated with DT in the HCM group (r = -0.40, p less than 0.02). Peak LV filling rate was markedly decreased in the ASH, APH and HOCM groups compared with that of the normal subjects. There was a significant negative correlation between peak LV filling rate and DT (r = -0.49, p less than 0.01). In conclusion, the mode of LV filling in HCM showed various patterns according to the location of ventricular hypertrophy and the presence of cavity obstruction of the LV.(ABSTRACT TRUNCATED AT 400 WORDS)

[Studies on the mechanisms of the third and fourth heart sounds: with special reference to the phase analysis of mitral flow velocity pattern]

To investigate the genesis of the third ( IIIs ) and fourth heart sounds (IVs), apical phonocardiograms were recorded simultaneously with pulsed Doppler signals of the mitral flow and interventricular septal (IVS) and left ventricular posterior wall (PW) echoes by M-mode echocardiography in 26 cases with the IIIs and 11 cases with the IVs. The following results were obtained: Cases with the IIIs were classified into the following three groups according to the time relationship between the IIIs and a rapid filling wave (D wave) of the mitral flow velocity pattern. IIIs -peak group: The IIIs occurred coincidently with the peak of the D wave in five healthy adolescents and in 12 cases with absolute left ventricular volume overload including mitral regurgitation (MR: eight cases), postoperative atrial septal defect (ASD: three cases) and ventricular septal defect (one case). IIIs -delay group: The IIIs occurred about 38 msec after the peak of the D wave in eight cases with relative left ventricular volume overload including congestive cardiomyopathy (CCM: three cases) and ischemic heart disease (IHD: five cases). IIIs -early phase group: The IIIs occurred about 35 msec before the peak of the D wave in a case with acute MR due to chordal rupture. In the IIIs -peak group, the IIIs coincided in time with the points of inflection (check points) of both the IVS and PW during rapid filling phase in three cases with MR of mild to moderate degree and one case of postoperative ASD. In the IIIs -delay group, the IIIs occurred simultaneously with either the check point of the IVS or PW in two cases with CCM and one case with IHD, and it occurred before the check points of both the IVS and PW in two cases with severe MR of IIIs -peak group and in a case with acute MR due to chordal rupture of IIIs -early phase group. Cases with the IVs were classified into following 2 groups according to the time relationship between the IVs and the atrial contraction wave (A wave) of the mitral flow velocity pattern. IVs-peak group: The IVs occurred coincidentally with the peak of the A wave in six cases with left ventricular hypertrophy including hypertrophic cardiomyopathy (five cases) and hypertension (one case). IVs-delay group: The IVs occurred about 33 msec after the peak of the A wave in five cases with left ventricular dilatation or dysfunction including old myocardial infarction (two cases), CCM (one case), postoperative ASD (one case) and aortic regurgitation (one case). There were two types of IVs in time relationship between the IVs and the check points of the left ventricular wall during atrial contraction phase.(ABSTRACT TRUNCATED AT 400 WORDS)

[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.

Effect of cycloheximide on the freezing tolerance and ultrastructure of cortical parenchyma cells from mulberry twigs

Experiments were performed using cycloheximide (CHI) on cortical parenchyma cells from mulberry twigs (Morus bombyciz cv. Gorogi) to understand the relationship between the sequence of cytological changes suggesting replacement of the plasmamembrane and the rapid increase in freezing tolerance. Cortical cells from twigs collected on October 16 and 27, which were hardy to −10 and −15 °C, respectively, were still alive after cooling to −70 °C if they had been exposed to −3 °C for 10 to 12 days. In these hardened cells, appearance of microvesicles (MVs) in the peripheral cytoplasm and fusion of these MVs with plasmamembrane were characteristically observed. Neither cytological change nor increase of freezing tolerance was observed in cells treated by CHI before their exposure to −3 °C for 10 to 12 days. However, the suppression of such changes by CHI treatment was effective only in cells which were hardy at −10 to −15 °C and not in the cells of twigs collected on November 4, which were hardy to −20 °C. Consequently, synthesis of some functional proteins during hardening was required for the further development of freezing tolerance, and synthesis had been accomplished before the cells became hardy to −20 °C. Ultrastructural changes brought about by CHI treatment suggest that synthesis of some functional proteins related to the presumed changes of plasmamembrane occurs during hardening.

[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.

[Exercise echocardiography in different types of hypertension classified by left ventricular geometry; comparison with hypertrophic cardiomyopathy]

We investigated left ventricular (LV) function in 40 patients (pts) with hypertension (HT), 16 pts with hypertrophic cardiomyopathy (HCM), 3 pts with ASH and HT and in 27 control subjects by M-mode echocardiography using supine exercise (50 watts, 3 minutes). The hypertensive subjects were echocardiographically divided into three subsets; the normal LV (17 cases), the hypertrophied LV (17 cases) and the dilated LV (6 cases). Similarly, pts with HCM were echocardiographically and cineangiographically divided into three subsets; ASH (asymmetric septal hypertrophy, 6 cases), APH (predominant apical hypertrophy, 6 cases) and DFH (diffuse left ventricular hypertrophy, 4 cases). Changes of left ventricular dimension Controls and HT: Stroke volume was increased during exercise in the controls, normal LV and hypertrophied LV groups by decreasing LV end-systolic dimension ( LVDs ), but it was increased in dilated LV group by increasing LV end-diastolic dimension ( LVDd ) (Frank-Starling mechanism). LVDd was increased transiently in the controls and normal LV group during recovery, but its grade and duration were more pronounced in the latter. LVDd did not change significantly in hypertrophied and the dilated LV groups. HCM: LVDd and LVDs did not change significantly during exercise in all 3 groups. LVDd was increased transiently during recovery in ASH group, but not in the other groups. Changes of peak velocity of circumferential fiber shortening (VCF) and the ratio of peak systolic blood pressure to LV end-systolic volume (PSP/ LVVs ). Controls and HT: Peak VCF was increased during exercise most markedly in the normal LV group, but it was not increased in the dilated LV group. PSP/ LVVs was increased significantly during exercise in the controls, the normal and hypertrophied LV groups, but not in the dilated LV group. HCM: Peak VCF showed a significant increase during exercise in ASH group, but not in the other two groups. Changes of the D/S ratio. The ratio of systolic to diastolic velocity of the LV posterior wall was expressed as a D/S. This ratio did not change significantly in the controls, HT and APH groups, but it was decreased significantly in ASH and DFH groups. LV end-systolic wall stress and LVDs relationship ( ESWst - LVDs ).(ABSTRACT TRUNCATED AT 400 WORDS)

[Mode of splitting of the second heart sound in patients with hypertrophic cardiomyopathy]

Mode of the splitting of the second heart sound ( IIs ) and left ventricular systolic time intervals (STIs) in patients (pts) with hypertrophic cardiomyopathy were compared with those in hypertension (HT) with the global hypertrophy of the left ventricular wall. Forty-seven pts with hypertrophic cardiomyopathy [non-obstructive type (HCM, 30 pts), obstructive type (HOCM, 17 pts)] and 21 pts with HT were studied. The pts with HCM were classified as septal hypertrophic type (19 pts) and apical hypertrophic type (11 pts) on the basis of the echocardiographic findings. The pts with HOCM were classified as resting type (13 pts) and latent type (provoked by amyl nitrite: 4 pts) on the basis of the obstructive sign at rest. Mode of the splitting of the IIs : a) The pts with HCM showed a wide splitting of the IIs . The mean split interval during held expiration (IIA-IIP) was 41.0 +/- 9.9 msec. Twenty pts (67%) showed abnormal respiratory splitting. The mean IIA-IIP interval in septal hypertrophic type (45.3 +/- 9.0 msec) was significantly wider than that in apical hypertrophic type (33.6 +/- 6.7 msec) (p less than 0.05). There was a positive correlation between IIA-IIP interval and the thickness of the upper portion of the interventricular septum (r = 0.63). b) Nine out of 13 pts with resting type of HOCM showed a paradoxical (reversed) splitting with a mean IIA-IIP interval of -23.8 +/- 24.4 msec. On the other hand, pts with latent type showed a wide splitting similar to HCM with a mean IIA-IIP interval of 35.0 +/- 7.1 msec. c) The pts with HT showed a single IIs or physiological splitting. The mean IIA-IIP interval was 14.5 +/- 9.3 msec, which was significantly decreased than that of normals or the pts with HCM (p less than 0.01). Left ventricular systolic time intervals: a) The pts with an either type of HCM showed a short corrected left ventricular electromechanical systole [(Q-IIA)c] due to the shortening of the corrected left ventricular ejection time (LVETc). b) The pts with resting type of HOCM showed a long (Q-IIA)c due to the prolongation of LVETc, but latent type showed the same change as in HCM. c) The pts with HT showed a tendency of prolongation of (Q-IIA)c due to slightly short LVETc and long corrected pre-ejection period (PEPc). Fractional shortening of the left ventricle (%FS) and mean velocity of circumferential fiber shortening (mean VCF) calculated from echocardiograms were significantly greater in both types of HCM than those in normals and HT (p less than 0.05). Left ventricular end-diastolic dimension was significantly decreased in the pts with septal hypertrophic type of HCM than in others.(ABSTRACT TRUNCATED AT 400 WORDS)

Partition of membrane particles in aqueous two-polymer phase system and its practical use for purification of plasma membranes from plants

A simplified method for the isolation of a plasma membrane-enriched fraction from plants utilizing an aqueous two-polymer phase system is outlined. Mainly, the plant used was Orchard grass (Dactylis glomerata L.). The two-phase system consisted of 5.6% (w/w) of dextran T500 and 5.6% (w/w) of polyethyleneglycol 4000 in 0.5 molar sorbitol-15 millimolar Tris-maleate (pH 7.3), and 30 millimolar NaCl. In this system, the plasma membranes and the other membranes were preferentially partitioned into the top phase and into the lower phase, respectively. The purity of the isolated plasma membrane was sufficiently high even after a single partition (i.e. about 85% purity) and more than 90% purity was obtained after repeating the partition in a newly prepared lower phase. The plasma membrane was identified with the aid of phosphotungstic acid-chromic acid stain and the association of vanadate-sensitive Mg(2+)-ATPase. The plasma membrane-associated ATPase had a pH optimum at 6.5 and showed a high specificity for Mg(2+) and ATP. KCl stimulation was low (6% stimulation) at the pH optimum, but a relatively high stimulation (23%) occurred at pH 5.5. This method for plasma membrane isolation may be applicable to a wide variety of plants and plant tissue including green leaves.

Cyclic adenosine 3', 5'-monophosphate, adenyl cyclase and phosphodiesterase in the conduction system of bovine heart

Cyclic adenosine 3', 5'-monophosphate (cyclic AMP) and adenyl cyclase and phosphodiesterase activities were determined in the specialized myocardial tissue of the conduction system of bovine heart and then compared with those in the ordinary myocardial tissue. The conduction system was comprised of the atrioventricular node (A-V node), the His bundle and the right and the left bundle branches (RBB and LBB). The content of cyclic AMP was higher in the ordinary myocardial tissue than in the specialized myocardial tissue. In the specialized myocardial tissue, its content was highest in the A-V node and lower in the His bundle than in the LBB and the difference between the contents in the RBB and the LBB was not significant. Adenyl cyclase activity as well as the content of cyclic AMP was higher in the ordinary myocardial tissue than in the specialized myocardial tissue. Its activity was higher in the A-V node than in the His bundle or the RBB, and the activities in the His bundle, the RBB and the LBB were similar. Phosphodiesterase activity was higher in the ordinary myocardial tissue than in the A-V node, and the activities in these 4 sections of the conduction system were similar.

[Echocardiographic study on systolic left ventricular posterior wall motion in patient with atrial septal defect]

Systolic motion of the left ventricular posterior wall (LVPW) was studied by M-mode and long-axis two-dimensional echocardiography in 35 patients (pts) with secundum type of atrial septal defect (ASD), comparing with that of 19 surgically closed ASD (post ASD), 27 with hypertrophic cardiomyopathy (HCM), 15 with old anteroseptal myocardial infarction (a-s MI) and 28 normal subjects. The results obtained were as follows: 1) Excursion of LVPW (PWE) was significantly increased in the pts with ASD compared with normal subjects (P less than 0.001), but there was no significant difference in PWE between the pts with ASD and the pts with HCM or a-s MI. 2) Mean systolic posterior wall velocity (MPWVs) was significantly decreased in the pts with ASD compared with the pts with HCM (p less than 0.05). However, no significant difference could be found in MPWVs between the pts with ASD and a-s MI or normal subjects. 3) End-systolic thickening of LVPW was significantly increased in the pts with ASD compared with normal subjects (p less than 0.05), the pts with a-s MI (p less than 0.05) and the pts with post ASD (p less than 0.01), except for the pts with HCM. There was a significant difference in % end-systolic thickness of lVPW between the pts with ASD and the pts with a-s MI or post ASD (p less than 0:05). 4) Mid-systolic thickening and % mid-systolic thickening of LVPW were significantly increased in the pts with ASD compared with normal subjects, the pts with a-s MI, the pts with post ASD and the pts with HCM (p less than 0.01). This characteristic mid-systolic bulging of LVPW in the pts with ASD was coincident with early-systolic anterior motion of IVS. 5) Basal portion of LVPW indicated the marked inward contraction during end-systole in 30 of 35 pts (86%) with ASD. In these 30 pts, association of mitral valve (MV) prolapse was observed. 6) Following surgical closure of ASD in 19 pts, MV prolapse disappeared following normalization of excessive endsystolic contraction of the LVPW in 16 pts (functional MV prolapse). In 3 pts, however, posterior MV showed multiple abnormal echoes, indicating MV prolapse or mitral regurgitation (organic MV prolapse). In conclusion, these results suggested that mid-systolic bulging of LVPW in ASD is compensatory reaction for systolic anterior IVS motion, and that mechanism of MV prolapse in ASD is related to abnormal left ventricular geometry due to excessive inward contraction of basal portion of LVPW during end-systole.

Comparison of superprecipitation and contractile protein contents of myosin B in the myocardium and conduction system

The extents of superprecipitation and contractile protein contents of myosin B in the myocardium and conduction system were compared. The extents of superprecipitation of myosin B of the two types of cardiac muscle were similar, but the onset of the superprecipitation reaction of myosin B from the conduction system was delayed and the clearing phase of the reaction was prolonged. On sodium dodecyl sulfate (SDS)-polyacrylamide gel (6%) electrophoresis of myosin B, myosin, actin, and tropomyosin were clearly separated. The amounts of protein present in stained bands of polyacrylamide gels were estimated. The weight ratios of myosin: actin, tropomyosin: myosin, and actin: tropomyosin in myosin B were not significantly different in the two types of cardiac muscle. However, the compositions of myosin light chains in the two types of cardiac muscle were quite different. It was suggested that this difference of myosin subunits might contribute to the difference in superprecipitation of myosin B.

Vectorcardiographic finding of varying degrees of left anterior hemiblock. A case report

A 16-year-old high school boy showed various types of aberrant QRS complexes during supraventricular premature beats. The aberrant beats showed right bundle branch block pattern associated with varying degrees of left axis deviation. Rosenbaum et al explained it by slowing in conduction through the anterior fascicle in a bifascicular nature of human left bundle system. The alternative explanation might be possible if we consider a fan-like left bundle as proposed by Massing et al: namely incomplete or slight left axis deviation results from block of a small group of anterior parts of the fan-like left bundle, whereas marked left axis deviation results from block of a large number of fibers. The initial QRS force also changed to various degrees according to changes of the QRS axis. This case suggested the existence of an incomplete type of left anterior hemiblock, which produced not only an incomplete QRS axis change but also an incomplete change of the initial QRS forces.

Fibrinolytic and plasmin inhibitor activities in patients with acute myocardial infarction

Fibrinolytic activity and plasmin inhibitor activity were determined by Blue Dextran-fibrin method in patients with acute myocardial infarction. The normal values of fibrinolytic activity and plasmin inhibitor activity were 3.34 +/- 0.74 units and 10.10 +/- 2.39 units (mean +/- SD), respectively. The fibrinolytic activity in normal women (3.63 +/- 0.99 units) was slightly higher than that in normal men (3.17 +/- 0.79 units), but the plasmin inhibitor was not significantly different in the two sexes statistically. Neither activity varied significantly with age. The blood fibrinolytic activity was depressed in the first week after acute myocardial infarction, the decrease being maximal 3 to 4 days after the event (1.73 +/- 0.31 units). The mean plasmin inhibitor activity remained normal after acute myocardial infarction, but it was increased in 3, and decreased in 4 of 7 patients in whom it was measured 3 to 4 days after the event.

[Studies on the genesis of the aortic thudding sound in patients with aortic insufficiency, with special reference to the aortic flow pattern (author's transl)]

To clarify the genesis of the aortic thudding sound (AK), phono-, mechano- and pulsed Doppler echocardiography were performed in 16 patients with pure aortic insufficiency (AI), 3 with AI associated with mild aortic stenosis (AIs) and 5 with AI associated with mitral insufficiency (AI + MI). The results obtained were as follows: 1) AK was composed of two components, that is, one (AK1) occurred in early systole and the other (AK2) near the end point of an ejection systolic murmur. Patients studied were divided into 4 groups following the appearance of AK1 and/or AK2: group with only AK1 (4 cases), group with only AK2 (7 cases), group with both AK1 and AK2 (5 cases) and group without AK (8 cases). 2) AK1 was a low frequency sound and was well recorded from the cardiac base to the right supraclavicular region. AK1 was not observed in cases with mild to moderate AI and with AI associated with mild AS. In atrial fibrillation, when the preceding R-R intervals were long, AK1 was loud and appeared in early systole, and when short, small and in mid-systole. Marked augmentation of AK1 was observed in the first beat after premature ventricular contraction with a compensatory pause. 3) AK2 was also low in frequency and was most intensively recorded near the apex. Although the intensity of AK2 tended to increase in the severe cases of AI, AK2 could be observed in mild to moderate cases. Intensity of AK2 also showed the post-extrasystolic potentiation similar to that of AK1. 4) The carotid pulse showed pulsus bisferiens in all cases with AK2 (group with only AK2 and group with both AK1 and AK2). On the other hand, in cases without AK2 (group without AK and group with only AK1), carotid pulse showed a monophasic systolic wave except 3 cases. These results suggested that there was a close relationship between AK2 and pulsus bisferiens in the carotid pulse. (5) In the apex cardiogram (ACG), systolic notches coincident with AK1 and/or AK2 were observed in 10 of 12 cases with AK2 and in 4 of 9 cases with AK1. In cases without AK, however, no notch was seen in ACG. Therefore, these notches might be resulted from the shock of the anterior chest wall produced simultaneously with the occurrence of AK. 6) Flow patterns at the left ventricular outflow tract (aortic flow patterns) were recorded in 13 cases, including 3 with only AK1, 2 with only AK2, 3 with both AK1 and AK2 and 5 without AK. In 5 of 13 cases the flow patterns were recorded simultaneously with phonocardiograms. Systolic aortic flow showed biphasic patterns in all cases with AK2, and monophasic patterns in cases without AK2. AK1 occurred coincidentally with the first peak of the biphasic flow patterns, and AK2 with the second peak. These results suggested that AK1 might be produced by rapid ejection of massive amount of blood containing a regurgitant flow into the aorta with the ordinarily distensiblwe aortic wall, and AK2 by the clash between the second ejected flow and the reflected flow returning from the peripheral artery against the first ejected flow.