[Detection of exercise induced left ventricular asynergy by two-dimensional echocardiography (author's transl)]

In order to detect an exercise induced asynergy, cross-sectional echocardiography was performed during multistage maximal bicycle ergometer stress test in the supine position. 1) Left ventricular (LV) asynergy occurred earlier than or simultaneously with the appreciable ST segment change. 2) In patients with angina, LV asynergy appeared in the area of dominant coronary stenosis, while ST depression was seen in V3-6 as well as II, III and aVF, despite of the localized area of asynergy. 3) In patients with myocardial infarction, LV asynergy increased or extended over or around the infarcted area except one case, ST segment elevated in the leads over the infarction with abnormal Q waves and depressed in the reciprocal leads. These observations revealed that ST depression does not necessarily mean an occurrence of new ischemia over the corresponding area in myocardial infarction. Thus exercise cross-sectional echocardiography was demonstrated to be a good method to detect an exercise induced ischemia and would be particularly valuable in view of the coronary artery bypass.

[Secondary atypical hypertrophy: hypertrophic cardiomyopathy with acquired risk factors (author's transl)]

New clinical concept of "secondary atypical hypertrophy" was proposed for hypertrophic cardiomyopathy (HCM) associated with an acquired risk factors such as hypertension, strenuous exercise, etc, based on the following findings. 1) Case-control study suggested that history of hypertension, physical labor and weight gain were thought to be risk factors of apical hypertrophy. History of hypertension was also demonstrated in 55% of older cases of HCM (greater than 35 yrs) with asymmetric septal hypertrophy, and this figure was appreciably higher than that in general population (around 26% in our population survey). Thus hypertension was suggested to have a causal relationship to HCM as an important risk factor in older cases. 2) Even in cases without hypertension, 29% of non-obstructive HCM exhibited a marked increase in systolic blood pressure on bicycle ergometer stress test, suggesting an important of transient hypertension during exercise as a risk factor of unusual hypertrophy. 3) The cases of HCM with definite family history and the cases of HCM with secondary atypical hypertrophy, with acquired risk factors such as hypertension, presented different clinical features. The latter is older and predominant in males. In the former, QRS pattern was les distorted, suggesting milder congenital defect of the myocardium. Left ventricular function was less impaired in cases with secondary atypical hypertrophy if judged from diastolic descent rate of the mitral valve, left ventricular enddiastolic pressure and functional aerobic impairment (FAI). On the other hand, no differences were observed between cases with ventricular septal hypertrophy and left ventricular outflow obstruction. 4) Follow-up study demonstrated rather favorable prognosis in cases with secondary atypical hypertrophy because of the absence of sudden death despite of their older age. These distinctive difference in clinical features, prognosis and then management in cases with HCM with acquired risk factors suggested a validity of the concept of secondary atypical hypertrophy in clinical practice.

The role of cell mediated immunity in coxsackie B viral myocarditis

The role of cell mediated immunity (CMI) in the pathogenesis of coxsackie B (Cox. B) viral myocarditis in the adult were immunologically investigated. The number of types of neutralizing antibody in patients with Cox. B viral myocarditis was more than that in controls. This fact suggested that these patients had a history of previous Cox. B viral infections. In the patient with Cox. B viral myocarditis, neutralizing antibody titer was increased as 20 folds by the reinfection. And also macrophage migration inhibition test showed that CMI was enhanced not only against the same type but also against the other types of Cox.B group viruses. In conclusion, it may be essential in the occurrence of adult myocarditis that the patient has been infected by Cox.B virus and immunized against the other types as well as the same type of Cox.B group viruses. CMI may also play a critical role in the occurrence of Cox.B viral myocarditis.

Further observations of the digital plethysmography in response to auditory stimuli and its clinical applications

Further observations of the digital plethysmography with auditory stimuli and its clinical applications were performed in patients with vibration disease and heart diseases. The responsive pattern to the auditory stimuli in the digital plethysmogram could be faithfully reproducible if it elapses more than 5 minutes apart between the first stimulus and the second one. The responsive patterns were divided into four types: normal (N), hyperreactive (I and D) types and hyporeactive (P) type. The values of urinary catecholamine increased in parallel to the activity level of the autonomic nerve. The hyperreactive type (D) had the highest value of urinary catecholamine, and vice versa. With regard to the age, the elderly was prone to show hyporeactive (P) type, and the young tended to be hyperreactive (D) type. Psychologic factors were examined by Cornell medical index. Neurosis was not necessarily related to the hyperreactive type. In clinical applications, it was observed by this method that the autonomic imbalance in patients with vibration disease, angina pectoris, or hypertension was recovered by the treatment, and the abnormal types of the response recovered to N type. In conclusion, the digital plethysmography with auditory stimuli as one of the autonomic nerve function tests would be much useful and non-invasive method for observation of clinical course and decision of the severity.

Effects of oral befunolol on heart rate and systolic blood pressure during submaximal exercise in man

For the purpose of determining exercise intensity required for evaluating the effect of beta-blocking agents, the multi-stage treadmill exercise was carried out up to intensity of 85% of maximal oxygen intake (VO2max) after administration of beta-blocking agents in 7 healthy men. To obtain a stable dose response in the inhibitory effect of beta-blocking agents on heart rate (HR) and systolic blood pressure (S-BP), the exercise intensity more than 65% of VO2max (75% of maximal heart rate) was needed. In order to evaluate the effect of befunolol (BFE), a submaximal treadmill exercise of 75% of the age adjusted predicted maximal heart rate was loaded in 6 healthy men at 1.5, 4, and 8 hours following a single oral administration of 10 mg, 20 mg or 40 mg of BFE and 20 mg or 40 mg of propranolol. Simultaneously, the plasma concentration of BFE was determined 1.5, 4, 6 and 8 hours after the administration of BFE at each dose. In human serum, BFE was detected together with its metabolite, revealing a significant correlation between BFE and metabolite (r = 0.94, p < 0.001). Almost a certain rate of metabolite (4--5 times) was detected against BFE. As for the biological half life, it was 1.79 +/- 0.13 hours with BFE and 3.67 +/- 1.33 hours with metabolite. The inhibitory effect of BFE on HR and S-BP during exercise exhibited a dose response with the oral dose and its plasma concentration, and was almost twice as much as that of propranolol at the same dose. Accordingly, the myocardial oxygen consumption which may be represented as rate pressure product was inhibited twice as much as propranolol. BFE is characteristic of its more rapid elimination of its effect compared to the other beta-blocking agents. The decrease in the inhibitory effect of BFE or HR during exercise was about 1.8 times quicker than that of propranolol.

Clinicopathological study of coxsackie B viral myocarditis

Autopsy cases of myocarditis caused by Coxsackie viruses in two infants, aged 5 years and 10 months and 12 years, and two adults, aged 24 years and 45 years, were presented. Of the four cases, three revealed a rise in serum neutralization titer to Cox B,4 virus and one to both Cox B2 and Cox B4 viruses. Compared with the adult cases, the 2 infant cases showed less inflammatory response with relatively prominent hypertrophy in the heart. Both of the adult cases revealed intensive inflammatory reaction. Extensive inflammatory cell infiltration remained in one of the adult cases though the case survived about 4 years after manifestation of the infection, suggesting possible involvement of immunological factors.

Changes of ventricular monophasic action potential duration by stellate ganglion stimulation in dogs

Left or right stellate ganglion stimulation resulted in changes of ST segments and T waves of electrocardiogram. The present experiments were performed in an attempt to elucidate alpha-and beta-adrenergic actions, and calcium action on the monophasic action potential duration (APD), that is, the repolarizing phase of myocardium. During experiments in open-chest dogs, right ventricular pacing was performed for avoiding the acceleration of heart rate by stellate ganglion stimulation. Administration of phentolamine, propranolol or D600 prolonged APD, while hydrazine shortened it. However, stellate ganglion stimulation caused a prolongation of APD after infusion of propranolol or hydrazine, and a shortening of APD after infusion of phentolamine, D600 or hydrazine. These results indicate that alpha-and beta-adrenergic actions as well as calcium ions can be related to APD in the ventricular myocardium of dogs; apparently, alpha-adrenergic action prolongs APD and beta-adrenergic action shortens it.

Clinical features of acute coxsackie B viral myocarditis

Clinical features of 11 patients of acute Coxsackie B viral myocarditis diagnosed by neutralizing antibody titers were reported. All patients had a flu-like symptom and 8 patients had fever. Initial cardiac manifestations were congestive heart failure in 9 patients, and syncopal attack in 4 patients. Electrocardiographic abnormalities frequently observed were non-specific ST-T changes, low voltage, and intraventricular conduction, disturbances including 4 patients of complete A-V block due to trifascicular block. Ten patients had a rise of serum enzymes. It seemed that in severe patients the serum enzymes rose markedly. From the analysis of laboratory and histological findings. Coxsackie B viral myocarditis were often complicated by hepatitis.

Isolated stenosis of the pulmonary artery branches--an autopsy case with review of the literatures

A necropsy of a 21-year-old male with isolated stenosis of the pulmonary artery was presented. The pulmonary artery branches showed various fibrous thickening including atheromata and mural thrombi. Those findings appeared mostly in elastic and large muscular pulmonary arteries as well as in medium sized arteries, while the small arteries and arterioles remained in slight changes. Systemic large elastic arteries seemed to be small and showed atheromatous lesions similar to those of the main pulmonary arteries. Moreover, eight autopsy cases with pulmonary artery stenosis from the literature were shortly reviewed and some pathological findings as an aid for angiographic cardiovascular studies were discussed.

Aneurysm of the ductus arteriosus

A 59-year-old man with an aneurysm of the ductus arteriosus is described. Macroscopically and histologically it was ascertained that the aneurysm had originated from the ductus arteriosus itself. We suggest the following pathogenesis: after obliteration of the pulmonary end, the aneurysm was formed, and as a result of a gradual increase in pressure in the lumen, the obliterated pulmonary end, the aneurysm was formed, and as a result of a gradual increase in pressure in the lumen, the obliterated pulmonary end recanalized.

Preoperative evaluation of the structural lesion of the mitral valve by M-mode scan echocardiography

M-mode scan echocardiographic studies of the mitral valve were performed in order to investigate structural architecture of the diseased mitral valve. Structural lesion of the mitral valve was assessed by the echo-pattern change, an increase in number or thickness of the diastolic mitral echo complex. The echo-pattern was classified into 4 grades according to number or thickness of the mitral echoes. The echo-pattern grade correlated with the degree of the structural lesion of 21 surgically excised mitral valves. Clinically, the echo-pattern grade was compared with subsequent operative procedure in 56 cases with pure or predominant mitral stenosis (42 open commissurotomy, 14 valve replacement). Grade I or grade II echo-pattern was a good indicator for mitral commissurotomy. Grade IV pattern was a reliable criterion for valve replacement. Mitral valve replacement should be also considered in cases with grade III pattern, 38% of whom underwent valve replacement. C-E amplitude of the mitral valve was not a useful parameter in assessing the surgical procedure. Thus, the echo-pattern obtained by M-mode scan technique appeared to be of valve in planning the surgical approach for patients with pure or predominant mitral stenosis.

Noonan syndrome with hypertrophic obstructive cardiomyopathy

A case of a 20 years old female who had Noonan syndrome associated with obstructive cardiomyopathy was presented. It is well known that Noonan syndrome is frequently complicated with cardiac anomaly, and although no autopsies were performed two cases have been diagnosed clinically as Noonan syndrome accompanied with idiopathic cardiomyopathy in our country. The present case would be the first autopsied case in Japan of Noonan syndrome associated with idiopathic obstructive cardiomyopathy.

Effect of low protein diet on cardiac function and ultrastructure of spontaneously hypertensive rats loaded with sodium chloride

The effects of low protein diet on cardiac metabolic and structural changes subsequent to an extremely high pressure load were investigated. Spontaneously hypertensive rats(SHR) were divided into four groups, and fed the following diets for four weeks: 1) Group A: regular diet (23% protein) and water, 2) Group B: regular diet and 1% saline, 3) Group C: low protein diet (10% protein) and water, and 4) Group D: low protein diet and 1% saline. Two weeks after the start of feeding, there was no significant difference in the left ventricular ultrastructures between the corresponding regular and low protein diet groups. Four weeks after, degenerative findings such as streaming of Z lines, dilatations of smooth endoplasmic reticulum, and disarrangements of myofilaments appeared Group D, while in Group B electron microscopic findings indicated hypertrophy. Incorporation of [14C] leucine into the myocardial myosin B in Group D was significantly low, with a resulting fall of the LVdP/dtmax per integrated isometric pressure (IIP) and a rise of the left ventricular end-diastolic pressure (LVEDP), as compared to that in Group C at four weeks after the start of feeding. These observations suggest that, in the heart with an extremely high pressure load, low protein diet hinders the development of hypertrophy to the load with resulting heart failure.

Echocardiographic classification of hypertensive heart disease. A correlative study with clinical features

Forty patients with systemic hypertension were classified into 4 types based on the left ventricular echocardiographic findings. Patients with normal left ventricular echogram, type I, showed little clinical symptoms and signs of hypertensive involvement. Higher systolic pressure and marked hypertensive retinal and renal changes were observed in patients with symmetric hypertrophy of the left ventricle, type II. Congestive heart failure was dominantly present in those with dilatation of the left ventricle, type IV. High voltages and marked ST-T changes in electrocardiogram were usually found in patients with asymmetric septal hypertrophy, type III, while retinal and renal damages were mild. Left ventriculograms obtained from 6 cases in type III also revealed hypertrophy of the interventricular septum and one of them demonstrated left ventricular outflow tract obstruction. These cardiac features in type III, which are quite similar to those in hypertrophic cardiomyopathy, seemed to be a secondary change induced by systemic hypertension on the basis of some predisposition.