P1307 An echocardiographic observation over the disappearing process of the prosthetic valve thrombus caused by the inflammatory hypercoagulability; a case report

Background

Whenever fever and inflammatory reaction continue for a while in the patients with a prosthetic valve, than usual, we must keep infective endocarditis in mind. On the other hand, inflammation and thrombosis are well known to coexist often. There are several reports of thrombotic valves associated with inflammation-activated hypercoagulability. Furthermore, C-reactive protein (CRP) has been reported to imply an increased risk of thrombus especially in the presence of an injury on the prosthetic valve.

Case report

We report a case of a 70-year-old male with a leaflet thrombus on the bioprosthetic aortic valve. He suffered from fever, and symptoms of heart failure and was hospitalized for treatment. Blood tests presented that white blood cell count was 4900/μL (neutrophil 81.1%) and CRP 10.82 mg/dL. Infectious endocarditis (IE) was suspected. Transthoracic echocardiography (TTE) was per-formed, however, vegetation and abscess were not found. Noteworthily, the bioprosthetic valve leaflet on the right coronary cusp showed thickening and opening dysfunction (Figure A, parasternal short axis). Mean pressure gradient (mPG) through the aortic valve was 15mmHg and peak velocity (Vmax) 2.7m/s. Blood culture was negative, and his body temperature and CRP were improved by empirical antibiotic administration. The anticoagulation therapy with warfarin was started, he was discharged from the hospital and followed up in the outpatient clinic. TTE after the initiation of anticoagulation therapy, did not reveal any more dysfunction on the bioprosthetic valve (mPG: 9mmHg, Vmax: 2.2m/s) (Figure B, parasternal short axis). The diagnostic and therapeutic process of this case implied success. The opening-dysfunction of prosthetic valve leaflets was reversible and therefore, we concluded that the thickening of the prosthetic valve could be attributed to thrombus adhesion. Computed Tomography (CT) was not performed because he suffered from chronic kidney disease.

Conclusion

Surely, CT is very useful for the evaluation of thrombotic valves in the patients in whom it is permissible to use contrast agent. However, we could successfully evaluate the recovery process of leaflet thrombosis by echocardiography because of a difficult reason of CT use in this case. The prolongation of inflammatory reaction in the patients with a prosthetic valve should keep IE in mind in everyday life. Even if the findings of bacterial infection are obscure, it is more and more important to observe carefully the change of leaflets, whenever an open-dysfunction and a thrombus adhesion of the prosthetic valves exist.

Abstract P1307 Figure.

P702 An unusual echocardiographic finding of protrusive vegetation caused by perivalvular abscess perforation into the left atrium

Background

It is well-known that Infective endocarditis (IE) caused by S. aureus progresses rapidly and is highly destructive. The most often abscess formation after aortic valve replacement (AVR) is the mitral-aortic intervalvular fibrosa (MAIVF). It is difficult to cure MAIVF radically once infection occurs, and then the abscess tends to spread. After abscess formation is once established, IE tends to be widespread, the prognosis is definitely poor unless surgical repairment is executed, and then an emergency surgery is essential and unavoidable for complete cure. We report an unusual case of aortic valve abscess with perforation of vegetation into the left atrium after aortic valve replacement.

Case report

A 77-year-old man underwent the bioprosthetic AVR for aortic valve stenosis one month ago. On the 9th day after discharge, he visited the hospital for the follow-up. At the time, the body temperature was 36.6 ° C, the blood pressure 133/50 mmHg, white blood cell count 10500/μL, and C-reactive protein 3.31 mg/dL. Transthoracic echocardiography (TTE) demonstrated the perivalvular abscesses on the prosthetic aortic valve and mass structures attached to the MAIVF in the left atrium (Figure A, C). He was hospitalized again and had an emergency re-operation. Intraoperative transesophageal echocardiography (TEE) showed a perivalvular abscess on the prosthetic valve, and a high-intensity structure (vegetation like) protruding from the Valsalva Sinus into the left atrium of the MAIVF (Figure B, D). Surgical findings did not reveal any wart on the native valve itself. One-third of the annulus was disrupted. The subvalvular tissue all around was abscessed. Notably, the abscess cavity between NCC and LCC reached MAIVF of the anterior mitral leaflet, and the structure projecting to the left atrium was vegetation. In this case, TTE pointed out a perivalvular abscess of the aortic valve, IE was suspected at the time of outpatient visit at an early stage after discharge, and the spread of inflammation was observed with a high speed beyond the expectation at the time of operation.

Conclusion

Early after the operation, TTE revealed a mass was protruded into the left atrium. Generally, vegetation is soft and flexible in itself. However, in this case, the vegetation was less mobile, and for that reason, abscesses or tumors were suspected. TEE enabled us to obtain anatomically more detailed information and to foresee the left atrial wall repairment at the time of reoperation. We reported an unusual case of IE with solid vegetation attached to the wall and difficult to diagnose.

Abstract P702 Figure.

P248 Changes of atrial septum defect caused by posture during three-dimensional transesophageal echocardiography ( a case of Platypnea-orthodeoxia syndrome)

Background

Platypnea-Orthodeoxia syndrome (POS) is a rare phenomenon which is characterized postural hypoxia due to the intracardiac shunt from right to left through a patent foramen ovale, an atrial septal defect or a pulmonary arteriovenous malformation. POS is often underestimated because the hypoxia by postural change is difficult to be detected. We evaluated three-dimensional transesophageal echocardiography (TEE) to diagnose POS in an elderly patient.

Case report

A 84-year-old woman suffered from repetitive syncope for several years. She undertook twelve leads electrocardiogram (ECG), screening transthoracic echocardiography (TTE), twenty-four hours ECG and treadmill stress ECG, however, the cause of syncope was not identified. After another syncope event happened, she was transferred to the emergency room. Then, the hypoxia caused by sitting position was pointed out for the first time.

Her hypoxia was improved by supine position and oxygen administration. TTE demonstrated no right heart enlargement. Shunt flow was suspected on her atrial septum; however, it was difficult to reveal it by TTE because of her obesity. Therefore, she underwent intravenous saline injection test. In the decubitus position, an intravenous injection of saline under Valsalva maneuver revealed the shunt flow from the right atrium to the left atrium. Her arterial oxygen saturation (SpO2) was 95%. In the sitting position, a visible shunt flow was observed, then her SpO2 dropped to 85%. By TEE, the shunt hole was found in the oval fossa of the atrial septum. TEE was evaluated by different positions. The atrial defect hole became larger in the sitting position (area 1.05cm2) than in the supine position (area 0.43cm2). As a result, the postural change to sitting revealed Platypnea-Orthodeoxia syndrome associated with ASD. The pulmonary blood flow/systemic blood flow ratio (Qp/Qs) was estimated at 1.6. After surgical ASD closure, she was discharged without any symptoms.

Conclusion

Unclearness of TTE and the absence of a right heart overload may lead to misdiagnosis of POS. If a syncope patient caused hypoxia in the only sitting position, detailed echocardiography should be needed to rule out a diagnosis of POS. This is considerably valuable case of three-dimensional TEE confirmed the changes of ASD size by postural change.

Abstract P248 Figure.

P1472 Concealed thrombus in a 12-year-old boy diagnosed by disappearance of intricate comb-like pectinate muscle form in the left atrial appendage

Background

As previously known, patients with prolonged atrial fibrillation often have atrial thrombus. However, in children, cardiogenic embolism due to atrial fibrillation is rare. Also, the diagnosis of residual thrombus in the left atrial appendage is sometimes difficult even by transesophageal echocardiography (TEE). We have obtained a meaningful comparison between TEE findings and surgical specimen of bilateral atrial appendage.

Case report

A 12-year-old boy admitted to the nearby hospital, because of sudden onset of right-side hemiplegia. Till then, he was born at normal weight and grew up without any problem. The electrocardiogram indicated atrial fibrillation. He was transferred to the pediatric cardiology department of a hospital with higher function for the treatment of cardiogenic thromboembolism.

After 72 hours from the onset of first thromboembolism, a new embolic event happened in his left brachial artery. The contrast-enhanced computed tomography (CT) showed thrombus of bilateral atrium and coronary sinus. Consequently, residual thrombus led to the potential risk of additional embolization. Therefore, catheter cerebral thrombectomy was performed, and then surgical thrombectomy for the bilateral atrium was planned. Preoperative CT showed thrombus in the left atrial appendage (LAA). However, intraoperative TEE showed no obvious thrombus in the LAA. Intricate pectinate muscle formation in the left atrial appendage almost disappeared (figure1A), which suspected remaining thrombus. In addition, massive thrombus was seen in the right atrium and coronary sinus. Coronary sinus thrombus was removed as far as possible, and bilateral atrial appendage resection and myocardial biopsy were performed. Simultaneously, modified-Maze was also done. Heart rhythm returned into sinus rhythm after surgery. Pathological findings did not show specific findings of myocarditis or pericarditis.

Until now, the cause of thrombotic factors has not been fully clarified. Although the time of onset is unknown, probably, heart failure was triggered by atrial fibrillation, and consequently thromboembolism occurred. In the resected left atrial appendage, small thrombus remained among pectinate muscle (figure1B); therefore, postoperative anticoagulation should be needed.

Conclusion

We experienced a boy with thrombus in bilateral atrial appendages. In the resected left atrial appendage, multiple small thrombi remained in the pectinate muscle. From our experience, the disappearance of comb-like form in pectinate muscle by TEE suspects the residual thrombus, especially in the case of cardiogenic embolism.

Abstract P1472 Figure.

[A case report of gastric perforation after coronary artery bypass grafting with right gastroepiploic artery]

A 71-year-old man, who had received coronary angioplasty to right coronary artery 1 year before, was admitted because of unstable angina. An urgent CABG was performed using the left internal thoracic artery and the right gastroepiploic artery. Coronary anastomosis was performed under ventricular fibrillation due to porcelain aorta. Seven days after surgery, abdominal pain was suddenly experienced. A chest X-P showed subphrenic free air. So an emergent laparotomy was performed, and a 2 x 2 cm gastric perforation was found on the anterior wall of the greater gastric curvature. Partial gastrectomy was performed. However, he unfortunately died on the 58th postoperative day for multiple organ failure. Pathological examination of the excised gastric wall revealed ischemic change, not ulcer. This gastric perforation was possibly caused by ischemia after harvesting the right gastroepiploic artery.

Aortic valve replacement after previous coronary artery bypass grafting in a patient with antiphospholipid syndrome

We report a 55-year-old female patient with antiphospholipid syndrome secondary to systemic lupus erythematosus. The patient had undergone coronary artery bypass grafting for myocardial infarction due to left main trunk stenosis at the age of 52. Subsequently, she developed aortic insufficiency and underwent aortic valve replacement without any hemodynamic or hemostatic problems. Both coronary and valve disease should be considered in patients with antiphospholipid syndrome secondary to systemic lupus erythematosus.

[A case report of aortoesophageal fistula due to thoracoabdominal aortic aneurysm]

Aortoesophageal fistulas due to thoracic aneurysms are usually fatal, with few reported survivors. A 57-year-old man with aortoesophageal fistula due to thoracoabdominal aortic aneurysm underwent the graft replacement of thoracoabdominal aorta. In the postoperative course, prosthetic graft infection had occurred in the result of residual esophageal fistula. On the 32nd postoperative day (POD), a subtotal esophagectomy was performed and the esophagus was reconstructed by gastrointestinal interposition technique via a retrosternal route. Following the second operative procedure, inflammatory reactions had been improved with systemic administration of antibiotics and continuous irrigation of the infected cavity. On 77th POD, he was discharged.

Hospital-wide PACS with a digital image intensifier TV system

Tokyo Hitachi Hospital, Hitachi Ltd., has used a hospital-wide PACS for over 1 year. The system runs a 100 Mb/s optical fiber network over the whole hospital including wards and outpatient clinic rooms, with 11 image workstations. The network links digital imaging modalities such as X-CT, MRI, computed radiography (CR) and digital radiography (DR) with a 2048 x 2048 (2k x 2k) matrix image intensifier television (I.I.-TV) system. These modalities generate about 200 images/day. The system has managed over 300,000 images of about 8000 patients so far. Although being still under improvement, the system has really been used for routine work. The hospital-wide PACS of a small hospital has been proved to be very useful for both image diagnosis and image management.

[An autopsied case of juvenile myocarditis which showed a remarkable cardiac enlargement during the course of six months]

A 19-year-old student was admitted for orthopnea. He had been a badminton player having no experience of serious diseases until he became aware of exertional epigastralgia ten days before admission. On examination, blood pressure was 102/70 mmHg, heart rate 148, and respiration 34. A third sound and moist rales were heard. The liver was enlarged and palpable at 8 cm below the right costal margin. The titers of the virus neutralizing antibodies determined on admission were all less than 32-fold. Chest roentgenogram as compared with that taken six months before admission showed a marked increase in the cardiothoracic ratio and pulmonary venous congestion. Echocardiogram showed a markedly dilated cavity of the left ventricule (LV) (LV diastolic diameter = 74 mm) compared with the cavity of the right ventricule (RV) (RV diastolic diameter = 20 mm) and diffusely impaired wall motion of the LV (fractional shortening = 9%). He died of intractable congestive heart failure two weeks after admission. Heart weight was 620 g. The LV cavity was markedly dilated, but the thickness of the LV free wall was within normal limits. Microscopy of the both atria, the RV, and the basal ventricular septum showed acute and chronic-staged inflammation. However, microscopy of the free wall of the LV showed only slight interstitial fibrosis without necrosis of the myocytes. The marked dilatation of the LV cavity would be due to either the same mechanism as that of dilated cardiomyopathy or excessive exercise after infection with myocarditis. This case showed that LV dilatation without myocardial necrosis/degeneration could develop among patients with myocarditis.

Inhibition of development of tolerance to nitroglycerin by preventive administration of N-acetylcysteine in rats

The efficacy of N-acetylcysteine in reversing nitrate tolerance has been controversial. This study examined whether continuous administration of N-acetylcysteine, a sulfhydryl compound, can prevent the development of tolerance to nitroglycerin; its acute effects on developed tolerance were also assessed. Rats were treated with subcutaneous injections of 1) 100 mg/kg nitroglycerin, 2) 100 mg/kg nitroglycerin and 700 mg/kg N-acetylcysteine, 3 times a day for 3 days. The sensitivity to nitroglycerin was studied in aortic preparations. The degree of developed tolerance to nitroglycerin was partially inhibited by simultaneous injection of N-acetylcysteine. Subsequent in vitro preincubation of aortic strips with nitroglycerin (10(-5) M) reduced the subsequent nitroglycerin sensitivity of vessels from rats treated with nitroglycerin and N-acetylcysteine; sensitivity returned to the initial control level after in vitro preincubation with N-acetylcysteine. The nitroglycerin sensitivity of vessels from rats treated only with nitroglycerin, though, was not affected by in vitro preincubation with N-acetylcysteine. In conclusion, N-acetylcysteine is not effective in reversing the high degree of tolerance developed to nitroglycerin. However, continuous administration of N-acetylcysteine is effective in preventing the development of nitroglycerin tolerance.

Comparison of functional responses of canine coronary artery and saphenous vein

Functional responses of canine circumflex coronary arteries and saphenous veins before and after grafting surgery were assessed following physiologic and pharmacologic interventions. Developed tension of ringed segments of vessels was recorded isometrically. Dose-dependent responses to norepinephrine revealed significantly greater responses of saphenous veins than coronary arteries (maximal responses were 2.79 +/- 0.45 and 0.44 +/- 0.34 g, respectively; p less than 0.001). Sensitivity to norepinephrine [as evaluated by 50% effective dose (ED50) value] was 3.3 times greater in the saphenous veins (p less than 0.001). STA2, a synthetic thromboxane A2 analog (see Methods), produced similar contractions of both vessels [maximal responses were 2.13 +/- 0.37 g in saphenous vein and 1.64 +/- 0.85 g in coronary artery; p less than not significant (NS)], while sensitivity to STA2 of saphenous veins was 3.1 times greater than that of coronary arteries (p less than 0.001). In contrast to the foregoing responses, coronary arteries demonstrated significantly greater responses to potassium than saphenous veins (maximal responses were 2.16 +/- 0.71 g and 1.40 +/- 0.56 g, respectively; p less than 0.001). Moreover, coronary arteries revealed 1.6 times greater sensitivity than saphenous veins (p less than 0.001). When saphenous veins were transplanted into the femoral artery, the segments of the grafts (2 weeks or 3 months after surgery) revealed 4.0 and 1.7 times greater sensitivity (denervation supersensitivity) to norepinephrine and potassium than those of the control veins (p less than 0.01, respectively). Contractile tension response, however, decreased by at least 50% 3 months after surgery, most probably due to a thickened vessel wall and a reduced compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral regurgitation due to abnormal reinsertion of chordae tendineae (looping) of the posterior mitral leaflet: clinical and echocardiographic features]

Two-dimensional (2D) echocardiographic and clinical characteristics of patients with mitral regurgitation (MR) due to abnormal reinsertion of chordae tendineae (looping) in the middle scallop of the posterior leaflet were described and compared with those of patients with chordal rupture of the posterior leaflet. Twenty-five patients with posterior mitral valve prolapse who underwent mitral valve replacement were studied. They were categorized in three groups; 14 patients with MR due to ruptured chordae tendineae (RCT) of the posterior leaflet (RCT group); three patients with looping of the chordae tendineae in the middle scallop of the posterior leaflet (looping group); and eight patients with both RCT and looping (looping + RCT group). It was difficult to distinguish the looping group from the other two groups by their 2D echocardiographic findings, which were characteristic of those of RCT. However, the following findings were more frequently encountered in the patients with looping than in those without: 1) aberrant or absent systolic coaptation with salient arc of the posterior leaflet, observed in six of the RCT group (43%), two in the looping group (67%) and seven in the looping + RCT group (88%); 2) with thickened edges of the posterior leaflet, shown in three of the RCT group (21%), two of the looping group (67%) and five of the looping + RCT group (63%) in the long-axis view, and also noticed in four of the RCT group (29%), two of the looping group (67%) and six of the looping + RCT group (75%) in the short-axis view. In the clinical history, the onset of a heart murmur, congestive heart failure and surgical treatment occurred at significantly younger ages in the looping group than in the RCT group. As for hemodynamic parameters, pulmonary hypertension was significantly milder in the looping group than in the RCT group. In conclusion, although 2D echocardiographic findings of patients with looping were similar to those of patients with RCT, it seemed possible to differentiate the looping group from the RCT group by the 2D finding of a prolapsed posterior mitral valve with a salient arc and a thickened edge. It was also suggested that the looping of chordae tendineae in the middle scallop of the posterior leaflet was congenital in origin.

[Metastatic thyroid cancer to the right ventricle causing obstruction of the right ventricular outflow tract and associated with disseminated intravascular coagulopathy: a case report]

A case of thyroid cancer causing right ventricular outflow tract obstruction is described. A 72-year-old woman was admitted because of shortness of breath, some ecchymoses, and marked anasarca. Her liver was palpable four fingerbreadths below her costal margin. Laboratory findings included leukocytosis, marked thrombocytopenia, and an increase in fibrinogen degradation products due to disseminated intravascular coagulopathy. Two-dimensional echocardiography demonstrated a solid mass in the right ventricle, which protruded into the right atrium and main pulmonary artery. Right ventricular outflow tract obstruction and tricuspid regurgitation were demonstrated by contrast echocardiography. These findings were confirmed by CT scans, RI angiography, and contrast angiography. The mass was partially resected from her right ventricle and her tricuspid valve was replaced successfully, but she died of sepsis three weeks after surgery. At autopsy, undifferentiated thyroid cancer and cardiac metastasis were verified. To date, only eight cases with initial symptoms of congestive heart failure due to right ventricular outflow tract obstruction caused by metastatic intracavitary tumors have been reported. Very rarely have cardiac tumors resulted in disseminated intravascular coagulopathy.

[Pseudoaneurysm of the left ventricle serially demonstrated from on-set using two-dimensional echocardiography: a case report]

A case of so-called pseudoaneurysm of the left ventricle without pericardial adhesion, serially demonstrated by two-dimensional echocardiography, was reported. A 76-year-old man developed congestive heart failure 10 hours after gastrectomy, and was diagnosed as having acute myocardial infarction. Two-dimensional echocardiography on the 21st day after onset revealed moderate pericardial effusion and an echo-free space in the posterolateral myocardium of the left ventricle. The echo-free space gradually expanded exteriorly and formed an aneurysm, which remained unchanged after the resolution of the pericardial effusion. Clinical diagnosis of pseudoaneurysm of the left ventricle was made by left ventriculography and coronary angiography. At autopsy, there was an aneurysm measuring 2.3 X 3.0 X 5.0 cm which communicated with the left ventricle via two small ostia, 5 mm each in diameter. There was a loose fibrous adhesion between the pericardium and the epicardium. The wall of the aneurysm consisted of organized fibrous tissue without any elements of the myocardium. Both myocardium and fibrous tissue were located at the junction of the left ventricular wall and the aneurysm. It is surmised that dissection of the infarcted myocardium expanded so greatly as to form an aneurysmal cavity, resulting in the formation of a so-called pseudoaneurysm of the left ventricle after fibrous changes of the outer wall in the infarcted myocardium. Therefore, this aneurysm might be termed a "dissecting" aneurysm of the left ventricle. The hypothesis that a pseudoaneurysm is derived from a localized hemopericardium should be reconsidered.

Periodic fluctuation of blood pressure in a case of norepinephrine secreting extra-adrenal pheochromocytoma

A rare case of pheochromocytoma with wide fluctuation of blood pressure at regular 7-min intervals is described. Direct blood pressure monitoring revealed periodic changes between 120/80 mmHg and 220/130 mmHg. The plasma norepinephrine concentration increased selectively in parallel with the elevation of the blood pressure. The tumor was found adjacent to the left kidney, and all abnormal data improved after its resection.

[Mitral regurgitation due to ruptured chordae tendineae: sensitivity and specificity of the diagnostic criteria by two-dimensional echocardiography]

The sensitivity and specificity of the two-dimensional (2D) echocardiographic criteria for diagnosing ruptured mitral chordae tendineae (RCT) were assessed in 52 cases with non-rheumatic mitral regurgitation undergoing mitral valve prostheses. At surgery, chordal rupture was confirmed in 38 cases (RCT group), but not in 14 cases (non-RCT group). Four presumptive and three definite findings for diagnosing mitral chordal rupture using 2D echo were evaluated. Mitral valve prolapse with incomplete coaptation of the mitral leaflets in the long-axis view was observed in 32 cases in the RCT group and in four cases in the non-RCT group (sensitivity 84%, specificity 80%). In the short-axis view at the level of the mitral orifice, delayed closure of the involved mitral leaflet was observed in four cases in the RCT group but in none of the non-RCT group (sensitivity 11%, specificity 100%), delayed protodiastolic opening of the involved leaflet in 15 cases of the RCT group and in one of the non-RCT group (sensitivity 39%, specificity 92%), and finally, increased excursion of the involved valve in 27 cases of the RCT group and in three cases of the non-RCT group (sensitivity 71%, specificity 79%). The following three echocardiographic findings were regarded as direct evidence of mitral chordal rupture: Fine echoes with abnormally rapid transverse and/or oblique motion around the mitral orifice in the short-axis view were observed in 13 cases of the RCT group (sensitivity 34%, specificity 100%); echoes with abnormal whip-like motion in the long-axis view in 10 cases (sensitivity 26%, specificity 100%).(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of pulmonary arterial pressure in adults by pulsed Doppler echocardiography

Doppler echocardiography was used to estimate pulmonary artery (PA) pressure in 45 adult patients with various kinds of heart disease and the patterns were compared with those of 32 normal control subjects. Doppler signals obtained in the right ventricular (RV) outflow tract just proximal to the pulmonary valve and electrocardiogram were recorded simultaneously. Doppler velocity time intervals were measured as follows: RV preejection period, acceleration time from the onset of the RV ejection flow velocity to the peak, and RV ejection time. Thirty patients had PA hypertension and 16 patients had a low cardiac index. The best correlation with PA pressure was achieved by the RV preejection period/acceleration time index (r = 0.89 vs mean pressure). Sensitivity and specificity for predicting PA hypertension were 93% and 97%, respectively. Acceleration time correlated best with the logarithm of PA mean pressure (r = 0.88). Patients were separated into 2 groups according to cardiac index. In those patients with a cardiac index of less than 2.5 liters/min/m2, both RV preejection period/acceleration time and acceleration time were significantly correlated with PA mean pressure (r = 0.87) and log (PA mean pressure) (r = -0.87), respectively. However, the slope of the regression line for acceleration time and log (PA mean pressure) was significantly steeper than that for patients with a cardiac index of greater than or equal to 2.5 liters/min/m2 (p less than 0.05), whereas the relation between RV preejection period/acceleration time and PA mean pressure in the 2 groups could not be differentiated statistically from each other. Other intervals and ratios were less quantitative because of late systolic turbulent flow and individual variability.(ABSTRACT TRUNCATED AT 250 WORDS)

Immobile right aortic leaflet in a case of the aortitis syndrome complicated by a left coronary sinus aneurysm

A 37-year-old housewife had the aortitis syndrome complicated by acute aortic regurgitation and severe coronary insufficiency. Her echocardiogram at the level of the aortic valve ring revealed an enlarged left aortic sinus and an oscillating membranous structure centrally in the lumen of the aorta. At emergency surgery, there was no intimal flap in the ascending aorta, but there was a 4 cm diameter aneurysm of the left aortic sinus. The leaflets of the aortic valve per se were normal. Following its surgical repair and an aortic valve replacement, prednisolone was administered, and all abnormal laboratory data were corrected. The oscillating structure in the ascending aorta was considered to be the right aortic leaflet whose reduced mobility was caused by a distorted aortic valve ring due to the aneurysm. An immobile aortic leaflet is an extremely rare echocardiographic finding worthy to be reported.

[Pulmonary regurgitation with special reference to the shape of the pulmonary valve ring: a pulsed Doppler and angiographic study]

Using pulsed Doppler echocardiography and cineangiography, the significance of pulmonic valve ring dimensions in the genesis of pulmonic regurgitation (PR) was studied in 40 patients, including 12 with valvular disease, 19 with coronary artery disease and nine with the normal heart. In nine of the 40 subjects, pulmonary hypertension (mean pulmonary artery pressure greater than or equal to 20 mmHg) was observed. The criterion for diagnosing PR was disturbed flow patterns recorded just below the pulmonic valve which spanned more than 40% of diastole, exceeding 1.5 KHz in peak frequency (corresponding to a flow velocity of about 50 cm/sec). Sagittal and transverse diameters of the pulmonic valve ring (PRDs, PRDt) at the upper edge of the pulmonary sinus, and the sagittal diameter of the pulmonary sinus (PSD) at the level of its maximal bulging were measured using pulmonary angiography. PR was detected in 15 subjects (37.5%). The prevalence of PR among three groups regardless of the absence or presence of pulmonary hypertension was not significantly different. The peak frequency of the regurgitant flow signals as well as the farthest point of the signals detected did not differ among the three groups irrespective of pulmonary hypertension. The ratio of the PRDs to the PRDt (PRDs/PRDt) was greater in patients with PR than in those without PR (p less than 0.001), but no correlation was established between PRDs/PRDt and mean pulmonary artery pressure. The PRDt index and PRDs index (normalized by body surface area) correlated well with the mean pulmonary artery pressure (r = 0.70, p less than 0.001 and r = 0.62, p less than 0.001, respectively). PSD also correlated with the mean pulmonary artery pressure (r = 0.49, p less than 0.01), whereas, PSD/PRDs correlated inversely with the mean pulmonary artery pressure (r = 0.40, p less than 0.01), indicating a relatively more prominent dilatation of the PRDs than of the PSD in cases with pulmonary hypertension. These results suggest that the etiology of PR in our series of patients was primarily attributable to the distortion of the pulmonic valve ring. The wide-spread concept that pulmonary hypertension dilates the pulmonic valve ring, leading to the development of PR, should be criticized.

[Two-dimensional echocardiographic measurement of the surgical aortic ring: its clinical significance in non-rheumatic regurgitation and in predicting the sizes of prosthetic valves]

The purpose of the present study was to determine the usefulness of two-dimensional echocardiographic measurements of the surgical aortic ring diameters (ARDs) in predicting correct sizes of the prosthetic valves and in determining the mechanisms of aortic regurgitation. Forty patients with aortic regurgitation who underwent prosthetic valve surgery, and 20 normal controls were selected for the study. The 40 patients consisted of 21 with rheumatic aortic regurgitation (RHD group), and 19 with non-rheumatic non-inflammatory aortic regurgitation (non-RHD group). Aortic regurgitation due to annuloaortic ectasia with or without the stigmata of Marfan's syndrome and bicuspid aortic valves were excluded from the non-RHD group. Echocardiographic estimates of the ARDs proved to be useful for predicting prosthetic valve sizes considering the good correlation between the echocardiographic and direct measurements (r = 0.814), despite a slight tendency to echocardiographic underestimation. The ARDs was 24.7 +/- 3 mm in the RHD group, 28.8 +/- 2.9 mm in the non-RHD group and 21.8 +/- 1.7 mm in the normal controls. The ARDs in the RHD group was significantly larger than that of the normal controls (p less than 0.001), and the ARDs of the non-RHD group was significantly larger than that of the RHD group (p less than 0.001). There were loose correlations between the ARDs and left ventricular end-diastolic dimension, and between the ARDs and left ventricular end-systolic dimension in the RHD group (r = 0.549 and r = 0.455, respectively), but there were no correlations between these two parameters in the non-RHD group. In four patients with aortic regurgitation in the non-RHD group, mitral regurgitation coexisted. Both the ARDs and the mitral ring dimension were markedly increased in these patients. It is concluded that in the non-RHD group, marked dilatation of the ARDs appears to be one of the cause of aortic regurgitation.

Familial amyloid polyneuropathy with marked hypertrophy of the peripheral nerves

Autopsy findings in a 40-year-old male with heredofamilial amyloidosis and polyneuropathy are reported. He had been suffering from progressive autonomic as well as sensorimotor dysfunctions. Prominent amyloid deposit was found in the kidney, heart, thyroid, and testis, and less in the interstitium and small vessels of almost all organs. The peripheral nerves, some showing prominent hypertrophy, were most severely involved by amyloid deposit in a form of stellate mass, which ultrastructurally consisted of radially arranged amyloid filaments. In the hypertrophied nerves and ganglia, in addition to amyloid, massive accumulation of acid mucopolysaccharide (AMPS) was seen filling up the interstitial space, which was the cause of hypertrophy. Ultrastructurally, AMPS was seen as finely granular substance. An extracted amyloid from the kidney showed 8 nm filament on negative staining and was estimated of having a molecular weight of 14,000.