[Effect of valve replacement on left ventricular function in chronic aortic regurgitation]

To ascertain the optimal time for surgery in chronic aortic regurgitation (AR), 66 patients with and without surgical correction were reviewed from the standpoint of left ventricular (LV) function based on their serial echocardiographic studies. Aggravation of the clinical status was usually associated with enlarged LV dimension, decreased %fractional shortening (%FS), and increased LV end-systolic meridional stress (sigma m). Fourteen patients developed congestive heart failure during follow-up periods of up to five years, and most of their echocardiographic findings showed %FS less than 27%, and LV end-systolic dimension (LVD) greater than 50 mm. Thirty-two patients underwent surgery. Preoperatively, sigma m and %FS were closely correlated, including cases whose %FS was decreased. This linear regression equation became steeper with dobutamine administration; however, in patients, whose mean preoperative LVD value exceeded 50 mm, the %FS remained depressed (delta FS less than 6%) and sigma m did not significantly decrease during dobutamine administration. Marked or moderate resolution of LV dilatation and hypertrophy was observed in all patients postoperatively. Compared to patients with preoperative %FS greater than or equal to 27%, much more time was required for recovery of patients with %FS less than 27%, though their %FS and their exercise capacity improved within two years of surgery. Immediate postoperative recovery was observed in cases with excellent preoperative response to dobutamine (delta FS greater than or equal to 6%). However, in patients with severely depressed preoperative %FS less than 20%, postoperative improvement was not so marked and the surgical results were unsatisfactory. From these results, we concluded that the optimal time for surgery for AR is when %FS = 27% and LVDs = 50 mm.

[Results of treatment of primary malignant tumor of the small intestine]

The results of treatment of 40 cases of primary malignant tumor of the small intestine are reported. The malignant tumors included 14 leiomyosarcoma, 12 malignant lymphoma and 14 adenocarcinoma. Our standard treatment for these tumors was segmental resection of the small intestine with its mesentery including the regional lymph nodes and we used additional adjuvant chemotherapy for some cases of malignant lymphoma and adenocarcinoma. Curative resection was performed in 57.1% of leiomyosarcoma, 50.0% of malignant lymphoma and 61.5% of adenocarcinoma. Cumulative 5-year survival rates were leiomyosarcoma 21.4%, malignant lymphoma 53.0% and adenocarcinoma 43.3% respectively. Serosal infiltration, lymph node metastasis and operative curability proved to be the prognostic factors. In particular, the 5-year survival rate of patients on whom curative resection could be performed was significantly better for each tumor type than that of patients for whom this was not possible, the figures being leiomyosarcoma 40.0%, malignant lymphoma 83.3% and adenocarcinoma 83.3%.

The degree of increment in plasma catecholamines in patients with mitral stenosis by mild exercise

Although sympathetic excitation during mild exercise may readily occur in patients with mitral stenosis (MS), the degree of increment in plasma catecholamines has not been fully investigated. We imposed mild ergometric exercise (50 watts, 300 kg/min for 5 minutes) on five patients with mild MS (mitral valve area greater than or equal to 1.0 cm2) and eight with severe MS (mitral valve area less than 1.0 cm2) while they were undergoing cardiac catheterization. In patients with severe MS, total plasma catecholamine levels during exercise were remarkably higher (2821 +/- 783 [SEM] pg/ml) than in those with mild MS (957 +/- 113 pg/ml, p less than 0.05) and in seven control subjects (612 +/- 75 pg/ml, p less than 0.05). This marked increment could not be predicted by heart rate response, which did not differ between severe and mild MS (166 +/- 5 vs 153 +/- 10 bpm). In contrast with catecholamine change, the cardiac index in severe MS showed a very small increment. Results suggest that mild daily exercise can remarkably increase plasma catecholamine levels in severe MS, and this may accelerate various complications of this disorder.

[A case of a perforation indicative of early gastric cancer with various macroscopic findings and a collective review of the relevant Japanese literature]

A case of perforated early gastric cancer and a collective review of the relevant Japanese literature is reported. A 83-year-old woman with free air discovered by an abdominal X-ray, was referred to our hospital. On operating, a perforated ulcer was found within and lesions, indicative of a IIc + III type early gastric cancer. Macroscopically, there was an elevated lesion at the antrum of the stomach as well. Histologically, these lesions were connected and moderately differentiated adenocarcinoma. Another lesion was also found at the anterior wall and diagnosed as IIb type gastric cancer.

Analysis of the left ventricular early diastolic function in old myocardial infarction by gated radionuclide angiography

In order to determine the validity of the left ventricular (LV) diastolic function for evaluation of ischemic heart disease, gated radionuclide angiography was performed in 37 patients with transmural myocardial infarction (MI) [18: anterior, 19: inferior infarction] and 10 normal control subjects. LV ejection fraction (LVEF) was decreased in patients with anterior MI but not in those with inferior MI. Time to peak filling rate was not significantly prolonged in both anterior MI and inferior MI. Filling fraction was apparently reduced only in anterior MI. However, peak filling rate (PFR) was significantly reduced even in inferior MI as well as in anterior MI. PFR correlated well with LVEF in normal control, anterior MI and inferior MI. In both anterior MI and inferior MI, their coefficients were smaller than in controls. The normal PFR always indicated normal LVEF, while normal LVEF was not necessarily indicative of normal PFR. Results indicated that LV diastolic function estimated by equilibrium radionuclide angiography might reflect more precisely LV dysfunction in old MI than LV systolic function. The reduction of LV diastolic function in old MI was more prominent than that of LV systolic function. Therefore, it may be deduced that evaluation of LV diastolic function is essential to the estimation of the degree of ischemic myocardial cell damage and the efficacy of drugs on ischemia-induced LV dysfunction.

Reduction of plasma norepinephrine levels in response to brief coronary occlusion in experimental dogs

Although an increased plasma norepinephrine (NE) level is sometimes observed during angina pectoris, it is difficult to say whether sympathetic overflow is its cause. The left anterior descending coronary artery was occluded by intracoronary balloon for 3 minutes in 12 closed-chest anesthetized dogs. During occlusion, heart rate did not change but aortic pressure slightly decreased. Occlusion caused a significant reduction in both NE levels in the aorta (177 +/- 17 to 134 +/- 16 pg/ml, p less than 0.01) and in the great cardiac vein (GCV) 296 +/- 44 to 249 +/- 44 pg/ml, p less than 0.01). After surgical vagotomy, the occlusion increased NE levels in the aorta (227 +/- 44 to 278 +/- 43 pg/ml, p less than 0.01) and in GCV (384 +/- 76 to 444 +/- 81 pg/ml, p less than 0.01), showing the release of vagal inhibition. These results may be applicable to patients with transient anterior myocardial ischemia; if plasma NE increases without marked hemodynamic changes, it is suggested that the sympathetic overflow is not a result but a possible cause of the ischemia.

[Left ventricular diastolic properties in dilated cardiomyopathy, transmural myocardial infarction, and hypertrophic cardiomyopathy]

Left ventricular (LV) diastolic properties in dilated cardiomyopathy (DCM), transmural myocardial infarction (TMI), and hypertrophic cardiomyopathy (HCM) were evaluated. Radionuclide angiography and M-mode echocardiography were performed for 11 cases of DCM, 40 cases of TMI, 21 cases of HCM, and nine normal control subjects. In DCM, the peak filling rate (PFR) and filling fraction (FF) were significantly reduced, but the time to the peak filling rate (TPFR) was not prolonged. In TMI, both the PFR and FF were significantly reduced. Moreover, the TPFR was significantly prolonged in TMI as compared to DCM. Although depression of the PFR in HCM was not apparent, prolongation of the TPFR in HCM was marked. In DCM, there was good correlation between the PFR and left ventricular ejection fraction (EF) (r = 0.71, p less than 0.03). In TMI, there was a good correlation between the TPFR and the standard deviation of the LV phase angle histogram (SDP), indicating LV asynergy (r = 0.589, p less than 0.005). In HCM, both the FF and PFR correlated inversely with the LV wall thickness (r = -0.74, p less than 0.008; r = -0.581, p less than 0.03, respectively). These results indicate that various factors affect LV diastolic properties in heart disease, and that radionuclide angiography is a valuable technique for evaluating LV diastolic function.

[A comparative study of 4'-epi-doxorubicin and doxorubicin cardiotoxicities]

The cardiotoxicities of 4'-epidoxorubicin (4-epiDX) and doxorubicin (DX) were compared in rabbits. Thirty-one male NZW rabbits weighing 2.4 to 2.6 kg were used for each compound and 15 were kept as controls. DX or 4'-epiDX was administered intravenously with a dose of 0.8 mg/kg for 3 consecutive days a week for 5-10 weeks. Rabbits were sacrificed at 5, 8 and 10 weeks after initial administration. Under nembutal anesthesia, electrocardiogram, phonocardiogram and carotidgram were recorded. Light and electron microscopic studies of the heart were performed according to conventional methods. Myocardial alterations were semi-quantitatively evaluated with light microscopy, using a modified grading system derived from Bertazzoli. Twelve of the DX-treated rabbits and 4 of the 4'-epiDX-treated rabbits died after 5 weeks or later. In the electrocardiogram study, ST-T changes were less frequently observed in rabbits treated with 4'-epiDX than those with DX. Significant increases of PEP/LVET were observed in rabbits treated with DX for 8 and 10 weeks, similar increases were only observed while in rabbits treated with 4'-epiDX for 10 weeks. Histologically, both drugs produced myocardial degeneration and necrosis. The lesions were characterized by multiple vacuolization of myocardial cells, atrophy of myocardial cells, interstitial edema and fibrosis. Myocardial alterations induced by 4'-epiDX were qualitatively similar to those induced by DX, but were much less severe at the same cumulative dose. These results demonstrate that 4'-epiDX is less cardiotoxic than DX.

Assessment of the magnitude of aortic regurgitation by dye injection into the descending aorta

A technique simpler than the angiographic method for estimating aortic regurgitant volume was tried with 31 patients with aortic insufficiency. During cardiac catheterization, we injected dye into the descending aorta while recording the dye dilution curve in the left ear. The distance between the aortic arch and the tip of the catheter at the lowest point from which the injected dye could be detected in the left ear was rated in terms of the number of corresponding vertebral bodies. This "distance score" closely correlated with the regurgitant stroke volume and with the fraction to total stroke volume, which were measured by angiocardiography (r = 0.927, p less than 0.001; and r = 0.900, p less than 0.001, respectively). The correlation coefficients of the aortographic grade to those parameters were not as high as they were in the relationship of the score to the same parameters. Therefore, these results indicate that the "distance score" is a practical method for assessing the magnitude of aortic regurgitant volume.

[Clinical studies of patients with bladder tumors]

One hundred and seventy eight patients treated in our clinic were analyzed. The five-year survival rates for the patients (69 cases) given transurethral resection (TUR), total cystectomy (65 cases) and palliative treatment (40 cases) were 92.7%, 61.1% and 3.9%, respectively. The four patients who could not be treated lived no longer than one month. The five-year survival rate for the patients treated with TUR of the tumor was the highest. The recurrence rate for the TUR group was 19.5% at one year, 39.5% at three years and 47.1% at five years after surgery; and, it was higher in the patients with histologically high grade tumors. Generally, we obtained good results with TUR, but total cystectomy had to be performed later on three patients due to progression of the tumor. We felt the need for an indicator to express the biological activity of the tumor, and maintain that regular follow-up by endoscopy and cytology is mandatory. The clinical results of the total cystectomy and urinary diversion were considered to be satisfactory compared to other reports; and, patients with high stage tumor had poor prognosis. Five patients died of progression of the disease after total cystectomy. Operative mortality was 10.7%, which should be decreased by avoiding operative morbidity. In our experience, two-stage operations or preoperative irradiation can increase the indication for total cystectomy; and, improved clinical results are expected.

Histopathological studies of the nervous system tumors in rats induced by N-nitroso-methyl-urea

Histopathological examinations were made on tumors of the nervous system induced in rats of Donryu strain by weekly intravenous injections with N-nitroso-methyl-urea (NMU) or by a single administration of NMU through the mothers. A total of 176 neural and nonneural neoplasms were produced in this study. It was suggested that the fetal nervous system of Donryu rats was also highly susceptible to the oncogenic effects of NMU. Of these tumors produced, those of the peripheral nervous system amounted to 121, comprising 68.7% of the total number of the neoplasm. Microscopically, most of the nerve tumors showed the histology corresponding to that of human neurinomas. Many tumors, however, disclosed more or less anaplastic cytological appearance. Fifteen gliomas were produced in the brain and spinal cord. Microscopically, they were classified into mixed glioma, oligondendroglioma and anaplastic astrocytoma. The commonest brain tumors produced in rats from intravenously treated group were periventricular mixed gliomas, while gliomas in rats from transplacentably treated group showed an isomorphic histology with a close resemblance to that of oligodendroglioma.