Masahiro Shikuwa

Serial changes in negative T wave on electrocardiogram in acute pulmonary thromboembolism

A negative T wave is frequently observed in precordial ECG leads in patients with acute pulmonary thromboembolism. We investigated the clinical significance of negative T wave in 15 patients with acute pulmonary thromboembolism who were treated with thrombolytic agents by measuring the mean pulmonary artery pressure and ratio of right to left ventricular end-diastolic diameter using echocardiography and ECG. The study included only patients with massive acute pulmonary thromboembolism of a mean age of 65+/-9.7 years (+/-SD). A negative T wave was observed on admission in 10 patients but was later detected in 14 of the 15 patients. The mean amplitude of the negative T wave increased within 1 week then decreased after thrombolytic treatment. The peak negative amplitude of the T wave was observed from 1 to 7 days (mean, 2.6+/-1.8 days) and disappeared afterwards. During this period, improvements in both the mean pulmonary artery pressure (37.8+/-11.2 to 19.1+/-6.7 mmHg) and the ratio of right to left ventricular end-diastolic diameter (0.97+/-0.16 to 0.51+/-0.13) were noted in all patients. Our results suggest that an increase in the amplitude of negative T wave in precordial leads after thrombolytic therapy in patients with massive acute pulmonary thromboembolism reflects improvement in cardiopulmonary hemodynamics.

Evaluation of Right-Ventricular Function by Doppler Echocardiography in Patients with Chronic Respiratory Failure

In patients with chronic respiratory failure, right-ventricular function was non-invasively evaluated by Doppler echocardiography. A total of 31 patients (16 men, 15 women; mean age 65.8 ± 7.12 years) with pulmonary tuberculosis sequelae who had received home oxygen therapy during the preceding 6 or more months, were studied. Right-ventricular inflow and outflow waveforms were recorded, and right-ventricular function was evaluated using a new Doppler index combining systolic and diastolic function. On continuous wave Doppler echocardiography, estimated systolic pulmonary arterial pressure was calculated from the gradient between the right atrium and right ventricle. There was no correlation between the new Doppler index and systolic pulmonary arterial pressure, and some patients showed high index values despite low systolic pulmonary arterial pressure. The new Doppler index facilitated evaluation of ventricular function irrespective of right-ventricular afterload.

Left Ventricular Mass and Global Function in Essential Hypertension after Antihypertensive Therapy

This study compares left ventricular global function in 55 patients (25 with hypertrophy and 30 without hypertrophy) with essential hypertension, whose blood pressure had been stable for longer than 1 year, with that in 35 healthy subjects. Left ventricular global function was calculated using the echocardiographic Doppler index as described by Tei et al. (Tei index). No significant differences were observed in echocardiographic left ventricular systolic function between the three groups. Left ventricular global function differed significantly between the three groups, however, suggesting impaired left ventricular global function even in the absence of left ventricular hypertrophy. Similar changes were observed in the ratio of peak velocity of atrial systole to peak velocity of early diastole during left ventricular inflow waveform (A/E), indicating that this disorder mainly reflects impaired left ventricular diastolic function. Unlike A/E, the Tei index is not affected by increasing age, and, therefore, is appropriate for evaluating left ventricular global function in hypertensive patients, most of whom are middle-aged or older. This index may be useful for determining treatment strategy and evaluating treatment effects.

Right Ventricular Impairment in Patients with Chronic Respiratory Failure on Home Oxygen Therapy — Non-Invasive Assessment Using a New Doppler Index

We evaluated the usefulness of the newly defined Doppler index combining systolic and diastolic myocardial performance, in assessing right-heart dysfunction in 29 patients with chronic respiratory failure caused by old tuberculosis who were on 24-h home oxygen therapy. We measured tricuspid inflow velocity, right-ventricular outflow velocity, late/early diastolic peak velocities (A/E), the ratio between pre-ejection period and ejection time (PEP/ET), and the new index of systolic and diastolic myocardial performance (SDMP) calculated as (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. The calculated A/E, PEP/ET and SDMP in our patients were significantly higher than those in age-matched healthy subjects (n = 37, mean age 67 ± 8 years). There was no overlap in the SDMP index between healthy subjects and patients and the index was not influenced by heart rate. Our results suggest that SDMP index is a better marker than A/E and PEP/ET for the assessment of right-ventricular impairment.

Use of [123I]-BMIPP Myocardial Scintigraphy for the Clinical Evaluation of a Fatty-Acid Metabolism Disorder of the Right Ventricle in Chronic Respiratory and Pulmonary Vascular Disease

The objective of this study was to evaluate whether or not right ventricle (RV) uptake of iodine-123-labelled-β-methyliodophenylpentadecanoic acid ([123I]-BMIPP) correlated with the degree of right ventricular pressure overload (RVPO). Myocardial scintigraphy of [123I]-BMIPP and thallium-201 (201Tl) was performed on 46 patients with RVPO. We determined the right ventricle (RV)/left ventricle (LV) ratio = (radioactivities of RV)/(radioactivities of LV), and the RV metabolic index (RVMI) = (RV/LV ratio of [123I]-BMIPP)/(RV/LV ratio of 201Tl). We also evaluated the correlation between RVMI and mean pulmonary arterial pressure (mPAP), and between RVMI and total pulmonary resistance (TPR). Significant correlations were found between the RV/LV ratio of [123I]-BMIPP and mPAP and between the RV/LV ratio of [123I]-BMIPP and TPR. In addition, a significant negative correlation was observed between RVMI and mPAP and between RVMI and TPR. RVMI declined as RVPO increased, suggesting the presence of a fatty-acid metabolism disorder of the RV. Moreover, [123I]-BMIPP myocardial scintigraphy could be useful for evaluating a disorder of the fatty-acid metabolism of the RV with RVPO.

The Left Ventriculographic Pattern and Serial Electrocardiographic Changes in Hypertrophic Cardiomyopathy Patients with Giant Negative T Waves

The configuration of the left ventriculogram (LVG) was classified in 64 patients with hypertrophic cardiomyopathy (HCM) observed in ECG, and characteristics of the configuration and serial changes in SV1+RV5 and giant negative T (GNT) waves were studied. The LVG configuration was classified into the spade (15 patients), papillary-muscle hypertrophy (PMH; n = 23), oval (n = 24) and banana types (n = 2). The spade, PMH and oval types were observed for mean periods of 66, 90 and 91 months, respectively. Serial changes in ECG were as follows: GNT decreased from 16.7 +/- 3.3 to 13.3 +/- 5.1 mm in the spade type and decreased significantly from 16.9 +/- 5.9 to 9.8 +/- 6.9 mm in PMH but showed no changes in the oval type. SV1+RV5 decreased significantly from 69.0 +/- 14.9 to 58.2 +/- 14.7 mm in PMH but showed no significant changes in the spade or oval types. Thus GNT decreased progressively in many patients with the exception of a few with the oval type. From these findings, we consider that apical hypertrophy had been established at the time of the initial LVG and changed over time thereafter in the spade and PMH types but that hypertrophy was still in progress in some patients with the oval type.

Community acquired pneumonia (CAP) caused by Cryptococcus neoformans in a healthy individual.

A 41-y-old male had been diagnosed as having community acquired pneumonia (CAP) with consolidations in the chest radiograph, fever and cough. Since clarithromycin and ß-lactam agents were not effective, bronchoscopic examination was performed. Indian ink staining of bronchial wash smears revealed yeast-like cells with a thick capsule, and Cryptococcus neoformans was isolated several d later. Serum glucuronoxylomannan antigen was≧×1024. The patient was treated with itraconazole for 16 weeks.

Spontaneous rupture of non-aneurysmal ascending aorta

Two autopsy cases with pericardial tamponade and spontaneous rupture of non‐aneurysmal ascendlng aorta are described. In case 1, no apparent predisposing factor was clinically noticed in a 74 year old male patient, but postmortem examination revealed laceration of the ascending aorta associated with aortic valvular deformity and slight dilatation of the ascending aorta. In case 2, a 61 year old man, a mild to moderate grade of aortic regurgitation was noticed clinically 5 months before death. Postmortem examination revealed a slight dilatation of the aortic annulus and post‐valvular portion of the ascending aorta. These two cases emphasize the clinical significance of aortic valvular disease with subsequent disordered blood flow, even when asymp tomatic, as a potential causative factor for spontaneous rupture of the ascending aorta.