A Case Report of Arteriovenous Fistula between the Right Renal Artery and the Inferior Vena Cava

Fistula between the right renal artery and the infereior vena cava is a rare disorder, of which only 7 cases were reported in so far as the authors have reviewed. A 34-year-old man, who had got a stab wound on the abdomen and undergone an abdominal surgery 12 years ago during his military service, visited the hospital because of occipital headache and known hypertension for 5 years. On examination, his blood pressure was 200/140mmhg, and a thrill and loud continuous vascular bruits over the paraumbilical and right loin region were noted. his blood pressure was refractory to usual antihypertensive regimens. The chest X-ray film showed cardiac enlargement and pulmonary congestion. With the aids of abdominal ultrasonogram, static and dynamic renal scanning with (99m)T-DTPA, excretory urogram, aortogram and selective right renal angiogram, he was diagnosed as right renal artery inferior vena cava fistula. After fistulectomy and repair of walls of both vessels, his blood pressure was successfully controlled with drugs.

Pulsed Doppler Echocardiographic Left Ventricular Inflow Velocity Patterns of Mitral Stenosis and Severity Grading

42 patients with mitral stenosis(MS), diagnosed by M-mode, 2-D sector scan and pulsed Doppler echocardiography, were evaluated. Among them 28 patients were complicated with atrial fibrillation and one foruth was normal sinus rhythm. Pulsed Doppler echocardiographic left ventricular inflow velocity patterns(PELVIVP) were compaired with the EF slop of anterior mitral valve leaflet. The results were as follows; The normal PELVIVP showed a biphasic pattern during diastole. PEVIVP in MS were classified into 5 types and measured EF slop of anterior mitral valve leaflet in each type. Type I was characterized by a biphasic flow pattern showing a relative increase in the atrial contraction wave compared with the rapid filling wave and the prolonged deceleration time. EF slop was 24.7+/-6.1mm/sec. Type II was turbulent scaphoid pattern during diastole. EF slop was 14.5+/-4.4mm/sec. Type IIIa was monophasic with gradual descending slop during diastole. EF slop was 16.9+/-4.0mm/sec. Type IIIb was also turblent monophasic with gradual ascending slop during diastole. EF slop was 8.1+/-2.3mm/sec. Type IV was diastolic turblent and was characterized by dome shaped pattern. EF slop was 7.9+/-1.9mm/sec. There was a significant correlation between the 3 groups(I, II and IIIa, IIIb and IV) of LVIVP in MS and EF slop(P<0.005). This result indicated that type I of the flow pattern was well observed in mild MS, type II and IIIa in moderate MS, and type IIIb and IV in severe MS. Pulsed Doppler flow pattern in MS was alterable in the atrial fibrillation.

Changes of A2D Time as an Index of Diastolic Function of the Left Ventricle

A2 D time, a time interval from aortic second heart sound to the D point of mitral valve echogram, was reported as a valuable index of the left ventricular relaxation in its early diastole. It was suggested, however, that A2D time is influenced by variable factors rather than single factor. This study was performed to evaluate the influences of several on the A2D time and to extend our understandings in A2D time. For this purpose, A2D time was measured in 4 groups whose hemodynamic states were different, i.e.31 normal subjects (group A), 32 patients with essential hypertension without decompensation (group B), 10 normotensive patients with clinically full blown congestive heart failure (group C), and 11 patients with hypertensive heart failure (group D), and the mean values of each group were compared between the groups. Concordantly systolic hemodynamic parameters were observed and the relationship of A2D time and each of these parameters were observed. A2D time was consistently influenced by the level of left ventricle impedance and it is well correlated with parameters representing left ventricular systolic performances. In hypertensive subiects, A2D time was increased before the deterioration of the left ventricular systolic function but shortened after clinical heart failure. These findings suggest that A2D time may be of value in longitudinal follow-up of the left ventricular function in the hypertensive patients even before the development of clinical heart failure.