[Mitral valve lesions in patients with right ventricular pressure overload: analysis using realtime, two-dimensional echocardiography]

Mitral valve lesions in patients with right ventricular pressure overload, such as pulmonary stenosis, tetralogy of Fallot, and pulmonary hypertension, were studied by real-time, two-dimensional echocardiography, and the following results were obtained. The abnormality observed in the mitral valve was a systolic dislocation of the anterior and posterior mitral leaflets at the coaptation zone. Mitral valve lesions were noted in 16 of 46 cases, i.e. nine of 11 with pulmonary hypertension (82%), four of 20 with tetralogy of Fallot (20%), and three of 15 with pulmonary stenosis (20%). The incidence was highest in patients with pulmonary hypertension. In eight of 16 cases with mitral valve lesions, mitral regurgitation was observed by either left ventriculography or two-dimensional Doppler echocardiography. Mitral valve lesions were always located at the posteromedial commissure of the anterior mitral leaflet. Considering the previous similar reports in secundum atrial septal defect, we attributed the cause of the mitral valve lesions to the same mechanism. No clear relation could be found between the left ventricular deformity index and the incidence of mitral valve lesion. Therefore, we could not conclude about the mode of production of mitral valve lesions occurring in the diseases with right ventricular pressure overload.

Mitral valve abnormalities in patients with right ventricular pressure overload. Analysis by real time cross sectional echocardiography

Abnormalities of the mitral valve in patients with pulmonary stenosis, tetralogy of Fallot, and pulmonary hypertension with right ventricular pressure overload were studied by real time cross sectional echocardiography. Dislocation of the anterior and posterior mitral leaflets at the coaptation zone in systole was present in 16 of 46 cases: nine of 11 (82%) cases of pulmonary hypertension, four of 20 (20%) cases of tetralogy of Fallot, and three of 15 (20%) cases of pulmonary stenosis. The incidence was highest in patients with pulmonary hypertension. In eight of the 16 patients with mitral valve lesions, mitral regurgitation was seen on left ventriculograms or cross sectional Doppler echocardiograms. The dislocation was located near the posteromedial commissure of the anterior mitral leaflet in all cases. These findings are similar to the mitral valve abnormalities seen in patients with secundum atrial septal defect, and therefore may be due to a common cause. No relation could be found between the left ventricular deformity index and the incidence of dislocation of the mitral leaflets. Thus, the reason why this mitral valve abnormality occurs in conditions with right ventricular pressure overload could not be established.

Echocardiographic features of bioprosthetic valve endocarditis

Abnormal echocardiographic findings in seven cases of bioprosthetic valve endocarditis were confirmed in six at operation. The echocardiograms showed three cases with thickening and increased echo intensity (group 1) and four (group 2) in which vegetations were seen initially without either of the two features in group 1. Two patients in group 1 had vegetations, the causative organism being a streptococcus. Staphylococcus epidermidis was the causative organism in three of the four cases in group 2; in two of these rapidly growing vegetations were detected. The large vegetations obstructed the ostium of the bioprosthetic valve. Thus if vegetations are detected in cases in which staphylococci are the causative bacteria surgery should be performed as soon as possible. In patients who develop a fever after bioprosthetic valve replacement and especially in those with evident bacteraemia echocardiography should be repeated frequently so that lesions may be detected early.

Clinical features of intracardiac thrombosis based on echocardiographic observation

The nature of intracardiac thrombi were studied, which were the clinical underlying conditions, relation to systemic embolism, growth of thrombus and effect of anticoagulant therapy on the size of the thrombi, in 818 patients with mitral valve disease and 1000 patients with myocardial infarction by two-dimensional echocardiography. (1) Common underlying conditions were atrial fibrillation, enlarged left atrial cavity and predominance of mitral stenosis in cases with left atrial thrombi, and apical asynergy and low ejection fraction in cases with ventricular thrombi. The blood stasis should be the major factor in the formation of intracardiac thrombi. In a condition of blood stasis, dynamic intracavitary echoes which may represent erythrocyte aggregation were observed. (2) The incidence of systemic embolism in patients with thrombi was higher than that in patients without thrombi in cardiac disease. (3) The intracardiac thrombi were living. They grew and/or reduced their size spontaneously and sometimes became detached from the cardiac wall in the form of ball thrombi. (4) The effect of anticoagulant therapy on the regression of thrombi depends on its age.

Chaotic echo motion in the left ventricular cavity. Visualization of ruptured chordae tendineae of the mitral valve by real-time two-dimensional echocardiography

The aim of the present study is to perform a detailed analysis of the spot echoes which show chaotic motion of the left ventricular cavity of patients with ruptured chordae tendineae. The subjects were 12 patients with surgically documented ruptured chordae tendineae. They were carefully examined preoperatively by real-time two-dimensional echocardiography with a commercially available wide-angle phased array system (Toshiba SSH-11A). An abnormal moving spot echo was often seen instantaneously in the left ventricle. Its motion was chaotic, and it moved both longitudinally and laterally. Lateral movements were seen in 10 of the 12 subjects and were not found in any of 10 controls. The site of this echo in the left ventricle was identical with the site of the rupture of the mitral chordae confirmed during surgery. Therefore, it was concluded that the spot echo with chaotic motion represents a direct visualization of ruptured chordae. This chaotic motion is considered to be a useful clue in diagnosis. The lateral component (left to right) of the movement is especially important. However, one must carefully examine the left ventricular cavity with moving pictures over a period of many heart beats in order to detect these chaotic movements of spot echoes.

Time course of deacclimatization to cold water immersion in Korean women divers

Seasonal basal metabolic rates (BMR), critical water temperature (Tcw), maximal body insulations (Imax), and finger blood flow during hand immersion in 6 degrees C water (Q finger) were measured periodically during the course of a 3-yr longitudinal study (1980-1982) of modern Korean diving women (ama), who have been wearing wet suits since 1977 to avoid cold stress during work. Methods and protocols were identical to previous studies of cotton-suited ama from 1961-1974. The BMR of modern ama did not undergo seasonal fluctuation (1980-1981) and was within the DuBois standard and comparable to nondivers year around Tcw of ama was still reduced by 2-3 degrees C in 1980 but increased progressively to equal that of nondivers in 1982, when compared at comparable subcutaneous fat thickness (SFT). Since modern ama and nondivers have 2.4 times thicker SFT (i.e., 4-13 mm) than in 1962 the absolute Tcw is significantly reduced. Q finger of ama was also significantly lower than controls in 1980 but in 1981-1982 was identical to controls. Imax of modern ama was identical to controls of comparable SFT in 1980-1982. The time course of cold deacclimatization thus was BMR, 3 yr; Imax, 3 yr; Q finger, 4 yr; and Tcw, 5 yr. This longitudinal study provides further evidence that acclimatization to cold did at one time exist in these diving women.

Energetics of wet-suit diving in Korean women breath-hold divers

Contemporary Korean women divers wear wet suits during diving work to avoid the cold water stress. The present study was undertaken to evaluate the effect of wearing wet suits on the daily thermal balance of divers and on the duration of diving work. Rectal (TR) and skin temperatures and O2 consumption (VO2) were measured in four divers before and during diving work in summer (22.5 degrees C water) and winter (10 degrees C water). Subjects wore either wet suits (protected) or cotton suits (unprotected) for comparison. TR decreased 0.4 degrees C in summer and 0.6 degrees C in winter after 2 h of diving work in protected divers, while it decreased to 35 degrees C in 60 min in summer and in 30 min in winter in unprotected divers. Mean skin temperature of protected divers decreased to 31 degrees C in summer and 28 degrees C in winter, while that of unprotected divers decreased to 24 degrees C in summer and 13 degrees C in winter. VO2 toward the end of the diving work period increased by 80 (summer) and 140% (winter) in protected divers and by 160 (summer) and 250% (winter) in unprotected divers. From these values total thermal cost of diving work was estimated to be 260 and 370 kcal . day-1 in summer and winter, respectively.

Supravalvular aortic stenosis and coronary ostial stenosis in familial hypercholesterolemia: two-dimensional echocardiographic assessment

The lesions of the aortic root, which are supravalvular aortic stenosis and coronary ostial stenosis, in familial hypercholesterolemia were studied using two-dimensional echocardiography. The subjects were 25 heterozygotes, six homozygotes and 30 control subjects. The internal diameters of the aortic ring, the sinus of Valsalva and the supravalvular aortic ring were measured. Measurement variation due to body size was avoided by normalizing the latter two values by the diameter of the aortic ring. Four heterozygotes and all homozygotes were judged to have stenosis of the supravalvular aortic ring; none of heterozygotes and four homozygotes had stenosis of the sinus of Valsalva. In three of the four patients with stenosis of both the supravalvular aortic ring and the sinus of Valsalva, a pressure gradient was demonstrated. The degree of supravalvular aortic stenosis correlated with the serum cholesterol level but not with patient age. All homozygotes, even very young ones, had a severe aortic root lesion. In the short-axis view of the aortic root, a lump (raised mass) on the aortic wall indicating atheromatous plaquing was demonstrated in five heterozygotes and all homozygotes. Coronary ostial stenosis was shown in three of the four patients whose plaquing echoes were adjacent to the coronary orifice. We conclude that two-dimensional echocardiography is useful in diagnosing lesions of the aortic root in patients with hypercholesterolemia.

[Diastolic filling of the right ventricle in hypertrophic cardiomyopathy studied with 2-dimensional Doppler echocardiography]

Inflow pattern at the tricuspid orifice was examined using two-dimensional Doppler echocardiography. The cases examined consisted of 24 cases of hypertrophic cardiomyopathy (HCM), 10 cases of left ventricular hypertrophy (LVH) due to hypertension or aortic valvular stenosis and 23 healthy subjects. The right ventricular inflow pattern in HCM was characterized by a slow deceleration of a rapid filling wave, an increase in the duration of an inflow due to atrial contraction and an increased ratio of the peak velocity in atrial contraction phase to that in rapid filling phase (A/R). No definite difference was noted in the right ventricular inflow pattern between HCM with and without left ventricular obstruction. The abnormalities in the right ventricular inflow pattern in LVH were similar to those in HCM. The abnormal inflow patterns in HCM and LVH suggested a reduced distensibility of the right ventricle in early diastole and the compensatory augmentation of right atrial contraction. The changes in the deceleration of the rapid filling wave and A/R ratio were significantly correlated with interventricular septal thickness (base and papillary muscle levels) in cases with LVH. This result seemed to indicate that the changes in the right ventricular inflow are mainly resulted from the influence of hypertrophy of the interventricular septum on right ventricular function. There was hypertrophy of the interventricular septum in all cases of HCM and, in addition, that of the right ventricular anterior wall in some of them. The changes in the inflow pattern in HCM are also considered to be resulted from hypertrophy of the right ventricular anterior wall and the influence of hypertrophy of the interventricular septum on right ventricular function. However, in the cases of HCM, the extent of the changes showed no significant correlation with right ventricular anterior wall thickness and interventricular septal thickness. In HCM, hypertrophy of the interventricular septum and right ventricular free wall may coexist, and ventricular hypertrophy is often nonuniform and may exhibit disarrangement in myocardial architecture. Therefore, influential factors on the right ventricular inflow are considered to be more complicated in HCM than in LVH, resulting in the absence of significant correlation to the abnormal inflow mentioned above.

Mechanism of systolic anterior motion of mitral valve and site of intraventricular pressure gradient in hypertrophic obstructive cardiomyopathy

The mechanism of systolic anterior motion of the mitral valve and the localisation of the intraventricular pressure gradient were determined in 15 cases of hypertrophic obstructive cardiomyopathy by the combined use of real time two dimensional echocardiography and intracardiac manometry. We arrived at the following conclusions. The systolic anterior motion of the mitral echo in the M-mode echocardiogram can be classified into two types, I and II, based on two dimensional echocardiographic findings. In type I, the echo sources of systolic anterior motion are the anteriorly shifted mitral chordae and, in part, the papillary muscles. The intraventricular pressure gradient occurs at the level of the tip of the papillary muscle. The suprapapillary part of the outflow tract and the inflow part show a low pressure, while the apical cavity shows a high pressure. In type II, the echo sources of systolic anterior motion are the anterior and posterior mitral leaflets which are oriented in such a way as to obstruct the outflow tract. The pressure gradient occurs at the level of the anterior and posterior mitral leaflets. The inflow tract and the outflow tract just below the mitral leaflets show a high pressure, in contrast to type I systolic anterior motion. The inappropriate and maloriented papillary muscles play an essential role in causing both types of systolic anterior motion and outflow obstruction. The direction of the axis of the papillary muscle is changed in late systole, moving its tip away from the interventricular septum, resulting in a simultaneous reduction in systolic anterior motion.

Mitral valve lesion associated with secundum atrial septal defect. Analysis by real time two dimensional echocardiography

Mitral valve lesions accompanying secundum atrial septal defect were examined in 120 successive patients from May 1978 to December 1980 using real time two dimensional echocardiography. The conclusions were as follows: (1) The characteristic feature of the mitral lesion accompanying secundum atrial septal defect is a dislocation of the mitral leaflet toward the left atrial side in the area of coaptation. (2) The mitral lesion is seen in about half the patients with secundum atrial septal defect. (3) It is usually seen only in the anterior leaflet, and is found near the posteromedial commissure. Lesions in other sites on the leaflet all accompany those near the posteromedial commissure. (4) The incidence, extent, and degree of the mitral valve lesion increase with age. (5) It is assumed that the mitral valve lesion in secundum atrial septal defect starts near the posteromedial commissure in the anterior leaflet, gradually deteriorates, and extends toward the anterolateral commissure. (6) It is probable that the mitral lesion results in mitral regurgitation. (7) The mitral valve lesion is similar in appearance to mitral valve prolapse caused by the floppy mitral valve, though their causative factors may be different. It is probably the reason why the mitral valve abnormality has been described as mitral valve prolapse in previous reports. In the present study the mitral lesion was evaluated on the distance of the dislocation between both leaflets at the area of coaptation. These criteria proved useful. Because of the similarity in appearance, it may be helpful in the assessment of primary mitral valve prolapse.

[New echocardiographic criterion in the diagnosis of mitral valve prolapse]

Currently, echocardiographic diagnosis of mitral valve prolapse is made when the mitral leaflets protrude into the left atrium crossing the mitral ring. However, there remains the possibility that some mitral valve prolapse, particularly mild one, is overlooked by the currently used criterion. In the present study, new echocardiographic criterion in the diagnosis of mitral valve prolapse is proposed. The criterion includes the systolic dislocation of the mitral leaflets at its coaptation zone. The validity of the new criterion is supported by the following facts. (1) Dislocation of the mitral leaflets at the coaptation zone was never observed in healthy subjects. (2) Real-time two-dimensional echocardiograms from eight cases with a midsystolic click and a late systolic murmur, the characteristic phonocardiographic findings of mitral valve prolapse, invariably demonstrated the dislocation of either the anterior or posterior mitral leaflet at the coaptation zone leading to the diagnosis of mitral valve prolapse. Four of five cases with a midsystolic click and a holosystolic murmur were also diagnosed echocardiographically as mitral valve prolapse based on the proposed criterion. However, two of the former cases and one of the latter cases did not demonstrate the protrusion of the mitral leaflets into the left atrium crossing the mitral ring, indicating inability to diagnose mitral valve prolapse based on the commonly adopted criterion. (3) Based on the extent and degree of dislocation of the coaptation of the mitral leaflets, mitral valve prolapse could be classified into nine grades. It was found that the incidence of mitral regurgitation proved by phonocardiography or angiocardiography is higher as the grade of prolapse becomes greater.

[Mitral regurgitation in hypertrophic cardiomyopathy: an analysis with two-dimensional ultrasonic Doppler echocardiography]

Intracardiac blood flow pattern in the left ventricle and left atrium was noninvasively studied by the ultrasonic pulsed Doppler flowmeter incorporated with a real-time, phased array two-dimensional echocardiography in 28 cases of hypertrophic cardiomyopathy. Emphasis was placed on the incidence and characteristic features of mitral regurgitation in this condition. The relationship of mitral regurgitation with an early systolic murmur was also studied. The results were as follows: 1) A mitral regurgitant signal by Doppler technique was noted in all cases of hypertrophic obstructive cardiomyopathy and in half of the cases of hypertrophic nonobstructive cardiomyopathy. 2) The Doppler signal of mitral regurgitation began immediately after the first heart sound. 3) The mitral regurgitant flow spread over the left atrium or directed toward the posterior half of the left atrium in the obstructive cases. However, it was localized in the vicinity of the mitral orifice in the nonobstructive cases. These findings were different from those in rheumatic mitral regurgitation or idiopathic mitral valve prolapse. 4) The findings on mitral regurgitation by the Doppler technique exhibited a satisfactory correspondence to those by left ventriculography. 5) The early part of the systolic murmur in hypertrophic cardiomyopathy was considered to be more closely related to mitral regurgitation than a turbulent forward flow due to outflow obstruction. Therefore, mitral regurgitation might have some contribution in causing a murmur in the latter period of systole.

Effect of ventricular hypertrophy on conduction velocity of activation front in the ventricular myocardium

To study the effect of ventricular hypertrophy on conduction velocity of the activation front noninvasively, transmural conduction indexes were obtained from findings of echocardiography and body surface potential mapping performed in 40 patients with right bundle branch block uncomplicated by the left anterior fascicular block. Because in these patients, left ventricular activation proceeds radially without being modified by right ventricular activation, the index was obtained by dividing ventricular septal thickness measured from the echocardiogram by transmural conduction time, which was taken as the time interval from the onset of the QRS complex to the time when the left ventricular epicardial breakthrough minimum appeared on the potential map. The indexes, ranging from 11 to 45 cm/s, has a good positive linear correlation with the septal thickness (Y = 2.37X - 1.33, correlation coefficient [r] = 0.83) and were abnormally small in some failed hearts. Further, both the mean ventricular activation times in lead V5 and the mean value for total duration of left ventricular activation did not differ significantly in patients with and without left ventricular hypertrophy. These findings suggest that conduction velocity was increased in the hypertrophied ventricle and decreased in the failed hearts. Because there were no significant differences in the mean serum sodium and potassium concentrations in the patients with and without left ventricular hypertrophy, it is concluded that hypertrophy itself most likely caused greater conduction velocity. Enlarged cells and multiple intercalated discs abundant in hypertrophied ventricle would have facilitated intercellular current flow and, hence, conduction velocity and impaired cellular connection in the failed heart would have reduced them. Thus, the transmural conduction index is suggested to be an important aid in interpreting electrocardiograms as well as in estimating the pathologic state of the heart.

Idiopathic mitral valve prolapse-analysis by real-time two-dimensional echocardiography

Mitral valve prolapse is diagnosed in real-time two-dimensional echocardiograms when there are discrepancies in the coaptation zone of the anterior mitral leaflet and the posterior mitral leaflet. Out of the 100 cases of mitral valve prolapse diagnosed in this way, 65 had prolapsed anterior mitral leaflets, 28 prolapsed posterior mitral leaflets and 7 prolapses of both the anterior and posterior mitral leaflets. In addition to the cases with mitral valve prolapse 23 cases of ruptured chordae tendineae of the mitral valve, including 15 cases which had undergone surgery, were investigated. The frequent site of mitral valve prolapse was the posteromedial commissure in the anterior leaflet and the posteromedial and anterolateral commissures in the posterior leaflet. These sites coincide with those where rupture of the chordae tendineae of the mitral valve was apt to occur. An investigation of the relation between age and mitral valve prolapse showed that the number of cases of prolapsed anterior leaflet did not increase with age, but there was an age-related increase in the number of cases of prolapsed posterior leaflets. It was also found that the degree of the prolapse progressed with age. Many of the cases of ruptured chordae tendineae of the mitral valve were in their forties or fifties, and there appeared to be some relation between the progress of the prolapse and age. Mitral regurgitant murmurs were recorded on phonocardiograms, and the severer the degree, the wider the range of the prolapse. Mitral regurgitation was more likely to occur in cases of prolapsed posterior leaflets than in those with prolapsed anterior leaflets, even if the degree and the range of the prolapse were mild.

[Evaluation of myocardial ischemia by (RAO) long-axial myocardial imaging using slant-hole collimator]

Myocardial perfusion imaging with thallium chloride has been found to be effective in the clinical evaluation of patients with myocardial infarction. However, conventional myocardial perfusion imaging of the myocardium showing the postero-septal and antero-lateral wall cannot be obtained clearly by the conventional collimator due to the inevitable distance between the collimator and the heart. In contrast, 30, 60-degree RAO images were obtained clearly using slant-hole collimator with the collimator closely contact with the heart, which enables us to observe the postero-septal and antero-lateral walls of the myocardium. As a result, we obtained myocardial perfusion images every 30-degrees in a radial direction. By dividing RAO images into 12 segments, we compared perfusion defect in the myocardial scintigram with akinesis detected by echocardiography and contrast left ventriculography segmentally and referred to the character and accuracy of these three examinations. As a result, these three methods well agreed in cases with myocardial infarction of single vessel disease, but did not always agree in cases with triple vessel disease. The character of each method was as follows: 1) Left ventriculography, which gives direct information concerning wall motion of the left ventricle, was most sensitive to detect ischemic lesions, but had a tendency to overestimate hypokinesis of wall motion due to its invasive nature. 2) In myocardial scintigraphy, when hypoperfusion is associated with perfusion defect, we occasionally diagnose mistakenly the hypoperfusion area as normal because the scintigraphic evaluation is based on the relative distribution of perfusion. To avoid such underestimation, exercise myocardial scintigraphy should be performed and myocardial ischemia should be evaluated by comparing exercise images with redistribution images. Moreover, we studied extension of perfusion defect in the anterior and infero-posterior infarction groups. In anterior myocardial infarction, perfusion defect extended beyond the apex and reached the point one-third away from the apex to the base. In infero-posterior myocardial infarction, perfusion defect extended into the apex but did not exceed the apex. It seemed that the most suitable point to make the boundary between apical and infero-posterior areas was the point one-third away from the apex to the base along the inferior half of the RAO image of the myocardium.

Echocardiographic study of abnormal position and motion of the posterobasal wall of the left ventricle in cases of giant left atrium

In 35 of 70 patients with rheumatic mitral valve disease, two dimensional echocardiography revealed the posterobasal wall of the left ventricle to be entrapped between the left ventricular and atrial cavities and bent inward. The motion of the bending segment was paradoxical. This abnormality was assumed to be induced by the left atrial dilatation extending inferiorly behind the left ventricle, because the length of the bending segment correlation with the left atrial dimension. There was no correlation between the degree of abnormal bending and left atrial pressure, mitral valve pressure gradient or left ventricular dimension. The systolic excursion of the posterobasal wall of the left ventricle was reduced according to the length of the bending segment. This abnormal feature was also observed in five postmortem heart specimens with an extremely dilated left atrium. The macroscopic and microscopic findings in the myocardium of the bending segment were not different from those of the remaining segment of the left ventricle. Therefore, the asynergic motion of the bending segment is assumed to be caused by the abnormal spatial orientation of the left ventricle and the left atrium. It should be considered that the giant left atrium not only oppresses the surrounding organs but also affects the left ventricle.

[Mechanism of the systolic anterior motion of the mitral valve and site of the intraventricular pressure gradient in hypertrophic obstructive cardiomyopathy (author's transl)]

The mechanism of the systolic anterior motion (SAM) of the mitral valve and the relationship between SAM and the intraventricular pressure gradient in hypertrophic cardiomyopathy were analyzed. The subjects were 15 cases, in which SAM was observed on the M-mode echocardiograms. Real-time two-dimensional echocardiography was performed at the time of cardiac catheterization and the measurement of left ventricular pressure was made with observing the spatial relationship between the tip of of the catheter and the surrounding intracardiac structures. There were two modes of the systolic anterior motion of the mitral valve in cases with SAM as follows: (1) The hypertrophied papillary muscle protruded into the left ventricular cavity in systole and it caused the displacement of the chordae tendineae, but also the tips of both anterior and posterior mitral leaflets were anterosuperiorly pulled up by the enlarged papillary muscles and the leaflets seemed apparently to intersect the left ventricular outflow tract (type II). These two types seem to make a continuous spectrum. Seven of the 15 cases examined exhibited type I and 8 cases exhibited type II or the intermediate condition. In the cases of type I, the pressure gradient was noted at the level of the tip of the papillary muscles. The inflow tract and the suprapapillary of the outflow tract exhibited a low pressure, while the apical cavity exhibited a high pressure. It is suggested that the enlarged papillary muscles make the ventricular cavity much more narrowly, resulting in the development of pressure gradient at their level. In the cases of type II, the pressure gradient was noted across the anterior and posterior mitral leaflets perpendicular to the outflow tract (subaortic area). The inflow tract exhibited a high pressure in contrast to that in the cases of type I. It is suggested that the anterosuperiorly pulled anterior and posterior leaflets dam up the ventricular cavity, resulting in the development of pressure gradient across them. Here, it should be emphasized that not only the anterior mitral leaflet, but also the posterior leaflet participates to yield the SAM and the intraventricular pressure gradient.

A study on the transmural conduction velocity of activation front in the left ventricle of RBBB patients

To investigate the effect of ventricular hypertrophy on the conduction velocity, the transmural conduction velocity was obtained from the findings of echocardiographic, and body surface potential mapping examinations on 20 RBBB patients. The transmural conduction velocity was linearly correlated with the ventricular septal thickness and the greater the thickness, the faster was the conduction velocity. There was no statistically significant difference in the duration of the left ventricular activation obtained from the mapping examinations as well as in the time of onset of intrinsicoid deflection in V5 between the group of left ventricular hypertrophy and that of non-hypertrophy. There was a good linear correlation between the imaginary distance covered by the activation front which proceeded in the direction from endocardium to epicardium during the left ventricular activation and the ventricular septal thickness. These findings were explicable from the faster conduction velocity in the hypertrophied ventricle. The increase in the conduction velocity in the hypertrophy group would be due to cable characteristics of hypertrophied cardiac cells and also due to increase in the number of multiple intercalated discs in the hypertrophied ventricle. It was concluded that the conduction velocity would be an important information to interpret the ECGs in ventricular hypertrophy as well as to estimate the pathological state of the heart.

[Echocardiographic features of the eustachian valve and its clinical significance (author's transl)]

The detailed informations and clinical significance of the Eustachian valve have not yet been elucidated. Real-time two-dimensional echocardiography has enabled one to investigate the Eustachian valve non-invasively. The valve was usually very small. The larger valve was a few cm in length and moved with heart beat. Its motion was analyzed with M-mode echocardiography. In the cases with sinus rhythm, the valve opened gradually in systole, and opened further in rapid filling phase,. followed by the rapid closing at the time of atrial contraction. In the cases of atrial fibrillation with severe tricuspid regurgitation, the valve remained at the semi-closed position throughout systole and opened in rapid filling phase. In one case of tricuspid regurgitation the valve was observed to flutter in systole. After the surgical repair of the tricuspid valve, systolic opening of the valve was noted, though atrial fibrillation persisted.

[Visualization of the false tendon in the left ventricle with echocardiography and its clinical significance (author's transl)]

Echocardiographic features of the false tendon in th left ventricle and its clinical significance were reported. The subjects consisted of 132 consecutive patients, in whom the left ventricle was satisfactorily examined from various aspects with two-dimensional echocardiography. In general, the false tendon was detected in the long axis view of the left ventricle from the apical approach. It was detected in 61 of 132 consecutive patients with echocardiography. The incidence did not seem to be related to the kinds of underlying conditions. The false tendon was usually a string, a few millimeters in width, crossing the ventricular cavity from the vicinity of the papillary muscles to the interventricular septum. In a few patients it looked as Y-figure and net like. Sometimes, several sticks of the false tendon were detected. It was observed to be stretched in diastole and relaxed in systole. On the M-mode echocardiogram the false tendon was displayed as a linear echo moving with heart beat. The false tendon revealed near the interventricular septum, exhibited a motion so similar to that of the interventricular septum that it should be carefully differentiated from the echo of the left ventricular surface of the septum. In 2 patients of valvular heart disease, it was observed to be fluttered in diastole. Echocardiography was more useful in detecting the false tendon than left ventriculography.

Mitral cleft in ostium primum atrial septal defect assessed by cross-sectional echocardiography

We attempted to detect mitral deformities in ostium primum atrial septal defect using real-time cross-sectional echocardiography. Transverse sections of the anterior mitral leaflet echo were examined in 11 patients with this malformation who subsequently received surgical treatment. The section for observing the transverse view of te anterior leaflet was along the sagittal plane of the body, because of the deformity of the mitral annulus. Each echocardiographic finding was compared with the surgical and angiographic findings. On the echocardiogram, the superior and inferior parts of the anterior mitral leaflet separated into two parts during diastole in all patients with mitral cleft. Thin linear echoes connected the ridges of the cleft and the ventricular septum in seven patients in whom the accessory chordae at that area were revealed at surgery. The systolic configuration of the anterior leaflet echo varied among the patients. The severity of the miral regurgitation seemed to relate not only to the size of the cleft but also to the systolic configuration of the anterior mitral leaflet. After surgery, diastolic separation of the anterior leaflet echo was no longer observed. However, the abnormal systolic configuration of the anterior leaflet was unchanged.

Single-day treatment of trichomonas vaginitis with low dose of ornidazole

A total of 107 cases of trichomonas vaginitis were treated with different regimens of ornidazole. The overall success rate of the treatment assessed by wet smear and clinical signs after three days in 68 cases was 98.5%. The side effects were mild and of short duration. These were noted in 14.7% of the assessable cases. No significant differences were seen in the success rate between the three drug regimens and the preliminary conclusions of the trial are that ornidazole is safe and effective in the treatment of trichomonas vaginitis in Korean women with an oral dose of 1.0 gm, 1.0 gm plus 0.5 gm intravaginally or 2.0 gm given in a single day.