Surface marker studies on activated peripheral blood lymphocytes in idiopathic dilated cardiomyopathy

Expression of interleukin 2 (IL-2) receptor on peripheral blood lymphocytes after stimulation with concanavalin A (Con A) or anti-T3 monoclonal antibody was analyzed in patients with dilated cardiomyopathy (DCM) in order to clarify the abnormalities of lymphocyte activation mechanism in DCM. The expression of IL-2 receptor after the stimulation with either Con A or anti-T3 monoclonal antibody was found to be reduced in the patients with DCM when the results were compared with those of controls. A significant correlation was noticed between the expression of IL-2 receptor after Con A stimulation and T4+/T8+ cell ratio, and between the expression of IL-2 receptor after anti-T3 monoclonal antibody stimulation and the left ventricular end-diastolic pressure (LVEDP). The results suggest that there are abnormalities of lymphocyte activation in DCM and that the alteration may be associated with the cause or clinical conditions of DCM.

[Hypertrophic cardiomyopathy manifesting different modes of illness: report of three cases]

Three cases of hypertrophic cardiomyopathy (HCM) which presented with different modes of appearance of left ventricular hypertrophy are reported. Case 1: A 24-year-old man had three relatives with HCM. At 13 years of age, he showed no electrocardiographic or echocardiographic abnormalities characteristic of HCM. During the ensuing 11 years, he developed asymmetric septal hypertrophy (ASH) and systolic anterior motion of the mitral valve (SAM), with right bundle branch block and T-wave inversion. Cardiac catheterization confirmed the diagnosis of hypertrophic obstructive cardiomyopathy by demonstrating an intraventricular pressure gradient of 25 mmHg. These observations indicate that this case developed abnormal hypertrophy during adolescence on the basis of genetic predisposition of an autosomal dominant trait. Case 2: A 51-year-old woman had three proven and three possibly affected relatives. At 35 years of age, she had a normal electrocardiogram, although the echocardiogram was not available. Now, 16 years later, she had developed ASH with abnormal Q-waves and was diagnosed as having non-obstructive HCM. These suggest that ASH can be manifested as late as during middle-age, even in those with genetic predisposition. Case 3: A 47-year-old woman was diagnosed as having hypertension and her blood pressure was 190/100 mmHg at 40 years of age, though she had no abnormal electrocardiographic findings and heart murmurs. Now, at 47 years of age, she had developed T-wave inversion, ASH, SAM, and an intraventricular pressure gradient of 50 mmHg. Thus, her ASH appeared during middle-age, and was probably provoked by hypertension, though a complete family survey could not be conducted. These three patients' findings indicate that there may be various modes of appearance of left ventricular hypertrophy in HCM. In the majority of patients with genetic predisposition, abnormal hypertrophy may develop during adolescence as in Case 1. In others, it may develop in middle-age, as it did in Case 2. The disease spectrum of HCM may additionally include those who develop abnormal hypertrophy during middle-age, following provocation by hypertension, as in Case 3.

Quantitative evaluation of regional myocardial blood flow by videodensitometric analysis of digital subtraction coronary arteriography in humans

Videodensitometric analysis of digital subtraction coronary arteriography, a new approach for calculating contrast disappearance half-life (T1/2), was assessed in determining regional myocardial blood flow quantitatively. Forty-one patients with coronary artery disease and 12 with angiographically normal coronary arteries underwent digital subtraction coronary arteriography by manual injection of contrast medium into the left main coronary artery. The T1/2 was calculated from a time-density curve generated in the four sectors of the myocardium perfused by the left anterior descending coronary artery. The mean T1/2 value of the four sectors correlated inversely with the great cardiac vein flow measured by the thermodilution method (r = -0.89), and appeared to be a reliable index of myocardial blood flow. The relation of mean T1/2 with percent stenosis of the left anterior descending coronary artery was curvilinear (r = 0.88) and an abnormally high T1/2 occurred in patients with coronary stenosis greater than 75%. In patients with comparable stenosis of the left anterior descending artery, the apical T1/2 was significantly increased in those with impaired apical wall motion, while it was significantly decreased in those with coronary collateral vessels. These findings suggest that regional myocardial blood flow begins to decrease in vessels with greater than 75% stenosis, and that myocardial contraction and collateral flow are additional factors that modify regional myocardial blood flow. Thus, the contrast disappearance half-life (T1/2) derived by computerized washout analysis of digital subtraction coronary arteriograms proved useful as an index for quantitative evaluation of regional myocardial blood flow.

Comparable effects of oral diltiazem and verapamil in the treatment of hypertrophic cardiomyopathy. Double-blind crossover study

The effects of oral diltiazem, 180 mg/day, were compared with those of oral verapamil, 240 mg/day, in 32 patients with hypertrophic cardiomyopathy (HCM), using a double-blind crossover study design. In the first treatment period, diltiazem and verapamil improved subjective complaints in 83% and 71% of those who were symptomatic in the baseline period. Maximal oxygen consumption on exercise stress test increased with verapamil by 2.9 +/- 4.2 ml/Kg/min (p less than 0.05), and tended to increase with diltiazem. Verapamil also reduced the amplitude of negative T wave. In the statistical analysis based on the crossover design, diltiazem and verapamil did not differ in global improvement, overall safety and global utility ratings. In addition, both drugs showed comparable effects on electrocardiographic and echocardiographic variables and exercise tolerance except for minor differences in diastolic blood pressure, T wave amplitude and peak exercise heart rate. On the other hand, verapamil tended to induce more serious side effects, forcing the discontinuation of medication in 3 patients. Therefore, the present study indicates that diltiazem is essentially equally as effective as verapamil and is preferable in the treatment of patients with HCM since it may exhibit fewer serious side effects.

Relationship of exercise or pacing induced ST segment depression and myocardial lactate metabolism in patients with hypertrophic cardiomyopathy

To elucidate a mechanism and clinical implications of chest pain and ST segment depression during exercise in patients with hypertrophic cardiomyopathy (HCM), we investigated myocardial lactate metabolism during atrial pacing in 18 patients with HCM and 7 control subjects with normal coronary arteriograms. At an average peak pacing rate of 146 beats/min, 11 patients with HCM showed the lactate extraction ratio decreasing to less than 5%, and 6 of them produced lactate, suggesting the development of myocardial ischemia. These 11 patients with abnormal lactate metabolism demonstrated ST segment depression (82%) and chest pain (73%) during pacing and also presented abnormal results (55%) on an exercise stress test. These abnormal findings were not observed in the other 7 patients who had ratios of 5% or more at peak pacing. These observations suggest that ST segment depression and chest pain are manifestations of myocardial ischemia even in patients with HCM who have normal coronary arteriograms, and that patients with pacing induced abnormal lactate metabolism are at an increased risk of developing myocardial ischemia during exercise.

Lymphocyte subsets in patients with dilated cardiomyopathy and perimyocarditis

Lymphocyte subsets were analyzed in patients with DCM, arrhythmias following influenza symptoms and acute perimyocarditis, respectively by an automated laser flow cytometry system with the use of monoclonal antibodies. A lower percentage of OKT8+ cells and a high OKT4/OKT8 ratio were found in the DCM and arrhythmias groups. No phenotypic abnormalities in the lymphocyte subsets were found in patients with acute perimyocarditis who were favorably progressing in clinical features. The results suggest that an immunological disturbance thought to play a part of the pathogenesis of DCM or heart failure may cause the abnormality of lymphocyte subsets.

The role of drinking and cigarette smoking in the excess deaths from liver cancer

A long-term cohort study of 639 males in a farming area and 677 males in a fishing area in Kyushu, Japan, has been conducted to evaluate risk factors for ischemic heart disease. The present investigation utilized this long-term cohort study to assess the role of drinking and cigarette smoking habits in the causation of liver cancer. The O/E ratio (ratio of the observed to expected number of deaths) of liver cancer was 7.5 (P less than 0.001) among shochu drinkers in the fishing area. Further, a clear dose-response relationship of O/E ratio was noted: 5.7 (P less than 0.001), 7.5 (P less than 0.001) and 20.0 (P less than 0.001) for drinkers of less than 1, 1-2, and 2 or more units of shochu (a distilled alcoholic beverage made in Japan; about 25% alcohol). Although no excess risk was found among shochu drinkers in the farming area, observed and expected numbers were too small to make valid judgements. Among sake drinkers, the observed and expected numbers were very similar in both areas. Cigarette smokers in the fishing area appeared to have a high risk for liver cancer, the O/E ratio being 4.8 (P less than 0.001). However, there was no clear dose-response relationship and O/E ratios among cigarette smokers according to their drinking habits indicated no excess risk among nondrinkers. A multiple logistic regression analysis showed an insignificant effect of cigarette smoking on the development of liver cancer after adjustment for shochu drinking. These findings suggest a significant involvement of shochu drinking in the etiology of liver cancer, at least in this fishing area.

An advanced form of familial hypertrophic cardiomyopathy showing massive myocardial fibrosis with intramural small arterial thickening. An autopsy case

An autopsy case of an advanced form of hypertrophic cardiomyopathy (HCM) showing marked fibrosis with intramural small arterial abnormalities is presented in this report. A 52-year-old woman, who had a positive family history of HCM, was admitted because of palpitations. The chest roentgenogram showed a mildly enlarged cardiac silhouette and the electrocardiogram revealed abnormal Q waves and R wave and T wave abnormalities. The echocardiogram revealed hypokinesis with thinning of the interventricular septum and the anterior wall of the left ventricle. Percutaneous right ventricular endomyocardial biopsies demonstrated moderate interstitial fibrosis with small arterial thickening. At necropsy, the anterior and posterior walls of the left ventricle and the interventricular septum were markedly thinned and showed a massive transmural fibrosis. Moreover, the intramural small arteries, 50-300 microns in diameter, showed marked intimal and medial hypertrophy with proliferation of elastic fibers and smooth muscle cells. From these findings, it is suggested that this was originally a case of HCM which progressed to a decompensated stage because of the abnormal intramural small arteries. The significance of small arterial lesions in HCM is discussed.

Increased cardiovascular response to epinephrine in hypertrophic cardiomyopathy

To study the role of catecholamines in the pathogenesis of hypertrophic cardiomyopathy (HCM), hemodynamic responses to low and high dose infusions of epinephrine (0.037 and 0.074 micrograms/Kg/min) were compared between 21 patients with nonobstructive HCM and 21 healthy controls, matched for age and sex. During low dose infusion, patients with HCM showed significantly greater responses (p less than 0.05) than controls in echocardiographic left ventricular (LV) end-systolic dimension (-8 +/- 1% vs -4 +/- 1%, mean +/- SEM), fractional shortening (12 +/- 2% vs 7 +/- 1%) and peak systolic velocity of the LV posterior wall (32 +/- 5% vs 15 +/- 4%), but the differences disappeared during high dose infusion. Thus, patients with HCM started to respond to epinephrine earlier than controls and seemed to have an increased sensitivity of beta-adrenergic receptors in the cardiovascular system. As the augmented responses were more evident in younger patients (less than 35 years) who manifested frequent familial occurrences of HCM, the increased sensitivity to catecholamine was postulated to be genetically determined and to be related to the abnormal myocardial hypertrophy of HCM.

[Dysfunction of Carpentier-Edwards porcine mitral bioprosthesis causing a musical systolic murmur: a report of two cases]

Two patients with disruption of Carpentier-Edwards porcine mitral bioprosthesis presenting with a musical systolic murmur were reported. The two patients noted sudden development of a loud musical murmur 4 (Case 1) and 6.5 (Case 2) years after surgery. Case 1 had associated heart failure. Phonocardiogram disclosed a loud musical systolic murmur with regular vibrations at 230-240 Hz in Case 1, and 250-260 Hz in Case 2. In Case 1, echocardiography demonstrated fine fluttering of the porcine mitral valve at the same frequency as the murmur. Doppler echocardiography revealed characteristic Doppler signals from the porcine valves at a frequency of 250-300 Hz with several harmonics above and below the baseline. In addition, in Case 2, similar Doppler signals were obtained from the aortic walls, ventricular septum and posterior wall of the left ventricle. In both cases, left ventriculograms demonstrated grade 3 mitral regurgitation without paravalvular leakage, and at surgery, the porcine bioprosthesis showed a tear in one of markedly thinned cusps, without evidence of calcification. It was considered that a torn cusp was the source of the murmur, and this, in association with the resonance of the entire heart, produced the loud musical murmur. Thus, a musical systolic murmur is suggested to be one of important signs of dysfunction of porcine bioprosthesis.

Termination of ventricular tachycardia by an implantable atrial pacemaker and external pacemaker activator

An atrial pacemaker was implanted in a patient who had dilated cardiomyopathy, sinus node dysfunction, and drug-resistant ventricular tachycardia (VT). VT episodes were terminated by atrial overdrive pacing using an implanted pacemaker and a newly developed hand-held external programmer/transmitter. Although successful cases of termination of intractable VT by ventricular pacing have recently been reported, the ventricular method might increase the risk of accelerating VT. Atrial overdrive pacing is a safer method since it minimizes the possibility of tachycardia acceleration and, combined with antiarrhythmic drugs, it appeared to be a unique and useful approach for the treatment of drug-resistant VT.

[Left ventricular peak filling velocity and its relevant factors in hypertrophic hearts]

To evaluate the relevant factors of left ventricular peak filling velocity, M-mode echocardiograms showing the left ventricular cavity were recorded and digitized for 81 patients with hypertrophic hearts (HTH) due to hypertensive heart disease (HHD, n = 30), hypertrophic cardiomyopathy (HCM, n = 25), aortic valve stenosis (AS, n = 9), and HHD and HCM with congestive heart failure (HHD and HCM with CHF, n = 17). Peak rates of increase or decrease in dimension (Vf and Ve, respectively) and peak values of instantaneous circumferential fiber lengthening and shortening velocities (Vf/D and Ve/D, respectively) were determined by computer analysis of left ventricular internal dimensions. Systolic excursion (SE), percent fractional shortening (%FS), mean circumferential fiber shortening velocity (mVcf), thickness of the interventricular septum and posterior wall at end-diastole and the sum of them (WThivs, WThpw, and WThivs + pw, respectively) were also calculated. Their variables were compared with those of normal subjects (n = 24). The results obtained were as follows: Systolic functions in HTH without CHF were similar to those of the normal subjects, but Vf and Vf/D were significantly decreased. Differences in Vf and Vf/D between various HTH without CHF were not significant. In AS and HTH with CHF, Vf and Vf/D were significantly decreased together with systolic function. Vf correlated significantly with WThivs + pw, SE, Ve, and WThivs, and Vf/D with %FS, SE, Ve/D, and Ve.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical management of infective endocarditis; limitations and indication for surgery

Problems and limitations of medical management for infective endocarditis were studied and surgical indications were discussed based on the retrospective analysis of 55 episodes. Since perioperative complications still occur during highly active infection, antibiotic treatment was suggested as the primary management. Intractable or progressing heart failure appeared to be a definite indication for emergency surgery, but medical therapy was recommended for mild to moderate heart failure. For uncontrolled infection of more than one month duration despite the best available antibiotics, surgical debridement of the infected tissue was indicated. Occurrence of peripheral or fatal emboli was difficult to predict from clinical features and echocardiogram and therefore presented a therapeutic dilemma. Since major or fatal emboli frequently occurred during highly active infection, early initiation of effective antibiotic therapy was considered to be of primary importance. Demonstration of vegetation by echocardiography alone did not seem to justify urgent surgery. In addition, disseminated intravascular coagulation appeared to be a serious complication and thus sedimentation rate should be followed carefully. In the healed stage, prophylactic surgery seemed unnecessary for prevention of recurrent infection or embolization, as they were relatively rare.

Research on cardiomyopathy in Japan

Many experimental and clinical studies have been performed in Japan, since the Idiopathic Cardiomyopathy Research Committee sponsored by the Ministry of Health and Welfare of Japan was organized in 1974. Much interest has been focused on myocarditis as a possible pathogenesis of dilated cardiomyopathy and extensive experimental studies have been performed as well as histopathologic assessment at autopsy or biopsy. In the clinical field, suspected cases of myocarditis are not uncommon, but determination of etiological viruses is quite difficult in most patients except at the acute stage. Therefore, endomyocardial biopsy has been recently introduced in more than 13 institutes in Japan in an effort to obtain more accurate diagnosis. In 1983, the Idiopathic Cardiomyopathy Research Committee performed a study on the prognosis of cardiomyopathy in 1255 patients (786 hypertrophic and 469 dilated). The prognosis of dilated cardiomyopathy was poor, with a 5-year survival rate of only 54.3%. This figure contrasted with the better prognosis in those with hypertrophic cardiomyopathy (92%).

Serum N-acetyl-beta-D-glucosaminidase activity in a large population--a useful index of cardiovascular impairment

Serum N-acetyl-beta-D-glucosaminidase (NAG) levels were measured in 1080 residents in Tanushimaru, Fukuoka, aged 20 to 84 years old, during a periodical epidemiological survey performed in 1982. Thirteen pregnant women were excluded from this study. Serum NAG levels showed an increase with age, but were not different between sexes. We found high serum NAG values in those with high blood pressure, high serum total cholesterol, low serum HDL-cholesterol, or reduced creatinine clearance rate, and women with high serum uric acid, increased skinfold thickness, or high hematocrit. Multiple regression equation was as follows: NAG = 3.53 + 0.07 (age) + 0.14 (hematocrit) + 0.03 (total skinfold thickness) + 0.04 (systolic blood pressure) - 0.03 (HDL-cholesterol) - 0.04 (mean blood pressure) - 0.01 (creatinine clearance). The multiple correlation coefficient was 0.37 (F = 24.4). We suggest that NAG may be a useful index in screening cardiovascular impairment and for cardiovascular risk factors.

Changes of left ventricular pressure-diameter-velocity relations by alterations of heart rate in conscious dogs

Changes of left ventricular (LV) pressure-diameter-velocity relations by alterations in heart rate (HR) were investigated in 6 conscious dogs, instrumented with a pair of ultrasonic crystal probe, a micromanometer in LV and pacing electrodes on the left atrium. By atrial pacing the following four stages of HR were produced: stage (S)-I 112, S-II 134, S-III 158 and S-IV 179 bpm (mean HR). These alterations in HR were repeated before and during acute pressure loadings by methoxamine infusion. LV pressure-diameter and pressure-velocity relations were evaluated by the slope value of LV peak systolic pressure (LVSP)-end-systolic diameter, E (D) max, and by the ratio of changes in mV cf (mean velocity circumferential fiber shortening) and LVSP before and during pressure loading, delta mVcf/delta LVSP, respectively. The average of E(D) max at each stage of HR was 9.45, 12.63, 12.59, 11.22 mmHg/mm, and delta mVcf/delta LVSP was -0.009, -0.006, -0.007, -0.009 circ./sec.mmHg, respectively. E(D) max increased more at S-II and S-III than at S-I, and reversely, E(D) max decreased more at S-IV than at S-II. Similarly, delta mVcf/delta LVSP increased more at S-II than at S-I and decreased more at S-IV than at S-II, while delta LVSP and delta EDD (end-diastolic diameter) were not different between stages. These changes in E(D) max and delta mVcf/delta LVSP presented the mountainous pattern effected by alterations in HR, whose changes were almost similar to that of LV peak positive dp/dt and mVcf before pressure loading. Thus, E(D) max is augmented by an increase in HR, which suggests the Bowditch-effect. Reversely, a decrease in E(D) max at a higher rate indicates a depressed inotropic state. E(D) max is dependent on HR and is a sensitive indicator of the contractility of LV.