Cross sectional echocardiographic demonstration of the mechanisms of abnormal interventricular septal motion in congenital total absence of the left pericardium

OBJECTIVE

To investigate the influence of the absence of the pericardium on the left ventricular wall, particularly on interventricular septal motion, using M mode and cross sectional short axis echocardiography in patients with congenital total absence of the left pericardium.

METHODS

21 patients with, congenital total absence of the left pericardium were divided into three groups according to the interventricular septal motion; systolic type (n = 6) with paradoxical motion during systole, diastolic type (n = 11) with abnormal posterior motion during mid to late diastole, and mixed type (n = 4) with paradoxical motion during systole and abnormal posterior motion during diastole.

RESULTS

On cross sectional short axis echocardiograms of the left ventricle, in the diastolic type the degree of angular displacement of the papillary muscles during end diastole to end systole showed excessive anticlockwise rotation about the long axis of the left ventricle without marked anteroposterior displacement. In the systolic type, there was shift of the left ventricle towards the anteromedial portion in systole and towards the posterolateral portion in diastole without significant rotation. There was a significantly positive correlation between the degree of angular displacement and the amplitude of diastolic interventricular septal motion during mid to late diastole in all patients.

CONCLUSIONS

There was abnormal interventricular septal motion during systole and diastole in patients with total absence of the left pericardium. Abnormal systolic motion was induced by anteroposterior displacement of the left ventricle, and abnormal diastolic motion by left ventricular rotation about the long axis of the heart during the cardiac cycle. Analysis using cross sectional echocardiography was useful for elucidating the mechanisms of abnormal interventricular septal motion.

The 'sail sound' and tricuspid regurgitation in Ebstein's anomaly: the value of echocardiography in evaluating their mechanisms

We describe a patient with Ebstein's anomaly in whom Doppler echocardiography was used to clarify the mechanism responsible for 'sail sound' and tricuspid regurgitation associated with this condition. Phonocardiography revealed an additional early systolic heart sound, consisting of a first low-amplitude component (T1) and a second high-amplitude component (T2, 'sail sound'). In simultaneous recordings of the tricuspid valve motion using M mode echocardiography and phonocardiography, the closing of the tricuspid valve occurred with T1 which originated at the tip of the tricuspid leaflets, while T2 originated from the body of the tricuspid leaflets. Using color Doppler imaging, the tricuspid regurgitant signal was detected during pansystole, indicating a blue signal during the phase corresponding to T1 and a mosaic signal during the phase corresponding to T2 at end-systole. Thus, 'sail sound' in patients with Ebstein's anomaly is not simply a closing sound of the tricuspid valve, but a complex closing sound which includes a sudden stopping sound after the anterior and/or other tricuspid leaflets balloon out at systole.

Tricuspid inflow and regurgitant flow dynamics after mitral valve replacement: differences relating to surgical repair of the tricuspid valve

BACKGROUND AND AIMS OF THE STUDY

Changes in tricuspid inflow and regurgitant flow dynamics were evaluated in patients with functional tricuspid regurgitation (TR) who underwent mitral valve replacement (MVR) with and without tricuspid annuloplasty (TAP).

METHODS

In a group of 30 patients, all with atrial fibrillation, 15 underwent TAP performed according to the modified De Vega technique; the remaining 15 did not undergo TAP. Patients were studied before and serially after surgery, using pulsed and color Doppler echocardiography. The mean follow up was 4.7 years in the TAP group and 5.1 years in the non-TAP group.

RESULTS

In the TAP group, immediately after surgery, the area of the TR jet decreased markedly, and the deceleration time of the tricuspid inflow velocity wave was significantly prolonged compared with that before surgery. By contrast, in the non-TAP group, both the area of the TR jet and deceleration time of tricuspid inflow velocity were virtually unchanged. The area of the TR jet remained small for a long period in the TAP group, but in non-TAP patients was increased in four cases over seven years, with two patients developing right-sided heart failure. Recent data showed the area of the TR jet to be significantly smaller, with maximum tricuspid inflow velocity significantly increased, and deceleration time of the tricuspid inflow velocity wave significantly prolonged in the TAP group compared with the non-TAP group.

CONCLUSIONS

In patients with functional tricuspid regurgitation undergoing MVR, concomitant TAP may cause mild tricuspid stenosis, but produces sustained preventive effects against TR. Careful follow up is needed in patients who have not undergone TAP, as TR is not markedly decreased and may even be exacerbated. Aggressive TAP is recommended in patients showing dilatation of the tricuspid annulus, even if TR is mild.

[A case of systemic origin of an aberrant artery to the basal segment of the lung]

We report on a rare case of systemic origin of an aberrant artery to the basal segment of the lung (Pryce I type intralobar pulmonary sequestration) that caused occasional bloody sputum. The patient was admitted to our hospital after an abnormal image was discovered in Chest X-ray film. The chest MRI showed an abnormal vessel originating from the descending aorta. The aortagram showed an abnormal artery originating from the descending aorta and entering the left lower lobe, and the left pulmonary angiogram revealed a poorly blood supply to the left basal segments. The preoperative diagnosis of systemic origin of an aberrant artery to the basal segment of the lung was given. The patient was subjected to surgical treatment. During surgery, it was found that the abnormal artery, 12 mm in diameter, which was connected from the descending aorta to the left basal segments. The abnormal artery was dissected, and the left basal segments was removed. The postoperative course was uneventful.

[Role of leukotriene B4 in monocrotaline-induced pulmonary hypertension]

Monocrotaline (MCT) causes lung inflammation and chronic pulmonary hypertension associated with lung vascular thickening in rats. We hypothesized that leukotriene B4 (LTB4) and LTB4-induced accumulation of leukocytes in the lung play a role in MCT-induced lung disease, and therefore measured LTB4 and myeloperoxidase (MPO) levels in lung tissue of MCT-treated rats. Next, we examined the effect of an orally active LTB4 receptor antagonist (ONO4057) on MPO levels in lung tissue, on pulmonary hypertension, and on pulmonary vascular remodeling induced by MCT. Lung LTB4 and MPO levels had increased by 3 days after MCT injection. In the ONO4057-treated MCT rats, lung MPO levels were significantly lower than in the rats given MCT but not ONO4057. By the third week after injection. MCT had caused increases in mean pulmonary arterial pressure, in the ratio of right ventricular weight to left ventricle+septum weight (RV/[VS + S]), and in media wall thickness of the muscular arteries of the lung. Treatment with ONO4057, either for 3 weeks or during the first week after MCT injection, significantly reduced pulmonary hypertension, right ventricular hypertrophy, and lung vascular thickening induced by MCT. These results indicate that ONO4057 reduces both the accumulation of leukocytes in lung tissue and the chronic pulmonary hypertension induced by MCT, and they suggest a role for LTB4 in the inflammatory process that contributes to pulmonary hypertension and lung vascular remodeling induced by MCT in rats.

Relation of disease activity during chronic hepatitis C infection to complexity of hypervariable region 1 quasispecies

We studied the heterogeneity in the E2/NS1 hypervariable region 1 of the hepatitis C virus (HCV) genome in relation to the natural course after infection. The subjects were composed of 38 chronic hepatitis C carriers who had been followed for 9 to 218 months after the onset of non-A, non-B (type C) hepatitis, being tested monthly for serum alanine aminotransferase levels. The complexity of the sequence heterogeneity was assessed by single-strand conformation polymorphism analysis. The quasispecies complexity had no relation to the route of infection, the time from infection and the duration of aminotransferase elevation after the onset. However, it had a significant relationship with the degree of aminotransferase elevation in the course of the disease. The quasispecies complexity was directly correlated with the first peak of serum aminotransferase at the onset (r = .48, P < .01) and the mean aminotransferase levels during the period of persistent aminotransferase elevation (r = .58, P < .01). Twenty-three of the 38 patients were further followed for 24 months with biweekly alanine transaminase (ALT) tests. Their aminotransferase levels remained within the normal range during follow-up, and no significant change was seen in the quasispecies complexity after this asymptomatic period. However among the 23 patients, the quasispecies complexity increased in six cases (26%) and decreased in five (22%). A significant direct relation was seen between changes in the quasispecies complexity and the mean aminotransferase levels during the asymptomatic period (r = .55, P = .01). These findings suggest that the development of the HCV quasispecies nature may be related to the severity of the hepatitis in the course of infection.

Inhibition of lymph node metastasis by an anti-angiogenic agent, TNP-470

We assessed the inhibitory action of TNP-470 on lymph node metastasis in a metastatic model system using athymic nude mice. Mice were injected subcutaneously with 5 x 10(6) HT-1080 cells in the right groin. TNP-470 (10, 30 and 100 mg kg-1) was injected subcutaneously nine times in total every other day from the 7th day after tumour inoculation. Axillar and inguinal lymph nodes were dissected, and DNA was extracted 5 weeks after tumour inoculation. Specific detection of a human beta-globin-related sequence in metastasized human tumour cells in nude mice was done by the polymerase chain reaction (PCR) technique and analysed by Southern blotting. Anti-tumour effects on primary sites were seen only in the 100 mg kg-1 treatment group. Lymph node metastasis of transplanted HT-1080 cells was seen in all mice of the no treatment group (5/5). On the other hand, incidences of lymph node metastasis in treated mice were 2/4 mice (100 mg kg-1, 2/5 mice (30 mg kg-1) and 4/5 mice (10 mg kg-1). The inhibition ratios of lymph node metastasis were 82.3% at 10 mg kg-1, 97.2% at 30 mg kg-1 and 97.5% at 100 mg kg-1 respectively. This agent may be useful to inhibit lymph node metastasis.

Concealed left ventricular hypertrophy and diastolic dysfunction in hypertrophic cardiomyopathy in the presence of acute left ventricular volume overload. A case report

We report a patient in whom hypertrophic cardiomyopathy, with both left ventricular hypertrophy and diastolic dysfunction, was masked by acute severe aortic regurgitation and marked left ventricular dilation. Upon admission, 1) two-dimensional echocardiogram of the left ventricle revealed a dynamic and flail vegetation on the aortic right coronary cusp and marked left ventricular dilation, 2) a massive aortic regurgitant signal was recorded by color Doppler flow imaging, and 3) transmitral flow velocity by pulsed Doppler echocardiogram revealed a pseudonormalization. However, symmetric hypertrophy of the left ventricular wall, a decrease in early diastolic wave and a compensatory increase in atrial systolic wave of the transmitral flow velocity appeared after successful aortic valve replacement.

History of vitamin D treatment of renal osteodystrophy

Vitamin D treatment was tried when renal osteodystrophy was first recognized in the early 20th century, using vitamin D2, D3, or dihydrotachysterol. Large doses of vitamin D2 or D3 (150,000-500,000 IU) were prescribed by monitoring serum calcium, phosphate, and alkaline phosphatase. After the discovery of 1,25-dihydroxycholecalciferol, this compound or 1 alpha-hydroxycholecalciferol was applied to the treatment of renal osteodystrophy. In a preclinical study, especially of 1 alpha-hydroxycholecalciferol, nephritogenoside nephritis was the most responsive condition. These active vitamin D preparations are now widely used in patients with chronic renal failure under hemodialysis. Other active vitamin D compounds, such as hexafluoro-1,25-dihydroxycholecalciferol and 22-oxacalcitriol, are also under investigation.

Relationship between the angiotensin converting enzyme gene polymorphism and the effects of enalapril on left ventricular hypertrophy and impaired diastolic filling in essential hypertension: M-mode and pulsed Doppler echocardiographic studies

OBJECTIVE

To investigate the relationship between the angiotensin converting enzyme (ACE) gene polymorphism and the effects of the ACE inhibitor enalapril on left ventricular hypertrophy and impaired diastolic filling.

DESIGN AND METHODS

Enalapril (5-10 mg/day) was administered for 12 months to 60 previously untreated patients with essential hypertension. M-mode and pulsed Doppler echocardiography were performed before and after treatment, and changes in various parameters after treatment with enalapril were examined. ACE gene polymorphism was examined by the polymerase chain reaction method and the patients were classified as having the 190 bp deletion homozygous (DD) genotype, the 490 bp insertion homozygous (II) genotype or the 490 bp insertion 190 bp deletion heterozygous (ID) genotype.

RESULTS

The DD genotype was observed in 10 patients (17%), the ID genotype in 24 patients (40%) and the II genotype in 26 patients (43%). Plasma ACE activity before treatment with enalapril was significantly higher in seven patients with DD genotype than it was in 18 patients with ID genotype and in 14 patients with II genotype. In all of the 60 patients, the left ventricular mass index, the peak atrial systolic velocity:early diastolic velocity ratio and the deceleration time from the peak of the early diastolic wave to the baseline in transmitral flow velocity were decreased significantly after treatment with enalapril. The changes in left ventricular mass index and atrial systolic velocity:early diastolic velocity ratio after enalapril administration were significantly greater in the DD genotype group than they were in the other two genotype groups.

CONCLUSION

Enalapril-induced regression of left ventricular hypertrophy and improvement in left ventricular impaired diastolic filling were significantly greater in the DD genotype group than they were in the ID and II genotype groups, suggesting that the circulating and tissue renin-angiotensin systems, particularly the former system, are most active in hypertensive patients with the DD genotype.

The effect of oral 1 alpha-hydroxycalciferol treatment on bone mineral density in hemodialysis patients

We have studied the effect of different doses of 1 alpha-hydroxycalciferol (1 alpha [OH]D3) on bone mineral density (BMD) of 165 male hemodialysis patients (ages from 24 to 71 years) using dual X-ray absorptiometry (DXA) in a one-year follow-up study. There were no fractures in their lumbar spine participated in the study. 1 alpha (OH)D3 was administered orally at a low dose (0.25 microgram/day, n = 56, Group L) or at a higher dose (0.5 to 1.0 microgram/day, average 0.58 +/- 0.02 microgram/day, n = 65, Group H), and the absolute BMD values and the percent annual changes of BMD were compared with those who took no 1 alpha (OH)D3 (n = 44, Group N). BMD was measured three ways at the start and the end of the study; 1) lumbar spine BMD at anterior-posterior view (AP-BMD), 2) lumbar spine BMD at lateral view (Lat-BMD), and 3) 1/3 distal radius BMD. Plain spinal radiographs indicated no bone fracture before nor during the study. Although there were no detectable changes in the absolute values of BMD during the one-year period, significant differences were observed in the percent annual changes of lumbar spine BMD among the three groups. The annual changes of lumbar spine BMD among the three groups. The annual changes of AP-BMD were -0.4 +/- 0.7%, +0.1 +/- 0.6%, and +2.4 +/- 0.8% in Group N, Group L and Group H, respectively. These changes were statistically significant (p = 0.011 by one-way ANOVA). The positive effect of 1 alpha (OH)D3 on Lat-BMD was also significant (p = 0.028 by one-way ANOVA), while the treatment did not affect the change of BMD at 1/3 distal radius. There was no significant difference among the three groups in the initial or final levels of biochemical parameters including serum calcium, phosphorus, alkaline phosphatase, osteocalcin and parathyroid hormone. These results indicate, in male hemodialysis patients, that oral 1 alpha (OH)D3 treatment is effective in the prevention of lumbar spine BMD loss which is frequently observed in hemodialysis patients.

Influence of left atrial pressure on left atrial appendage flow velocity patterns in patients in sinus rhythm

To examine changes in left atrial appendage flow velocity patterns in relation to left atrial pressures during sinus rhythm, transesophageal echocardiography and cardiac catheterization were performed in 31 patients with myocardial diseases in sinus rhythm and 20 control subjects without cardiovascular disease. The 31 patients were divided into two groups according to mean pulmonary capillary wedge pressure: the group with high wedge pressure (19.9 +/- 5.8 mmHg) and the group with low wedge pressure (8.6 +/- 2.9 mmHg). The left atrial appendage peak early emptying velocity was decreased significantly in the groups with both high and low wedge pressure compared with the control group. The left atrial appendage peak late emptying velocity was significantly greater in the group with low wedge pressure compared with the control group, whereas it was decreased significantly in the group, with high wedge pressure compared with the control group. The left atrial appendage peak late emptying velocity had a significant negative correlation with wedge pressure. The maximum left atrial appendage area at end systole in the group with high wedge pressure was significantly greater than that in both the group with low wedge pressure and the control group. There was a significant positive correlation between the maximum left atrial appendage area and the wedge pressure, as well as a significant negative correlation between the left atrial appendage ejection fraction during atrial contraction and the wedge pressure. In the group with high wedge pressure, one patient had evidence of left atrial appendage thrombi and two had spontaneous echo contrast. These results suggest that even in patients in sinus rhythm, a marked elevation in the left atrial pressure is likely to reduce the left atrial appendage peak early and late emptying velocities. These changes may be accompanied by an increased incidence of thrombus formation in the left atrial appendage compared with individuals with normal or only slightly elevated left atrial pressures.

Relationship between pulmonary capillary wedge V wave and transmitral and pulmonary venous flow velocity patterns in various heart diseases

BACKGROUND

A large V wave in a pulmonary capillary wedge pressure (PCWP) tracing is characteristic of mitral regurgitation. However, the V wave is often increased in patients without or with no significant mitral regurgitation.

METHODS AND RESULTS

The V wave was in the PCWP tracing investigated in 65 patients using transmitral flow (TMF) and pulmonary venous flow (PVF) velocity patterns obtained by transesophageal pulsed Doppler echocardiography. A large V wave was defined if the peak V wave minus the mean PCWP (V-mPCWP) was greater than 7 mmHg. Three study groups were formed: 15 patients with large V waves and significant mitral regurgitation, 15 patients with large V waves with no significant mitral regurgitation, and 35 patients with small V waves. The mPCWP and left ventricular end-diastolic pressure were greatest in the group with large V waves and no significant mitral regurgitation. Peak early diastolic TMF and PVF velocities were significantly greater in the two groups with large V waves. The peak second systolic PVF velocity was lowest in the group with large V waves and significant mitral regurgitation, followed by the group with large V waves and no significant mitral regurgitation. The V-mPCWP was positively correlated with the peak early diastolic TMF and PVF velocities and negatively correlated with the peak second systolic PVF velocities. Additionally, mitral regurgitation severity in patients with large V waves and significant mitral regurgitation was positively correlated with the peak early diastolic TMF and PVF velocities and negatively correlated with the peak second systolic PVF velocity.

CONCLUSIONS

These results suggest that large V waves in PCWP tracings appear not only in severe mitral regurgitation, but also in any condition with markedly elevated left ventricular end-diastolic pressure. Combined analysis of the TMF and PVF velocity patterns is helpful in determining the etiology of these hemodynamic abnormalities.

[A case of gastric cancer with peritoneal dissemination and malignant biliary stenosis treated by loco-regional cancer therapy]

A 68-year-old male diagnosed as Borrmann 2 type gastric cancer (T3N3P3H0M0: Stage IVb) was treated by distal gastrectomy and administration of CDDP 50 mg+MMC 10 mg intraperitoneally. After operation intraperitoneal chemotherapy was continued until adhesional ileus occurred four months later. At reoperation peritoneal dissemination was not found either macroscopically or microscopically. After four months, and expandable metallic stent (Wallstent) was applied for malignant biliary stenosis due to lymph node metastasis. Although the patient died 23 months after the first operation, our loco-regional cancer therapy seemed effective for support of quality of life.

Possible mechanisms of mitral regurgitation in dilated hearts: a study using transesophageal echocardiography

HYPOTHESIS

This study was undertaken to clarify the mechanisms of mitral regurgitation (MR) in dilated hearts.

METHODS

In all, 68 patients with dilated heart and MR, including 26 patients with dilated cardiomyopathy (DCM), 24 with prior anterior myocardial infarction (A-MI), and 18 with prior posteroinferior myocardial infarction (I-MI), as well as 25 normal subjects were examined by transesophageal two-dimensional and color Doppler echocardiography.

RESULTS

The maximum area of the MR signal in the DCM group correlated positively with the anteroposterior diameter of the mitral annulus at late systole. Although the coaptation edge length of the anterior and posterior mitral leaflets appeared shorter in dilated hearts than in the hearts of controls, a significant difference did not exist. The length of the coaptation edge correlated negatively with the maximum area of the MR signal in all dilated hearts, and characteristic systolic displacement of the coaptation point of both mitral leaflets occurred. The MI groups demonstrated anterior and posterior displacement in the direction of the short axis of the left ventricle in the A-MI and I-MI groups, respectively. However, the DCM group demonstrated inferior displacement toward the long axis of the left ventricle; its magnitude correlated positively with the maximum area of the MR signal.

CONCLUSION

A major cause of MR in dilated hearts is mitral malcoaptation due to displacement of the coaptation point of the mitral leaflets along the long or short axis of the left ventricle. This is caused by left ventricular enlargement and/or asynergy of the left ventricular wall, rather than by a decrease in mitral coaptation edge length due to mitral annular dilation.

Renovascular hypertension with massive proteinuria

A 65-year-old woman with renovascular hypertension and massive proteinuria is reported. Her urinary protein ranged from 3 to 5 g/day. Serum potassium was 2.9 mEq/l. Plasma renin activity and plasma aldosterone concentration were very high. A CT scan disclosed atrophy of the left kidney. Renogram showed a non-functioning pattern of the left kidney. An abdominal aortogram showed complete occlusion of the left renal artery at its ostium. After left nephrectomy, her high blood pressure and urinary protein were normalized. It seemed that the massive proteinuria was mainly due to some endocrinological effect of the left kidney.

Detour factors in water and plastic phantoms and their use for range and depth scaling in electron-beam dosimetry

Average penetration depths and detour factors of 1-50 MeV electrons in water and plastic materials have been computed by means of analytical calculation, within the continuous-slowing-down approximation and including multiple scattering, and using the Monte Carlo codes ITS and PENELOPE. Results are compared to detour factors from alternative definitions previously proposed in the literature. Different procedures used in low-energy electron-beam dosimetry to convert ranges and depths measured in plastic phantoms into water-equivalent ranges and depths are analysed. A new simple and accurate scaling method, based on Monte Carlo-derived ratios of average electron penetration depths and thus incorporating the effect of multiple scattering, is presented. Data are given for most plastics used in electron-beam dosimetry together with a fit which extends the method to any other low-Z plastic material. A study of scaled depth-dose curves and mean energies as a function of depth for some plastics of common usage shows that the method improves the consistency and results of other scaling procedures in dosimetry with electron beams at therapeutic energies.

Peculiar patterns of aortic regurgitation and carotid pulse due to dysfunction of a Medtronic Hall prosthetic valve: a case report

We describe a patient with dysfunction of a Medtronic Hall prosthetic valve showing peculiar patterns of aortic regurgitation and carotid pulse caused by valvular thrombosis. The aortic regurgitation was considered to be caused by a significant delay in prosthetic valve closure, manifested by a peculiar regurgitation pattern limited to early diastole, in association with widely split closing clicks and an abnormally low dicrotic notch in the carotid pulse. At surgery, fibrin thrombi were noted just below the prosthetic ring in the minor outflow region which restricted disc movement. The fibrin thrombi were removed and the valve was rotated 90 degrees. Following reoperation, all abnormalities disappeared.

Influence of aging on left atrial appendage flow velocity patterns in normal subjects

Transesophageal pulsed Doppler echocardiography was performed to examine changes with age in the left atrial appendage flow velocity patterns in 50 normal subjects (15 to 80 years) in sinus rhythm. There was a significant negative correlation between the peak early diastolic forward and backward left atrial appendage flow velocities and age, as well as a significant positive correlation between the peak early diastolic forward left atrial appendage flow velocity and the peak early diastolic transmitral and pulmonary venous flow velocities. Although there was a significant positive correlation between the peak atrial systolic transmitral flow velocity and age, there was a negative correlation between the peak atrial systolic forward and backward left atrial appendage flow velocities and age. There was a positive correlation between both the maximum left atrial diameter and the amplitude of the interatrial septal motion during atrial systole and age. There was a significant negative correlation between the left atrial appendage ejection fraction during atrial systole and age. Left atrial appendage thrombi and spontaneous echo contrast were detected in two subjects with low peak early diastolic and atrial systolic left atrial appendage flow velocities. In conclusion, both peak early diastolic and atrial systolic left atrial appendage flow velocities decreased with age. A decrease in the peak atrial systolic flow velocity appeared to be an important sign of left atrial appendage thrombus formation even in normal elderly subjects in sinus rhythm.