Low Resilience Polyurethane Slabstock Foam with Microphase Separated Morphology

The purpose of this paper is to elucidate the nature of the low resilience foam with microphase separated morphology. Takeda has developed a unique homogeneous polyol mixture, which provides a low resilience foam with two glass transition temperatures. The existence of two tan 8 peaks, a glass transition and P glass transition around -40°C and room temperature, respectively, indicates the presence of the microphase separation. The chemical structure and the reactivity of the homogeneous polyol is well designed for the simultaneous formation of the heterogeneous morphology during the blowing process. The newly developed foam did not increase its hardness in the range of 0 to -20°C and did not become glassy even at -20°C; the storage modulus curve has a plateau region around -10°C. The a glass transition temperature was sensitive to the formulation factors, polyol ratio, water level, index and plasticizer, whereas the f glass transition temperature is less sensitive to those factors.

Molecular typing and epidemiological study of Salmonella enterica serotype Typhimurium isolates from cattle by fluorescent amplified-fragment length polymorphism fingerprinting and pulsed-field gel electrophoresis

One hundred twenty Salmonella enterica serotype Typhimurium strains, including 103 isolates from cattle gathered between 1977 and 1999 in the prefecture located on the northern-most island of Japan, were analyzed by using fluorescent amplified-fragment length polymorphism (FAFLP) and pulsed-field gel electrophoresis (PFGE) to examine the genotypic basis of the epidemic. Among these strains, there were 17 FAFLP profiles that formed four distinct clusters (A, B, C, and D). Isolates that belonged to cluster A have become increasingly common since 1992 with the increase of bovine salmonellosis caused by serotype Typhimurium. PFGE resolved 25 banding patterns that formed three distinct clusters (I, II, and III). All the isolates that belonged to FAFLP cluster A, in which all the strains of definitive phage type 104 examined were included, were grouped into PFGE cluster I. Taken together, these results indicate that clonal exchange of serotype Typhimurium has taken place since 1992, and they show a remarkable degree of homogeneity at a molecular level among contemporary isolates from cattle in this region. Moreover, we have sequenced two kinds of FAFLP markers, 142-bp and 132-bp fragments, which were identified as a polymorphic marker of strains that belonged to clusters A and C, respectively. The sequence of the 142-bp fragment shows homology with a segment of P22 phage, and that of the 132-bp fragment shows homology with a segment of traG, which is an F plasmid conjugation gene. FAFLP is apparently as well suited for epidemiological typing of serotype Typhimurium as is PFGE, and FAFLP can provide a source of molecular markers useful for studies of genetic variation in natural populations of serotype Typhimurium.

[Investigation of gastric cancers detected at a medical check-up center]

Most of the gastric cancers investigated in this study were detected during mass screening at a Medical Check-up Center. The research period was 5 years, from 1990 to 1994. The total number of patients undergoing initial gastric examinations was 300,658. Four point eight percent of these needed detailed examinations, and 77.2% actually underwent detailed examinations. Over the 5 years, the number of gastric cancers detected was 253. The rate of detection of these cancers was almost unchanged every year, with the average rate of change being 0.11%. The rate of detected gastric cancers was investigated according to age and sex. No cancers were found below age 29, and the rate gradually rose over age 30. Over age 50, the rate in males was twice that in females. The rate of early gastric cancers was 66.4% of all reported cancers. As regards location of 253 cases, 16.5% were in the C-area, 45.8% in the M-area, 36.2% in the A-area; 19.2% were in the greater curvature, 33.9% were in the lesser curvature, 17.3% in the anterior wall, and 26.1% in the posterior wall. The sizes of the lesions were as follows: 11.5% were below 1.0 cm, 29.6% were from 1.1 cm to 2.0 cm, 46.6% were from 2.1 cm to 5.0 cm, and 12.3% were over 5.1 cm. It was considered that indirect X-rays were slightly inferior to direct X-rays in detecting early gastric cancer. The X-ray positionings in which cancers were detected were: 75.7% by supine double contrast and 48.6% by compression in 144 cases of early cancer. On the other hand, the rate were 75.6% by supine double contrast, and 51.2% by compression in 82 cases of advanced cancer. A similar tendency was found in one-shot X-ray positioning which revealed cancers. The rate of gastric cancer notdetected by X-ray pictures was 5.9% of the 253 cases. The size of the cancers notdetected by X-ray was within 2.0 cm in all cases. 58.7% of the 155 early cancer patients and 48.2% of the 83 advanced cancer patients had examinations the previous year. Therefore, it is clear that some cases of advanced cancer were not detected in the mass gastric screenings. Endoscopically, 7 cases of gastric cancer were diagnosed correctly by means of repeated biopsies which were needed 3 or 4 times over 3 to 18 months owing to pseudonegative findings on the first bioptic examination. Consequently, it is necessary to make naked eye diagnosis by endoscopic examination. Six cases of death from gastric cancer were certified within one year after normal diagnosis during the mass screening. Three cases were Borr. 4, 2 cases Borr. 3, and 1 case was Borr 2. A retrospective investigation of X-ray pictures showed that it would have been difficult to identify the lesions in these cases. The above results show that the accuracy of examinations and diagnosis must be raised in mass gastric screenings, but it is doubtful whether relying on the present methods of screening will lead to a marked improvement. For the purpose of increasing the effectiveness of mass gastric screening, we would emphasize the necessity of the following new tests; serum pepsinogen measurement, reinvestigation of patient's ages, shortening the intervals between examinations in high risk groups, using direct X-rays rather than indirect X-rays, and intermitted endoscopic examinations.

[A case of cutaneous and brain metastasis of gastric carcinoma, treated effectively by chemotherapy with CDDP, MMC, etoposide and 5'-DFUR]

A case of cutaneous and brain metastasis of gastric carcinoma, treated effectively by chemotherapy, is reported. The patient was a 67-year-old female. She underwent total gastrectomy for advanced gastric carcinoma with direct invasion to liver. Six months later, she was admitted with headache and multiple skin nodules on the trunk. CT showed two round tumor shadows on the left side of brain, and a skin biopsy specimen revealed poorly differentiated adenocarcinoma. Chemotherapy with 10mg of CDDP, 2mg of MMC, 150mg of etoposide and 300mg/day of 5'-DFUR was performed. After the third course of chemotherapy, cutaneous and brain metastasis disappeared. Although the patient died of pulmonary metastasis 24 weeks after, cutaneous and brain metastasis disappeared 12 weeks.

[Intra-arterial infusion chemotherapy using an implantable reservoir in the treatment of hepatic metastases in colorectal cancer]

With colorectal cancer, the therapeutic outcome for multiple hepatic metastasis extending to the bilateral lobe, even when various chemotherapies are administered, is extremely poor. For multiple hepatic metastases at our clinic, from November, 1985, through February, 1991, we used an implantable reservoir to administer intra-arterial infusion chemotherapy and reviewed the results. We treated 16 patients with hepatic metastases of colorectal cancer, H2 in 3 cases and H3 in 13 cases. When we used the reduction rate of the tumor diameter as seen by CT scan as a criteria for antitumor effectiveness, 1 case was CR and 3 cases were PR, for an efficacy rate of 25.0%. Changes in the serum CEA level were related to antitumor effectiveness. Among the evaluable cases, the 1-year survival rate was 60.0%, which was significantly more favorable than the 20.0% obtained in the systemic chemotherapy group (p less than 0.05). Given the above, although there are a few problems such as the kind and dose of drugs, the use of intra-arterial infusion chemotherapy with an implantable reservoir to treat hepatic metastases of colorectal cancer permits a form of chemotherapy providing a better QOL out of hospital.

Effects of the prostaglandin synthetase inhibitor indomethacin on tumorigenesis, tumor proliferation, cell kinetics, and receptor contents of 7,12-dimethylbenz(a)anthracene-induced mammary carcinoma in Sprague-Dawley rats fed a high- or low-fat diet

The effects of indomethacin on tumorigenesis, tumor proliferation, cell kinetics, and receptor content of 7,12-dimethylbenz(a)anthracene-induced mammary carcinoma have been examined in female Sprague-Dawley rats. The rats were fed either a high-fat (20% corn oil) or low-fat (0.5% corn oil) diet with or without 0.005% indomethacin starting 7 days after intragastric administration of a single dose of 5 mg 7,12-dimethylbenz(a)anthracene. The results demonstrated that indomethacin completely blocked the stimulatory effect of fat on tumorigenesis, as demonstrated by a decreased tumor incidence, a decreased number of tumors per group, and an increased latency. Contrary to what had been expected, however, indomethacin promoted tumor proliferation in both the high- and low-fat diet groups, as evidenced by an increased tumor size, an increased bromodeoxyuridine-labeling index, and a decreased potential tumor-doubling time. No significant difference in either the estrogen receptor or progesterone receptor content of the tumor was noted. It can be concluded, therefore, that indomethacin significantly reduced tumorigenesis in the high-fat diet group but significantly promoted tumor proliferation in both the high- and low-fat diet groups.

Impact of neck dissection on survival in well-differentiated thyroid cancer: a multivariate analysis of 218 cases

The management of cervical lymph node metastases in well-differentiated carcinoma of the thyroid has been highly controversial. In the Department of Surgery (II), Kanazawa University Hospital, the surgical management of cervical lymph node metastases in curable well-differentiated carcinoma of the thyroid has been changed from a conservative approach to an aggressive one since 1973. In order to determine whether an aggressive approach for cervical lymph node metastases is adequate, a retrospective multivariate analysis was carried out of 218 cases of well-differentiated thyroid cancer. The patients have been followed up from 5 to 30 years. Multivariate analysis was conducted following Cox's model. As for the results, the aggressive management of cervical lymph node metastases appeared to have an impact on survival. Furthermore, age and sex were confirmed to be important prognostic factors and a partial lobectomy was confirmed to be inadequate as a type of thyroidectomy.

[Effect of high dietary fat on the total DNA and receptor contents in rats with 7,12-dimethylbenz[A]anthracene-induced mammary carcinoma]

The influences of high dietary fat on the malignant intensity and the hormone receptors of DMBA-induced mammary breast carcinoma were analyzed in female Sprague-Dawley rats. The rats were fed either a low-fat diet or high-fat diet after the DMBA administration. As the results, incidence, size, average latent period, DNA histogram, DNA index and % of S-phase fraction of tumor were significantly different between both groups. But the ER and PgR contents were not different between both groups. The results suggest that a high dietary fat could increase the malignant intensity of the tumor but does not influence the receptor contents of the tumors.

Bilateral cervical lymph node metastases in well-differentiated thyroid cancer

We analyzed the regional lymph node metastases of 98 patients with thyroid cancer who underwent bilateral modified neck dissection. Bilateral jugular lymph node metastases were frequent in patients with papillary carcinoma of the thyroid, especially in those patients with obvious carcinoma in both lobes of the gland, cancer arising in the isthmus, clinically detectable bilateral lymphadenopathy, and recurrent thyroid cancer. In patients whose cancer was clinically confined to one lobe, and where there were no obviously enlarged contralateral lymph nodes, the occurrence of contralateral jugular lymph node metastasis was significantly correlated with the contralateral paratracheal lymph node metastasis. The bilateral lymphadenectomy appears to be appropriate in these instances.

A retrospective study on the efficacy of cervical lymph node dissection in well-differentiated carcinoma of the thyroid

The management of cervical lymph node metastases in well-differentiated carcinoma of the thyroid is controversial. In our department, from 1963 to 1972, node plucking was performed only in patients with cervical lymphadenopathy whereas, from 1973 to 1983, modified radical neck dissection was therapeutically or electively performed. In order to determine whether the more extensive dissection is adequate, a retrospective analysis was performed using two groups of patients who were managed differently with regard to the treatment of cervical lymph node metastases. From this series of 206 patients with more than five years follow-up, it was found that the rates of survival and lymph node recurrence did not differ between the two groups. However, since the well-differentiated carcinoma of the thyroid has relatively indolent biological behaviour, further long-term follow-up seems to be necessary for demonstrating the efficacy of neck dissection.

Clinical and exercise echocardiographic findings in patients with mitral valve prolapse

To assess the relationship between left ventricular functional reserve and prognosis in patients with idiopathic mitral valve prolapse, ergometer exercise echocardiography was performed in 10 normal subjects and 30 patients with mitral valve prolapse having either mild, or no mitral regurgitation. These 30 patients with mitral prolapse were followed for 2 to 8 (mean 4.5) years. Increment of % fractional shortening during maximum exercise at the initial study in patients with mitral valve prolapse and normal subjects were 7 +/- 7 and 11 +/- 3%, respectively. Based on increment of % fractional shortening, patients with mitral valve prolapse were divided into 2 groups; Group I: 13 cases with delta% fractional shortening less than 5%, Group II: 17 cases with delta% fractional shortening greater than or equal to 5%. The incidence of cardiac symptoms was higher in Group I than in Group II (85 vs 41%, p less than 0.05). ST-T changes and life-threatening arrhythmias were more frequently observed in Group I. During the follow-up period, M-mode echocardiographic measurements did not vary in Group II, but left ventricular and left atrial dimensions increased significantly (p less than 0.05, p less than 0.01, respectively) and % fractional shortening decreased significantly (p less than 0.01) in Group I without any change in mitral regurgitation severity. Thus, some patients with mitral valve prolapse not having significant mitral regurgitation may develop progressive deterioration of the cardiac function, which may be predicted by exercise echocardiography.

Influence of hormones on proliferation of ER-positive cells and ER-negative cells of human breast cancer (MCF-7)

The influence of endocrine therapy on the proliferation of estrogen receptor (ER)-positive cells and ER-negative cells of human breast cancer (MFC-7) serially transplanted into nude mice was analyzed by tumor growth, dextran-coated charcoal (DCC) method, ER-immunocytochemical assay (ER-ICA) and ER-immunocytochemically stained 3H-thymidine autoradiography. In the tamoxifen (TAM) group and the medroxyprogesterone acetate (MPA) group, tumor growth was inhibited, but it was promoted in the 17-beta-estradiol dipropionate (E2) group. The ER level by the DCC method was significantly decreased in the TMA, the MPA and the E2 groups. The ER-ICA showed that the percentage of ER-positive cells was decreased in the TAM and the MPA group, but it was increased in E2 group. However, the ER-immunocytochemically stained 3H-thymidine autoradiography showed that not only the labelling index of ER-positive cells but also that of ER-negative cells was significantly decreased in the TAM and the MPA groups, while the labelling index was significantly increased in the E2 groups. Therefore, it was concluded that endocrine therapy affected the proliferation of both ER-positive cells and ER-negative cells of ER-positive breast cancer.

Effects of high dietary fat on the total DNA and receptor contents in rats with 7,12-dimethylbenz[a]anthracene-induced mammary carcinoma

The influence of high dietary fat on the malignant intensity and the hormone receptors of 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary carcinoma in female Sprague-Dawley rats were analyzed by the tumor incidence and growth, the DNA histogram type, the DNA index, the S-phase fraction, and the estrogen receptor (ER) and progesterone receptor (PgR) assays. The rats were fed either a low-fat (0.5% corn oil) diet or a high-fat (20% corn oil) diet after the DMBA administration. Tumor incidences in the low-fat and the high-fat diet groups were 46 and 86%, respectively (p less than 0.01). Tumors in the high-fat diet group were also significantly larger than those in the low-fat group. Average tumor latent period was significantly shorter in the high-fat diet group, comparing with that in the low-fat diet group (p less than 0.01). Sixty-nine percent of the tumors in the high-fat diet group had aneuploid type, while only 8% of those in the low-fat diet group had aneuploid type. The DNA index and S-phase fraction also were significantly higher in the high-fat diet group (p less than 0.01). But the ER and PgR contents were not different between both groups. Therefore, these results suggest that a high dietary fat could increase the malignant intensity of the tumor but does not influence the hormonal responsiveness of these tumors.

Human chorionic gonadotropin in colorectal cancer and its relationship to prognosis

The presence of human chorionic gonadotropin in large bowel cancers was studied immunohistochemically using an immunoperoxidase technique. HCG-positive tumour cells were present in 42 of 194 adenocarcinomas examined (22.0% of colon cancer and 21.2% of rectal cancers). On histological grading, the hCG-positive rate tended to rise as the degree of differentiation decreased. HCG was detected more frequently in cancers invading the total bowel wall (27%) than in those invading the partial wall (17.1%). Lymph node, liver or peritoneal metastases were present more frequently in hCG-positive tumours than in hCG-negative tumours. Furthermore, there was an intimate correlation between the presence of hCG-positive tumour cells and CEA doubling times in nine cases with untreated liver metastasis. The survival rate for patients with tissue hCG-positive cells was lower than for those with hCG-negative tumours. Thus, the presence of tissue hCG in colorectal cancers may be a biological marker of prognostic significance.

Breast cancer and regional lymph node dissections

Regional lymph node metastases were evaluated in 289 patients with operable breast cancer. The metastases of the axillary and internal mammary lymph node were shown to be closely related to the survival of patients, but the status of these nodes was shown to be impossible to estimate before the operation. Thus, axillary and internal mammary node dissections seem to be very important in order to attain an acceptable amount of information for staging of certain breast cancer patients. Due to the radicality of operations including internal mammary node dissection, the use of modified extended mastectomy is proposed as the staging operation. In this manner, the anterior chest deformity created by an extended radical mastectomy can be avoided and the pectoralis major muscle spared in patients without internal mammary lymph node involvement. Also found in this study, was some evidence of the beneficial use of en bloc extended radical mastectomy for the survival of a selected group of patients.

[Influence of endocrine therapy on the proliferation of estrogen (ER) positive cells and ER negative cells of human breast cancer (MCF-7)]

The influence of endocrine therapy on the proliferation of estrogen receptor (ER) positive cells and ER negative cells of human breast cancer (MCF-7) serially transplanted into nude mice was analyzed by tumor growth, dextran-coated charcoal (DCC) method, ER-immunocytochemical assay (ER-ICA) and ER-immunocytochemically stained 3H-thymidine autoradiography. In the tamoxifen (TAM) group and the medroxyprogesterone acetate (MPA) group, tumor growth was inhibited, but it was promoted in the 17 beta-estradiol dipropionate (E2) group. The ER level by the DCC method significantly decreased in the TMA, the MPA and the E2 groups. The ER-ICA showed that the ER positive cells rate in the TAM and the MPA group decreased, but it increased in E2 group. However, the ER-immunocytochemically stained 3H-thymidine autoradiography showed that not only the labelling index of ER-positive cells but also that of ER negative cells significantly decreased in the TAM and the MPA groups, but significantly increased in the E2 groups. Therefore it was concluded that endocrine therapy affected the proliferation of both ER positive cells and ER negative cells of ER positive breast cancer.

Gastric cancer heterogeneity

This study was carried out on 222 samples from 37 gastric carcinomas to assess the incidence of multiple stem lines in primary tumors and metastasis as reflected by multiple DNA stem lines and their relationship to epidermal growth factor (EGF) receptor expression, histologic grade, tumor size, and degree of wall infiltration. Fifteen primary tumors (40.5%) were homogeneously diploid/peridiploid whereas 22 (59.5%) were aneuploid. In the lymph node metastasis, seven patients (29.2%) had an homogeneous diploid/peridiploid pattern in all metastatic lymph nodes. On the other hand, 17 (70.8%) had at least one aneuploid peak in the lymph node metastasis. DNA content heterogeneity was seen in 12 (33%) of primary tumors whereas 14 (66.6%) of 21 patients had multiple cell clones in the metastasis. Therefore, 12 patients had a metastatic clone which was not observed in the primary tumor. DNA content heterogeneity was seen even in tumors with submucosal invasion suggesting that this phenomenon is also present at earlier stages. No correlation between the histologic grade and the DNA distribution was observed. Furthermore, histologic heterogeneity was independent of DNA content heterogeneity. The EGF receptor expression was observed in six of the 23 patients in whom this analysis was done. The EGF receptor expression was constant in all samples which were studied and even samples with a different DNA content and histologic grade were stables for the EGF receptor expression.

Cardiac thrombus in dilated cardiomyopathy. Relationship between left ventricular pathophysiology and left ventricular thrombus

The relationship between left ventricular thrombus and left ventricular dynamics in dilated cardiomyopathy (DCM) was studied by echocardiography and postmortem examination. The subjects were 57 patients with DCM, 40 were survival patients examined by echocardiography and 17 were autopsy patients. Systemic or pulmonary embolism occurred in 10 of 57 patients, 4 of 40 survival patients and 6 of 17 autopsy patients. Intracardiac thrombus was detected in 11 of 40 survival patients and was found in 8 of 17 autopsy patients. Left ventricular segmental wall motion abnormalities were observed in all 40 patients examined by two-dimensional echocardiography and apical dyskinesis or akinesis was observed more frequently in patients with left ventricular thrombus than in patients without left ventricular thrombus. Of 33 patients examined by pulsed Doppler echocardiography, Doppler ejection flow signals in the apical long axis view were recorded in 9% at the apex, in 17% at the middle portion and in 57% at the portion near the interventricular septal center. The signals at the portion near the interventricular septal center were recorded in only 2 patients with left ventricular thrombus but in 66% of patients without left ventricular thrombus. Systemic or pulmonary embolism and intracardiac thrombus occurred less frequently in patients treated with warfarin than in patients without warfarin. These results indicate that endomyocardial and blood flow disorders of the left ventricle play important roles in the occurrence of left ventricular thrombus and that anticoagulant therapy is useful for the prevention of systemic or pulmonary embolism and cardiac thrombus.

The significance of regional lymph node dissection in the surgical management of breast cancer

The results of an analysis done on the regional lymph node metastases of 300 patients with operable breast cancer, who were treated in the Department of Surgery (II), Kanazawa University Hospital from 1973 to early 1988 are reported herein. It was found that the metastases of the axillary and internal mammary lymph nodes were closely related to the survival of patients, but they were hardly diagnosed before the operation. Only the dissection of these lymph nodes proved useful for providing the prognostic information. Moreover, in a retrospective study comparing the en bloc extended radical mastectomy versus the other types of mastectomy, the extended radical mastectomy was seen to greatly improve the survival of patients with 3 or less than 3 metastatic axillary lymph nodes. Thus, the extended radical mastectomy provides the maximum diagnostic and prognostic information, and gives the best chance of loco-regional control of the disease. The anterior chest deformity created by the extended radical mastectomy, however, should be avoided in those patients without internal mammary involvement. We therefore propose the modified extended mastectomy as a staging operation.

[Regression of mitral valve prolapse to a state masquerading as dilated cardiomyopathy: a case report]

A 40-year-old man was admitted to our hospital in May 1982 for evaluation of a heart murmur. A standard 12-lead electrocardiogram (ECG) showed an abnormal Q wave in lead III. Echocardiography revealed prolapse of the anterior mitral valve leaflet (MVP), but neither dilatation nor wall motion abnormalities of the left ventricle (LV) were observed. Thallium-201 scintigraphy revealed an abnormal thallium uptake at the apex and inferior wall. He had no episode of acute myocardial infarction or myocarditis, but complete right bundle branch block suddenly appeared, and he was hospitalized in October 1984. He had no coronary artery lesions, and only mild mitral regurgitation on left ventriculography. The motion of the interventricular septum and apex was reduced on echocardiography and a persistent perfusion defect was observed at the inferior wall and the interventricular septum on T1-201 scintigraphy. In December 1985, he experienced an Adams-Stokes attack due to complete atrioventricular block. Echocardiographically, the left ventricle became enlarged and the wall motion abnormality and a perfusion defect on T1-201 scintigrams were of relatively severe degree. Thus, left ventricular dilatation and wall motion abnormality may progress in some cases of MVP as it did in this one. We consider this case a very interesting one in speculating on the relationship between MVP and DCM.

[Mitral valve prolapse with myocardial disarrangement and familial hypertrophic cardiomyopathy: a case report]

This is a report of a patient with mitral valve prolapse (MVP) and myocardial abnormalities on endomyocardial biopsy in whose relatives hypertrophic cardiomyopathy (HCM) was identified. A 19-year-old woman was admitted to our hospital for evaluation of a heart murmur. A systolic ejection murmur was audible in the third intercostal space at the left sternal border, and a standard 12-lead electrocardiogram showed ST-T wave changes in leads II, III and aVF. Echocardiography revealed prolapse of the anterior leaflet of the mitral valve, but no left ventricular hypertrophy. Endomyocardial biopsy disclosed mild hypertrophy and disarrangement of the myocardium. The family study revealed asymmetrical septal hypertrophy in her mother, who had no history of hypertension. Her younger sister had mild hypertrophy of the interventricular septum on echocardiography, and her histopathological findings suggested a diagnosis of HCM. This case was clinically regarded as MVP, but development of left ventricular hypertrophy as noted in her mother may occur in the future.

[Severity and non-uniformity of regional wall motion in dilated cardiomyopathy evaluated by two-dimensional echocardiography]

A two and a half year follow-up study of segmental left ventricular wall motion was performed by two-dimensional echocardiography for 26 patients with dilated cardiomyopathy (DCM). Segmental analysis of left ventricular wall motion abnormalities (WMA) was performed using 11 segments obtained by short- and long-axis views of the left ventricle. Wall motion in each segment was classified and assigned a numerical score as normal (0), hypokinetic (1), severely hypokinetic (2), and akinetic or dyskinetic (3). Based on this categorization, a wall motion abnormality index (WMAI) was derived as an overall assessment of left ventricular asynergy. The intersegmental standard deviation of the wall motion abnormality score was used as an index of left ventricular asynergy (non-uniformity index: NUI). During the follow-up period, the wall motion abnormality index increased in all of the 26 patients (from 1.23 to 1.82, p less than 0.001), but the non-uniformity index did not change (from 0.72 to 0.73). When comparing the non-uniformity index among three groups classified according to the grade of wall motion abnormality, both at the initial and during follow-up studies, the moderate wall motion abnormality group (1.0 less than or equal to WMAI less than 2.0) had larger non-uniformity indexes (0.83, 0.84) than the other groups, and the severe non-uniformity index (greater than or equal to 0.9) was observed solely in the moderate group. In the follow-up study, these 26 patients were categorized in two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypertensive heart disease simulating dilated cardiomyopathy]

Echocardiography was performed for 246 patients with hypertension. Among the 246 patients, echocardiographic features simulating dilated cardiomyopathy (DCM) were observed in 12. These patients had past history of hypertension and prominent left ventricular dilatation with reduced left ventricular contractility, but no left ventricular wall thickening. To elucidate the mechanism producing DCM-like features in patients with hypertension, the clinical and echocardiographic findings of the 12 hypertensive patients (HT-DCM) were compared with those of 50 hypertensive patients without dilated left ventricles and of 31 patients with DCM. On admission, all patients with HT-DCM had congestive heart failure (CHF) without high blood pressure and their echocardiograms revealed the abnormal findings described above. There were no differences of the clinical and echocardiographic findings on admission between HT-DCM and DCM. Following medical treatment, relatively early improvement of CHF was noted in all patients with HT-DCM; the LV dimension decreased and diffuse wall motion abnormality improved steadily with gradual elevation of blood pressure during the follow-up periods. The LV function of most patients with HT-DCM improved markedly but never reached normal levels. There were no significant differences the right ventricular endomyocardial biopsy findings of between DCM and HT-DCM. It was suggested the DCM-like features in these cases are caused, not only by hypertension, but by other factors, as well.

Study on the mitral valve prolapse. I. Incidence in Kobe University students. II. Follow up study

Incidence of mitral valve prolapse (MVP) in 4517 students of Kobe University, and clinical features in cases with MVP were studied. MVP was detected in 42 cases by two-dimensional echocardiography, and the prevalence of MVP was 0.93 percent (42 of 4517 cases). Among 42 cases with MVP, apparent mitral regurgitation (MR) was noted in one case with severe MVP, ventricular tachycardia was detected in one and ST-T wave abnormalities were detected in 10 respectively. In another follow up study of our hospital, 14 of 85 patients followed more than one year were noted to be deterioration in echocardiographic parameters. Eight of 14 patients had severe prolapse with severe MR, but remaining 6 had mild or moderate prolapse with mild or absent of MR. However, ST-T wave abnormalities, serious arrhythmias, and low response of %FS increase on exercise were found in high incidence in 6 of mild or moderate prolapse as well as in severe prolapse. So these follow up results suggested that not only students with severe MVP but also students with mild or moderate MVP with ST-T wave changes or VPC found in university medical examination must be followed up carefully.

Antithrombogenicity and oxygen permeability of block and graft copolymers of polydimethylsiloxane and poly(alpha-amino acid)

A-B-A-type block copolymers consisting of poly(alpha-amino acid) as A component and polydimethylsiloxane as B component and graft copolymers consisting of polydimethylsiloxane as trunk polymer and poly(alpha-amino acid) as branch polymer were synthesized. gamma-Benzyl-L- or DL-glutamate, epsilon-benzyloxycarbonyl L-lysine, and sarcosine were used as alpha-amino acid. Different microphase-separated structures were found on the film surface according to the copolymer composition and the casting conditions. In vitro antithrombogenicity test showed higher antithrombogenicity of block or graft copolymers than homopolymers. The best antithrombogenicity was independent of the kind of alpha-amino acid and the degree of polymerization of copolymers. The best ratio was 65-75% in block copolymer and 40-50% in the case of graft copolymer. The oxygen permeability of block and graft copolymer film was intermediate between those of homopolymers and varied with changing the composition of the copolymer. These experiments showed that the microphase-separated structure on the film surface was most important both for the antithrombogenicity and oxygen permeability of these copolymer films.

[Regional right ventricular hypertrophy in hypertrophic cardiomyopathy and hypertension]

The mode of right ventricular hypertrophy was assessed by two-dimensional echocardiography (2DE) for 24 patients with hypertrophic cardiomyopathy (HCM), and the results were compared with those of 51 patients with hypertension (HT). The patients with HT were categorized in four groups depending on the thickness of the interventricular septum (IVST) and left ventricular posterior wall (PWT): HT-ASH with both left ventricular hypertrophy (LVH) (IVST greater than or equal to 13 mm) and asymmetric septal hypertrophy (ASH) (IVST/PWT greater than or equal to 1.3), severe HT with LVH and without ASH, and mild HT without LVH and ASH. Anterior wall thickness (AWT), posterior wall thickness (PWT), and diaphragmatic wall thickness (DWT) of the right ventricle were obtained from 2DE in the parasternal long-axis view, the short-axis view and subxiphoid view, respectively. These were recorded on video tape, and the measurements were made on the stop frames. Right ventricular hypertrophy (RVH) was estimated by the maximal right ventricular wall thickness (max RVWT), and the ratio of the maximal and minimal thickness (max RVWT/min RVWT) was calculated to evaluate asymmetrical hypertrophy (AH) of the right ventricle (RV). The incidence of RVH (Max RVWT greater than or equal to 5 mm) and asymmetrical hypertrophy (AH) (max RVWT/min RVWT greater than or equal to 1.3) of the RV in HCM, HT-ASH and mild HT were 67% and 41%, 57% and 45%, and 15% and 11%, respectively. The incidence of RVH with AH was more frequent in patients with HCM as well as HT with ASH than in patients with HT without ASH.(ABSTRACT TRUNCATED AT 250 WORDS)

[Regional left ventricular function in dilated cardiomyopathy: observation of regional left ventricular wall motion before and during dobutamine administration]

To investigate left ventricular function and the prognosis of patients with dilated cardiomyopathy (DCM), regional wall motion of the left ventricle of 38 patients with DCM was observed before and during dobutamine infusion (8 micrograms/kg X min) by two-dimensional echocardiography (2DE). The left ventricle was divided into 11 segments and the severity of wall motion abnormality (WMA) was classified into 4 grades, i.e. akinesis or dyskinesis (A), severe hypokinesis (SH), hypokinesis (H) and normokinesis (N), and numerical scores were assigned to each grade of WMA as follow; A: 3, SH: 2, H: 1, and N: 0. In the 38 patients with DCM, the number of segments with WMA was 8.3 +/- 2.9 (mean +/- SD). Among 418 segments in the 38 patients, we observed A in 71 segments, SH in 104 segments, H in 140 segments, and N in 103 segments. The WMA was not uniform in the left ventricle, and severe WMA was observed in the apex (WMA score: 2.0 +/- 1.0), while the grades of WMA in the lateral and posterior walls were mild (WMA score: 0.8 +/- 1.1) compared with those of other segments. The total sums of the WMA scores in 11 segments for each patient (TWMAS) were significantly greater in patients with severe heart failure (New York Heart Association [NYHA] functional class III or IV) than in patients with mild heart failure (NYHA class I or II) (22.0 +/- 5.2 and 9.9 +/- 4.9, p less than 0.001). TWMAS correlated with the cardiac index (CI) (r = -0.58, p less than 0.005) and pulmonary capillary pressure (PCP) (r = 0.68, p less than 0.001). In 242 segments of 22 patients, whose regional wall motion was observed before and during dobutamine administration, wall motion was improved by one grade in 82 of 170 segments with WMA before dobutamine infusion; i.e. regional wall motion changed from A to SH in six segments, from SH to H in 31 segments, and from H to N in 45 segments with dobutamine administration. According to the change in grade of TWMAS induced by dobutamine administration, 22 patients with DCM were classified into two groups: a good response group (% change of TWMAS greater than or equal to 40%), and a poor response group (% change of TWMAS less than 40%). The poor response group had ventricular tachycardia more frequently, more severe heart failure, lower CI and higher PCP than the good response group.(ABSTRACT TRUNCATED AT 400 WORDS)

[Hypertrophic cardiomyopathy with progressive left ventricular hypertrophy: a case report]

A 64-year-old man was hospitalized in March 1983 for recurrent episodes of dyspnea and palpitation despite medical treatment. At 48 years of age (1967), hypertension was diagnosed, but well controlled by propranolol. At the age of 59 years (1979), his first episode of dyspnea and palpitation was noted, with electrocardiographic (ECG) evidence of left ventricular hypertrophy (LVH), and abnormal Q waves in leads III and a VF. The echocardiogram, however, showed mild LVH with neither asymmetric septal hypertrophy (ASH) nor systolic anterior movement (SAM). On admission (1983), his blood pressure was 130/70 mmHg, and a grade III systolic murmur was heard along the left sternal border and over the apex. On ECG, the left precordial voltage (Sv1 + Rv5) was diminished and the depth of the Q wave in lead III increased compared with that of 1978. On echocardiography, we observed prominent septal hypertrophy (IVST: 20 mm) with ASH (IVST/PWT = 2.0), SAM, an enlarged left atrium, and a diminished left ventricular (LV) cavity. Left ventricular catheterization showed a pressure gradient of 90 mmHg between the LV apex and outflow tract and histological examination of the bi-ventricular endomyocardial biopsy material showed markedly hypertrophied and mildly disarranged myocardial fibers with bizarre nuclei. We considered that this was an interesting case in which ASH and SAM developed in the progression of LVH during the follow-up period.

A long-term follow-up study of acute myocarditis an electrocardiographic and echocardiographic study

In an attempt to prove that myocarditis may be a cause of idiopathic cardiomyopathy, 10 cases with acute myocarditis were involved in a long-term follow-up study. There were 9 males and 1 female patient, ranging in age from 22 to 63 years. The etiology of myocarditis was idiopathic in 9 cases and rubella virus in 1 case. Clinical findings in the acute stage consisted of congestive heart failure in 6 cases, Adams-Stokes syndrome in 2 cases and cardiomegaly in 2 cases. The mean follow-up period was 55 months. Follow-up studies included physical examinations, 12-lead ECG, chest X-rays and two-dimensional echocardiograms. Various patterns of residual ECG abnormalities in the chronic stage were found, such as conduction disturbance in 1 case, pseudoinfarction pattern in 4 cases, ST-T changes in 2 cases and premature ventricular contractions in 2 cases. The cardiothoracic ratio of all cases was 60 +/- 4% in the acute stage. Two cases (Case 1 and 2) died 16 and 36 months after the acute onset, respectively. Four cases had residual cardiomegaly even in the last study period. An echocardiographic follow-up study of 7 cases disclosed progressive left ventricular (LV) dilatation and dysfunction in 3 cases, regression of LV dilatation in 2 cases and stable LV function in 2 cases. Two cases out of 3 with progressive LV dilatation and dysfunction expired after the acute illness. It was therefore suggested that acute myocarditis may cause LV dilatation and/or wall hypertrophy and that idiopathic cardiomyopathy may represent the end-stages of previous myocarditis.

[Three-dimensional evaluation of mitral regurgitation by pulsed Doppler echocardiography: analysis of the amount and direction of regurgitant flow]

Pulsed doppler echocardiography (PDE) was used to evaluate mitral regurgitation (MR) non-invasively and quantitatively in 156 patients including 51 of rheumatic valvular disease, 57 of mitral valve prolapse (MVP) or chordal rupture of the mitral valve (RCT), and 48 of ischemic heart disease (IHD) or dilated cardiomyopathy (DCM). The severity of MR was estimated three-dimensionally by a MR scoring system as follows: As an index of direction and extent of regurgitation, nine sampling sites were selected in the left atrium at the level of the mitral annulus. These include the anterior, mid, and posterior parts of each portion of the postero-medial, middle, and antero-lateral sides. The depth of regurgitation was graded by three degrees in the long-axis projection of the left ventricle; grade 1; MR signals localized within the level of the mitral annulus, grade 2; MR detected beyond the mitral annulus but not reaching the aortic valve level; and grade 3; MR detected beyond the aortic valve level in the left atrium. The MR score was comprised of the products of numbers of points at which MR signals were detected and the grades of the maximum depth. The MR scores correlated well with the severity of MR as determined by the left ventriculogram (LVG); the MR score was 4.0 +/- 1.6 (mean +/- S.D.) points in grade 1; 9.6 +/- 2.6 points in grade 2; 18.0 +/- 3.2 points in grade 3; and 23.0 +/- 1.7 points in grade 4 by LVG. Doppler mapping of the left atrium at the level of the mitral annulus suggested that the directions of MR varied with each disease and valvular lesion. Thus, these observations were helpful in the investigation of MR by PDE. We concluded that the above-mentioned MR scoring system proves a very useful method for quantitatively evaluating MR non-invasively.

Arrhythmia in young patients with mitral valve prolapse

Twenty four-hour ambulatory ECG monitoring were examined in 68 patients (33 patients in a young group and 35 patients in an adult group) with mitral valve prolapse (MVP) in order to characterize the features of arrhythmias in young patients with MVP in comparison with those in adult patients. Diagnosis of MVP was made by two-dimensional echocardiography. On 24-hour ambulatory ECG monitoring 29 patients (88%) in a young group had arrhythmias which was as frequent as those in adult group, but serious ventricular arrhythmias were more often detected in the young group (7 patients) than in the adult group (2 patients). It was considered that arrhythmias in young patients with MVP were frequently serious but accompanied without any symptoms and cardiac dysfunction.

Clinical significance of left ventricular hypertrophy in dilated cardiomyopathy: an echocardiographic follow-up of 50 patients

To evaluate the significance of left ventricular (LV) hypertrophy in patients with dilated cardiomyopathy (DCM), 50 patients seen between 1976 and 1983 were studied echocardiographically. We categorized the patients as four groups according to the degree of LV dilatation or hypertrophy. Group consisted of 17 patients with mild to moderate LV dilatation without hypertrophy (LV end-systolic I dimension: Ds less than 60 mm, LV wall thickness at end-systole: WTs less than 15 mm). Group II, 12 with mild to moderate LV dilatation and hypertrophy (Ds less than 60 mm, WTs greater than or equal to 15 mm). Group III, eight with marked LV dilatation and hypertrophy (Ds greater than or equal to 60 mm, WTs greater than or equal to 15 mm), and Group IV, 13 with marked LV dilatation without hypertrophy (Ds greater than or equal to 60 mm, WTs less than 15 mm). Twenty patients had LV hypertrophy and 30 patients were without LV hypertrophy at the start of this study. New York Heart Association functional classes, cardiothoracic ratio and ECG findings at the first study did not show any statistically significant differences among the four groups. During the prospective follow-up of 2.7 years in average, eight patients died of congestive heart failure including five of Group IV, and three of Group I who had progressive LV dilatation. Three patients of Group I, II and III died suddenly. Ambulatory ECGs showed life-threatening ventricular arrhythmias in all 32 patients studied.(ABSTRACT TRUNCATED AT 250 WORDS)

[Regional myocardial contraction in ischemic heart disease: evaluation of regional myocardial thickening by two-dimensional echocardiography]

There were many studies concerning the evaluation of regional wall motion in ischemic heart disease by left ventriculography (LVG) and two-dimensional echocardiography (2DE), but only a few observations on the regional myocardial thickening have been reported. In a survey of 48 cases of old myocardial infarction, we selected 21 cases with adequate 2DE images for the evaluation of regional wall motion and thickening. In all cases the 2DE examinations were performed within seven days before or after LVG examinations. The left ventricular wall on 2DE was divided into 11 segments and wall motion and thickening in each segment were graded to three classes, i.e. none, reduced and normal. The results on 2DE were then compared with the grade of wall motion of the corresponding segment on LVG. The sensitivity and specificity of 2DE wall motion were 50% and 89% in none, 59% and 48% in reduced, and 89% and 84% in normal, respectively. The sensitivity and specificity of 2DE myocardial thickening were 81% and 93% in none, 82% and 70% in reduced, and 92% in normal, respectively. These results indicated that the regional myocardial thickening by 2DE has a higher sensitivity and specificity. Therefore, observation of both myocardial thickening and wall motion will be necessary for the proper evaluation of regional myocardial contraction in ischemic heart disease.

A long-term follow-up study of acute viral and idiopathic myocarditis

In order to clarify the prognosis of myocarditis and the relationship between myocarditis and idiopathic cardiomyopathy, 20 patients with myocarditis (one with Coxsackie B; one with rubella and 18 with idiopathic myocarditis) were followed up for a long period using echocardiography and Holter electrocardiographic monitoring. The follow-up period was 49.1 +/- 39.3 months (mean +/- SD). Subjects were classified into the following 4 groups according to their prognoses, left ventricular end-diastolic dimensions (LVDd) and the presence of absence of life-threatening ventricular arrhythmias: Group I with a fatal prognosis, Group II with LVDd greater than or equal to 55 mm, Group III with LVDd less than 55 mm but associated with life-threatening ventricular arrhythmias, and Group IV with LVDd less than 55 mm and with no life-threatening ventricular arrhythmias. Patients of Group I (2 cases) had a marked left ventricular dilatation and a poor left ventricular function just before death. Patients of Group II (5 cases) had left ventricular and left atrial dilatation, and 2 of them had serious ventricular arrhythmias. All 3 patients of Group III had ventricular arrhythmia (ventricular tachycardias, coupled premature ventricular contractions and multifocal premature ventricular contractions, respectively), and 2 of them had asymmetric septal hypertrophy. All 10 patients of Group IV had no residual cardiac abnormalities. In conclusion, 50% of 20 myocarditis patients had residual cardiac abnormalities; 6 patients (2 of Group I and 4 of Group II) were complicated by left ventricular dilatation, simulating dilated cardiomyopathy, and 3 (one of Group II and 2 of Group III) showed asymmetric septal hypertrophy, simulating hypertrophic cardiomyopathy.

[Hypertrophic cardiomyopathy with dilatation of the left ventricle and congestive heart failure: comparison with postmyocarditis cardiomegaly and hypertensive heart failure]

In a total of 114 cases of hypertrophic cardiomyopathy (HCM), four cases were regarded to have dilated left ventricle and congestive heart failure. History of myocardial infarction was not present, and significant narrowing of coronary arteries was not detected in each case. The clinical manifestations were analyzed in the light of the differentiation from postmyocarditis cardiomyopathy (PMC: three cases) and hypertensive heart disease ( HHD : five cases). Representative case was a 47-year-old man with HCM, who showed congestive heart failure developed gradually over the last 20 years. The cardiothoracic ratio increased from 57% to 64% and high voltage of the precordial leads noted initially decreased gradually with normalization of ST-T changes. Meanwhile, a new abnormal Q wave appeared in aVL. The echocardiographic findings at the age of 47 were asymmetric septal hypertrophy and left ventricular enlargement. Myocardial biopsy of the right ventricle done at the same period revealed the marked progression of interstitial fibrosis as compared with that of 15 years ago. Clinical pictures demonstrated that PMC patients were younger than HCM or HHD patients. Abnormal Q waves were observed in three cases of HCM. In the remaining one, the Q wave was not discernible due to superimposed complete left bundle branch block. No abnormal Q waves were observed in cases of PMC and HHD . A high voltage of the left precordial leads with marked ST-T changes suggesting left ventricular hypertrophy was not seen in HCM with dilated left ventricle and HHD . Echocardiographically, the systolic anterior motion was absent in all cases. The left ventricular posterior wall in PMC and HHD was equally hypertrophied both at the apex and base, whereas in three of four cases of HCM, the apical region of the posterior wall was disproportionately hypertrophied. All cases of HCM and PMC showed asymmetric septal hypertrophy, while all the HHD cases except one showed concentric hypertrophy. In HCM, left ventricular end-diastolic dimension and left atrial dimension were increased to 60.0 +/- 6.1 mm and 45.3 +/- 9.4 mm, respectively, which were not different from those of PMC and HHD . Isometric relaxation time was prolonged to 100 msec or more in all cases of HCM, while in only one case of PMC it was prolonged and no prolongation was observed in HHD . Left ventricular wall motion revealed asynergy mainly at the hypertrophic apical area in HCM and PMC, whereas asynergy was found at the hypertrophic area, which was mostly apical, and also in the area without hypertrophy in HHD .(ABSTRACT TRUNCATED AT 400 WORDS)

[Two-dimensional echocardiographic findings in a case of arrhythmogenic right ventricular dysplasia]

Two-dimensional echocardiographic findings in a patient with arrhythmogenic right ventricular dysplasia ( ARVD ) were described. A 38-year-old male was admitted to our hospital on January 1982 because of palpitation and dyspnea caused by ventricular tachycardia. A cardiothoracic ratio was 45% and electrocardiogram revealed right axis deviation and T wave inversion in right precordial leads. A QRS configuration during ventricular tachycardia showed left bundle branch block pattern. The right ventriculogram showed dilatation and diffuse hypokinesis of the right ventricle, although the left ventriculogram and the coronary angiogram were normal. Histological findings of both right and left ventricular tissues obtained by endomyocardial biopsy revealed myocytolysis, scarcity of myofibrils and proliferation of collagen fibers, and the final diagnosis of ARVD was established. Echocardiographic examination disclosed right ventricular and right atrial dilatations, hypokinesis of the right ventricular anterior wall and abnormal motion of the interventricular septum. These seemed to be diagnostic of this condition, if right ventricular volume overload including atrial septal defect, endocardial cushion defect, Ebstein's anomaly, tricuspid regurgitation and pulmonary regurgitation was clinically excluded.

[Intracardiac flow pattern in dilated cardiomyopathy studied with pulsed Doppler echocardiography]

Left ventricular (LV) flow dynamics were analyzed by pulsed Doppler echocardiography in patients (pts) with dilated cardiomyopathy (DCM). Subjects consisted of five normal controls, 27 pts with DCM, five with myocardial infarction and five with valvular heart disease. The equipment used was a two-dimensional echocardiograph ( Toshiba SSH- 11A ) coupled with a pulsed Doppler flowmeter ( Toshiba SDS-10A). The long-axis plane through the left ventricle was obtained from an apical transducer position and Doppler flow signals were recorded at the apex (point A), the middle portion (point B), the inflow portion (point C), the portion near the mid-IVS (point D) and the outflow portion (point E) of the left ventricle, respectively. Left ventriculography was performed in all subjects, and ejection fraction (EF), the ratio of the short-axis to long-axis distance in end-diastole, percent shortening of the long axis and percent shortening of the short axis of the left ventricle were measured. Doppler signals of an ejection flow were recorded at points A, B, D and E in the normal controls, while in 27 pts with DCM Doppler signals of an ejection flow were detected only in two pts (7%) at the point A, in three pts (11%) at the point B, 16 pts (59%) at the point D and 27 pts (100%) at the point E. Twelve pts (44%) had abnormal Doppler signals with wide-band spectral pattern at the point C in systole. Toward flow signals in early diastole were recorded at the points A, B, C and D in the normal controls, while in pts with DCM the signals were visualized in only three pts (11%) at the point A, in 27 pts (100%) at the points B and C, and 10 pts (37%) at the point D. EF in pts with DCM was lower than that of the normal controls (36 +/- 11 vs 65 +/- 5%, p less than 0.005). The ratio of the short-axis to long-axis distance of the left ventricle was higher in pts with DCM compared with that of the normal controls (0.82 +/- 0.09 vs 0.60 +/- 0.02, p less than 0.005). Percent shortening of the long axis and the short axis was depressed in pts with DCM compared with the normal controls (11 +/- 5 vs 21 +/- 4%, p less than 0.02 and 15 +/- 6 vs 34 +/- 3%, p less than 0.001, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

[Evaluation of left ventricular function in patients with dilated cardiomyopathy by exercise echocardiography]

In order to evaluate left ventricular function of dilated cardiomyopathy, 24 patients and ten healthy subjects were studied by exercise echocardiography. The patients with dilated cardiomyopathy were classified into 3 groups according to the presence or absence of mitral regurgitation and the severity of left ventricular dilatation: Group I was consisted of five cases with mitral regurgitation. Group II was consisted of seven cases without mitral regurgitation who had marked left ventricular dilatation, where the left ventricular end-diastolic dimension index (DdI) was greater than 46 mm/m2 and left ventricular end-systolic dimension index (DsI) was greater than 40 mm/m2. Group III was consisted of 12 cases without mitral regurgitation who had moderate left ventricular dilatation, where the DdI was less than 46 mm/m2 or DsI was less than 40 mm/m2. The ergometer exercise tests were performed for 3 min at 25 watts in a supine position. There was no significant differences of exercise-induced increases in heart rate, elevations of systolic blood pressure and increases of rate pressure product, respectively, between healthy subjects and each group of dilated cardiomyopathy. In healthy subjects, both DdI and DsI were unchanged on exercise. In Group I, DdI was unchanged but DsI decreased (p less than 0.02), thus percent fractional shortening of the left ventricle (delta D) was increased (p less than 0.05). In Group II, both DdI and DsI were unchanged. In Group III, DdI was increased (p less than 0.05) while DsI was unchanged, thus delta D was increased (p less than 0.02). These results suggested that the left ventricle is able to respond to exercise by its further dilatation (increase of preload) in mild to moderate dilated cardiomyopathy (Group III). On the other hand, in cases with marked left ventricular dilatation (Group II), the further dilatation is not induced. The same was true in dilated cardiomyopathy with mitral regurgitation (Group I), where the left ventricle had almost the same size as in Group II, although changes in DsI and delta D were not evaluated precisely because of the associated regurgitation.

[Diagnosis of idiopathic mitral valve prolapse by two-dimensional echocardiography: evaluation of its clinical significance in the prospective follow-up study]

One hundred and five cases with idiopathic mitral valve prolapse (MVP) diagnosed by two-dimensional (2-D) echocardiography were classified into 5 groups according to the grade of prolapse (Fig. 1), 47 cases of which were followed prospectively for average 2.9 years. 1) Most of the cases with MVP of grade 3 or less showed normal left ventricular diastolic dimension (LVDd) and left atrial dimension (LAD) throughout the follow-up period, while the majority of the cases with MVP of grade 4 revealed increased LVDd and LAD. Thus the mitral regurgitation due to MVP seemed to be insignificant in cases of grade 3 or less, while it is significant in cases of grade 4. 2) During the follow-up period cases of grade 1, 2 and 3 showed the transition of the grade of prolapse each other. On the other hand, most of the cases of grade 4 at the initial examination did not show the change in its grade of prolapse. 3) Fifty-eight cases (55.2%) had symptoms such as chest pain, palpitation and dizziness, and various electrocardiographic abnormalities such as ST and T wave changes, prolongation of QT interval and arrhythmias were also frequently observed. However, the incidence of these symptoms and signs was independent from the grade of MVP. It was concluded that MVP with grade 4 or more is hemodynamically significant, while it was insignificant in cases of grade 3 or less. Therefore, those with symptoms and/or electrocardiographic abnormalities in cases with MVP of grade 3 or less will not require any treatment but only a follow-up observation.

[Two-dimensional echocardiographic findings of patients with papillary muscle dysfunction]

Two-dimensional echocardiographic examination was performed to investigate pathophysiological mechanism of mitral regurgitation due to papillary muscle dysfunction in 6 patients with myocardial infarction (anterior : 3, inferior: 2 and subendocardial: 1) and 13 patients with dilated cardiomyopathy. The patients were divided into 2 groups; Group I was 9 with mitral valve prolapse and Group II was 10 without mitral valve prolapse (MVP). In Group I MVP was observed in the posterior leaflet in 6 and in both leaflets in the remainder. The apical four-chamber view of all patients in Group II showed that the point of mitral valve coaptation displaced toward the apex of the left ventricle during systole and the both mitral leaflets were convexed toward the left ventricle. Follow-up observation in a patient with dilated cardiomyopathy revealed that the heart was not enlarged (CTR 50%), no murmur was heard and mild anterior mitral leaflet prolapse was observed in 1979, but, in 1981, CTR became 63%, and a grade IV systolic murmur suggesting mitral regurgitation was noted. Two-dimensional echocardiography revealed that mitral leaflets became convex toward the left ventricle and coaptation point of the mitral closure shifted to the apex of the left ventricle below the level of mitral annulus. Thus, the transition to Group II from Group I was suggested. Echocardiographic measurements revealed that left ventricular end-diastolic dimension was 71 +/- 11 mm in Group I and 74 +/- 10 mm in Group II, left ventricular end-systolic dimension was 61 +/- 11 mm in Group I and 62 +/- 11 mm in Group II, and anterio-posterior mitral ring dimension was 31 +/- 3 mm in Group I and 35 +/- 3 mm in Group II (p less than 0.05). In conclusion, it was suggested that two mechanisms of mitral regurgitation are present in papillary muscle dysfunction; 1) mitral valve prolapse and 2) shift of mitral coaptation point toward the apex of the left ventricle associated with marked dilatation of the mitral annulus.