Tsuguya Sakamoto

New subtype of apical hypertrophic cardiomyopathy identified with nuclear magnetic resonance imaging as an underlying cause of markedly inverted T waves

OBJECTIVES The aim of this study was to elucidate the clinical importance of a new subtype of apical hypertrophic cardiomyopathy that could not be diagnosed with the classical diagnostic criteria. BACKGROUND Apical hypertrophic cardiomyopathy is recognized by a characteristic spade-shaped intraventricular cavity on the end-diastolic left ventriculogram in the right anterior oblique projection, often associated with giant negative T waves [negativity > or = 1.0 mV (10 mm)]. As an underlying cause of giant negative T waves, an additional new subtype of apical hypertrophic cardiomyopathy has been identified. METHODS In 40 patients with inverted T waves (negativity > or = 0.5 mV), including 26 patients with giant negative T waves, nuclear magnetic resonance (NMR) long-axis images corresponding to the left ventriculogram in the right anterior oblique projection and short-axis images at various levels, including the apical level, were obtained to define the site of hypertrophied myocardium. RESULTS Long-axis images indicated a spadelike configuration in 17 patients, whereas this diagnostic configuration was not present in the other 23 patients. Nine of these 23 patients had significantly hypertrophied myocardium at the basal level. In the 14 remaining patients, short-axis images indicated no hypertrophy at the basal level and proved that the area of hypertrophied myocardium was confined to a narrow region of the septum or the anterior or lateral wall at the apical level (nonspade apical hypertrophic cardiomyopathy). The hypertrophied myocardium of the nonspade type was so narrowly confined that the mass did not form a spadelike configuration or could not be detected on the long-axis image. CONCLUSIONS Nonspade apical hypertrophic cardiomyopathy was newly identified on NMR short-axis images, and this could be an additional, important underlying cause of moderately to severely inverted T waves.

Left ventricular filling determined by Doppler echocardiography in diabetes mellitus

Abstract Diabetes mellitus is associated with a high mortality from cardiac disease attributed to coronary artery atherosclerosis or systemic hypertension. Increasing evidence indicates that cardiac dysfunction occurs even in diabetics with normal coronary arteries. 1–3 In 1972, Rubier et al 1 reported 4 adult-onset diabetic patients who had cardiomegaly and congestive heart failure in the absence of major coronary artery disease or hypertension. Hamby et al 2 observed a high incidence of diabetes mellitus in their series of patients with idiopathic cardiomyopathy. Furthermore, several investigators have shown that abnormalities of left ventricular (LV) diastolic function are common even in diabetics without clinical manifestations of congestive heart failure. 3–6 Whether these abnormalities result from a microangiopathic process in the heart or from metabolic abnormalities inherent to diabetes mellitus is still unclear. 7 Measurement of transmitral flow velocity by Doppler echocardiography has recently been shown to be useful in identifying abnormal LV diastolic filling properties in a variety of disease states. 8–11 This study evaluates the diastolic LV filling characteristics in patients with adult-onset diabetes mellitus using pulsed Doppler echocardiography.

Doppler echocardiographic-determined changes in left ventricular diastolic filling flow velocity during the lower body positive and negative pressure method

Changes in parameters of left ventricular (LV) diastolic filling flow obtained with Doppler echocardiography during the lower body positive and negative pressure method were analyzed in 15 patients (12 with coronary artery disease and 3 with dilated cardiomyopathy). Lower body pressure was altered at 5 steps (+20, +10, 0, -20 and -40 mm Hg vs atmospheric pressure). Pulmonary capillary wedge pressure measured with a balloon-tipped catheter was changed proportionally with lower body pressure during the procedures (p less than 0.01). Mean systemic arterial pressure was changed slightly during lower body positive pressure and negative pressure of -40 mm Hg. Heart rate was almost unchanged except at lower body pressure of -40 mm Hg. The peak velocity of LV early diastolic filling flow was changed with pulmonary capillary wedge pressure in an almost parallel fashion during the procedures (p less than 0.01). The peak velocity of LV late diastolic filling flow showed smaller changes than that of early diastolic filling flow. Changes in pulmonary capillary wedge pressure correlated positively with changes in the peak velocity of LV early diastolic filling flow (r = 0.759, p less than 0.01), but not with changes in the peak velocity of LV late diastolic filling flow (r = 0.039, not significant) during lower body negative pressure of -20 mm Hg. These data suggest that left atrial pressure is one of the important determinants of LV early diastolic filling flow in this acute clinical setting and that LV late diastolic filling flow is less sensitive to changes in left atrial pressure than LV early diastolic filling flow.

Diagnosis of patent ductus arteriosus in adults by biplane transesophageal color Doppler flow mapping

Abstract In infants and children, direct visualization of patent ductus arteriosus and shunt flow is often successful using transthoracic 2-dimensional 1 and color Doppler echocardiography. 2 In adults, however, transthoracic echocardiography may fail to yield diagnostic information on patent ductus arteriosus because the ductus is located far from the transducer on the chest wall. 3 Since the recent development of a transesophageal transducer with the capabilities of color-coded Doppler flow imaging, both single- and biplane transesophageal echocardiography have been extensively used in the assessment of patients with cardiovascular diseases. 4–8 Transesophageal approach affords consistent high-quality 2-dimensional images of the arch and descending aorta without being restricted by lung tissue or ribs. This study evaluates the diagnostic usefulness of transthoracic and biplane transesophageal color Doppler echocardiography in adolescent and adult patients with patent ductus arteriosus.

Follow-Up in mitral valve prolapse by phonocardiography, M-mode and two-dimensional echocardiography and Doppler echocardiography

To assess the serial phonocardiographic and echocardiographic change in patients with mitral valve prolapse (MVP), phonocardiograms and echocardiograms were reviewed retrospectively in 116 patients (48 men and 68 women, mean age 27 years) who had been determined to have MVP and were reexamined 4.3 years (range 1 to 14) later by phonocardiography and echocardiography between 1971 and 1988. Follow-up phonocardiograms showed periods when 5 of 18 patients with silent MVP developed mid- or late systolic clicks. Of 57 patients with mid- or late systolic clicks, 15 had silent MVP, 6 developed a late systolic murmur with or without systolic clicks and 1 developed a pansystolic murmur. Two of 9 patients with an isolated late systolic murmur developed a pansystolic murmur. M-mode echocardiograms showed that left atrial and left ventricular dimensions at end-diastole and end-systole increased in patients with systolic murmur (33 +/- 10 vs 35 +/- 11, 46 +/- 6 vs 50 +/- 7 and 29 +/- 4 vs 31 +/- 5 mm, respectively, all p less than 0.001) and no statistically significant changes in any of these dimensions were found in patients without a systolic murmur. The degree of MVP evaluated by the anteroposterior mitral leaflet angle on the 2-dimensional echocardiogram was more severe in patients with a systolic murmur than in patients without systolic murmur (157 +/- 12 vs 131 +/- 16 degrees, p less than 0.001). The degree of prolapse did not change during the follow-up periods. The number of patients with mitral regurgitation detected by pulsed Doppler echocardiography increased from 21 of 72 (29%) to 31 of 72 (43%).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of acute systemic blood pressure elevation on left ventricular filling with and without mitral regurgitation

Abstract Left ventricular (LV) diastolic filling is determined by multiple factors. 1–4 Recently, diastolic LV filling has been shown to be affected not only by LV diastolic property but also by left atrial filling pressure. 1 Acute blood pressure elevation alters both diastolic LV property and left atrial pressure. 1 In addition, the presence of mitral regurgitation (MR) also affects left atrial pressure 5 and, therefore, LV filling. 4 This study evaluates the effects of acute blood pressure changes on diastolic LV filling characteristics in subjects with and without MR.

Recurrent multiple myxomas

one of its leaflets. RA myxoma may be confused with mobile RA thrombus;7 this primary tumor, however, usually is round, has a mottled appearance, and is commonly attached to the interatria septum.’ In most reported cases3-’ the mobile RA thrombus originates from the inferior vena cava or peripheral veins in patients with deep leg vein thrombosis and may be transiently entrapped by the tricuspid valve3 or by a patent foramen ovale’ before it travels to the lungs. Our patient had no history of heart disease; the excised RA thrombus had the gross appearance of a leg vein cast and there was evidence of deep vein thrombosis by venogram, thus confirming the above sequence of events which led to massive pulmonary embolism. Immediate surgery and removal of RA thrombi and of several thrombi from the pulmonary arteries were carried out and the patient had an uneventful recovery. Although the exact frequency of this finding in patients with suspected or impending pulmonary embolism is not known, the identification of RA thromboembolus by 2DE raises important questions regarding diagnostic and therapeutic interventions. Confirmatory cardiac catheterization is probably not necessary and may even be dangerous in these patients.4,’ Intravenous anticoagulation with heparin or streptokinase is probably ineffective and may cause partial dissolution of the thrombus.4,fi In our patient and in two other reported cases,4.7 immediate surgical embolectomy after an RA thromboembolus was identified by 2DE resulted in survival and uneventful recovery of the patient. Without such therapy patients invariably develop massive pulmonary embolism, resulting in a fatal outcome.3-fi Although the RA thrombus in our patient was present for at least 2 days prior to the development of massive pulmonary embolism, urgent surgery should be undertaken without the delay or hazards of catheterization as soon as the RA thromboembolus is detected by 2DE.

Visualization of Sinus Venosus-type Atrial Septal Defect by Biplane Transesophageal Echocardiography

In this article we describe three patients in whom biplane transesophageal echocardiography was useful in diagnosing sinus venosus type atrial septal defects. In two patients, diagnosis of anomalous pulmonary venous drainage was made correctly by biplane transesophageal echocardiography.

Postural changes of vectorcardiogram in defect of the left pericardium.

Effects of postural changes upon the vectorcardiograms (VCGs) of four cases with a defect of the left pericardium (three complete and one partial) were compared to those of 115 control cases. Changes in the direction of a given instantaneous vector brought about by postural changes were significantly larger in cases with a pericardial defect than in controls. By turning to the left lateral position, the magnitude of the maximum leftward force decreased in all cases with complete defect, and increased in the case with partial defect and in 96% of controls. These findings were considered to reflect the increased mobility of the heart in cases with pericardial defect due to the lack of the restraining function of the pericardium.

Effect of amyl nitrite on mitral valve prolapse and mitral regurgitation : a transesophageal echocardiographic study

To test the hypothesis that amyl nitrite (AN) increases the degree of prolapse by reducing the left ventricular size and making the mitral apparatus relatively more redundant in patients with mitral valve prolapse (MVP), transesophageal echocardiography was performed in 23 patients with MPV before and after AN inhalation. The heart rate increased from 84±20 to 104±25 beats/min (p<0.001), and the left ventricular end-diastolic dimension decreased from 40±6 to 37±5 mm (p<0.001) after AN administration