Shoso Nezuo

Left recurrent laryngeal nerve palsy associated with primary pulmonary hypertension and patent ductus arteriosus

Two patients with left recurrent laryngeal nerve paralysis in association with pulmonary artery hypertension are described. One had primary pulmonary hypertension and the other had patent ductus arteriosus. The greatly dilated pulmonary artery in these patients resulted in compression of the left recurrent laryngeal nerve and produced a cardiovocal (Ortners) syndrome. The pathogenesis of the vocal cord palsy was documented by cross-sectional computed tomography. In conclusion, computed tomography is of great help in differentiating this syndrome from other diseases such as mediastinal mass or lymphadenopathy whenever hoarseness is complicated by pulmonary hypertension.

Thallium-201 imaging with color display computer system in old myocardial infarction

In 13 patients with old myocardial infarction diagnosed with use of the electrocardiogram, coronary angiogram and left ventriculogram and in 11 patients without infarction, thallium-201 imaging with a color display computer system was carried out. In the group without infarction the average ratio of activities in two regions of interest within the myocardial wall, excluding the apex, was 1.14 (1.08 to 1.23). In the group with infarction the average ratio of noninfarcted to infarcted areas was 1.44 (1.23 to 1.78). Objective detection of infarction was possible in 12 patients (92 percent) in the group with infarction. In two patients, the earlier electrocardiographic pattern of infarction had resolved by the time of imaging. These results suggest that the sensitivity of thallium-201 imaging in the diagnosis of old myocardial infarction may be greatly enhanced by objective and quantitative analysis using a color display computer system.

Decreased mid-to-late diastolic decay of diastolic coronary artery flow velocity in pressure-overloaded left ventricular hypertrophy.

SummaryThis study was carried out to investigate the characteristics of coronary arterial flow in left ventricular hypertrophy secondary to systemic hypertension. The blood velocities in the left anterior descending coronary artery (LAD) were measured by a No. 3F 20 MHz Doppler catheter in 23 hypertensive patients with left ventricular hypertrophy (systolic/diastolic pressure: 181 ± 15/100 ± 4 mmHg) and 13 patients with atypical chest pain, but without left ventricular hypertrophy and any abnormal hemodynamic findings. All patients had normal coronary arteriograms. The LAD blood velocity waveforms in pressure overloaded left ventricular hypertrophy were characterized by both a decreased mid-to-late diastolic deceleration rate (ΔV/ΔT) and a normalized value of ΔV/ΔT by peak diastolic velocity [ΔV/(ΔT · Vpeak)], as well as delayed early diastolic inflow (time for diastolic rise; TDR). The values of the ΔV/(ΔT · Vpeak) in the patients with hypertensive left ventricular hypertrophy and in the normotensive controls were 1.26 ± 0.61 and 3.03 ± 1.18/s, respectively (P < 0.001). The TDR was 145 ± 56 and 66 ± 15 ms (P < 0.001). In patients with hypertensive left ventricular hypertrophy, the ΔV/(ΔT · Vpeak) correlated well with the degree of hypertrophy (r = 0.75,P < 0.01) and with the TDR (r = 0.82,P < 0.01). The coronary flow reserve, calculated from the ratio of the diastolic mean velocity after intracoronary injection of papaverine to the resting flow velocity increased with the ΔV/(ΔT · Vpeak) (r = 0.68,P < 0.01). In conclusion, the increase in blood flow in the later part of diastole may compensate for the decrease in early diastolic inflow and may cause the reduction in the coronary flow reserve in pressure-overloaded LV hypertrophy.

Noninvasive Evaluation of Diastolic Filling Patterns in Patients with Atrial Fibrillation by Ejection Time and Preceding Cycle Length

Abstract To study the relation between ejection time and preceding cycle length (heart rate), the carotid arterial pulse tracing and electrocardiogram were simultaneously recorded in 104 patients with atrial fibrillation in various conditions. Ejection time was plotted against preceding heart rate in 30 consecutive cardiac cycles in each patient. The correlation coefficient between ejection time and heart rate, and the slope of the regression line derived from the formula, Y = aX + b, were calculated. In patients with mitral stenosis both the correlation coefficient and the slope were highest (− 0.91[− 0.79 ~ 0.98], − 1.89 ± 0.42); in those with congestive cardiomyopathy the coefficient was low (− 0.68[− 0.45 ~ − 0.85]) whereas the slope was high (− 1.32 ± 0.30); both were lowest in patients with constrictive pericarditis (− 0.08[− 0.06 ~ − 0.11], − 0.28 ± 0.07); and the coefficient was low (− 0.64[− 0.25 ~ 0.95]) but the slope was moderate (− 0.77 ± 0.34) in those with an atrial septal defect. After surgical correction, both the correlation coefficient and the slope decreased in patients with mitral stenosis and increased in those with constrictive pericarditis, indicating a postoperative lessening of abnormal diastolic filling patterns. These results suggest that this method may be useful in evaluating the effect on ejection time of pressure-volume changes brought about by diastolic filling. This method would also be of value in clarifying the hemodynamic patterns and effect of surgery in atrial fibrillation of various origins.

Significant coronary artery disease detected by amyl nitrite and systolic time intervals

The relation between changes in left ventricular systolic time intervals with amyl nitrite (AN) inhalation and the severity of coronary artery disease (CAD) was evaluated in 77 patients who underwent catheterization because of chest pain. In 25 subjects with normal coronary angiograms (control group), AN inhalation increased the ejection time (ET), shortened the preejection period (PEP) and increased the ET/PEP markedly. In the 52 patients with CAD (CAD group), the ET/PEP changed insignificantly after AN. The difference between the 2 groups was significant (p less than 0.001). At cardiac catheterization, the increase of left ventricular dP/dt after AN in the control group was significantly larger than that in the CAD group. Although a positive correlation between changes in ET/PEP with AN and ejection fraction at rest was noted in patients with 1-vessel CAD, no such correlation was noted in those with multivessel CAD. This suggests that factors in addition to pump function, such as the degree of CAD, influence the effect of AN inhalation on systolic time intervals. When an increase of less than 30% in ET/PEP occurs with AN inhalation, the presence of significant CAD can be detected with a sensitivity of 92%, a specificity of 84% and the predictive value of 92%. The AN inhalation test is safe and simple, and thus could serve as a stress test for evaluating the presence and severity of significant CAD.

Electrocardiographic features differentiating dilated cardiomyopathy from hypertrophic cardiomyopathy

To determine the usefulness of electrocardiographic (ECG) features in differentiating between hypertrophic cardiomyopathy with features mimicking dilated cardiomyopathy (D-HCM) and true dilated cardiomyopathy (DCM), we compared ECGs of 52 consecutive patients (11 with D-HCM, 41 with DCM). Left atrial dimension, left ventricular internal dimension, and septal and posterior wall thickness were employed as echocardiographic indexes, while QRS duration, amplitude of RV5 or V6 + SV1, number of abnormal Q waves, P-terminal force in V1, and frontal plane QRS axis were used as ECG parameters. The patients with D-HCM demonstrated a larger number of abnormal Q waves (P < .0001), greater prolongation of QRS duration (P < .0001), and lower amplitude of RV5 or V6 + SV1 (P < .0001). In all cases of D-HCM, atrial overload was observed and abnormal QRS axis in 9 (82%) of the 11 patients. These features were noted in 21 (51%) and 17 (41%), respectively, of the 41 DCM patients (P < .005 and P < .05, respectively). Despite significant differences in the echocardiographic parameters between D-HCM and DCM, excluding left ventricular end-diastolic dimension, ECG abnormalities were more significant between the two groups. The results indicate that ECG features are extremely useful in differentiation between DCM and D-HCM.

Right ventricular outflow obstruction secondary to post-infarction aneurysm: A possible new syndrome

SummaryTwo patients with extensive anterior myocardial infarction developed a hitherto unreported type of right ventricular outflow tract obstruction. A 71-year-old woman, who had had an acute infarction 10 years before, was admitted for sustained ventricular tachycardia. A loud ejection murmur was heard in the mid-precordium. The echocardiogram and left ventriculogram showed a septal aneurysm, with a systolic gradient of 21 mmHg between the right ventricular outflow tract and apex. The ejection murmur was detected in the outflow tract by intracardiac phonocardiography. The second patient was a 60-year-old man who had had an acute infarction at age 47. He was also referred because of ventricular tachycardia, and his clinical situation was almost the same as that of the first case. Our search of the literature failed to disclose any similar case with a loud ejection murmur confirmed by intracardiac phonocardiography to be due to an obstructive septal aneurysm.