Continuous murmur in Lutembacher syndrome analyzed by Doppler echocardiography.

A continuous murmur was heard in a 47-year-old woman with Lutembacher syndrome. Transesophageal and intraoperative Doppler echocardiography revealed the murmur originating from the accelerated blood flow passing through the small atrial septal defect. To our knowledge, this is the first reported case of a continuous murmur in Lutembacher syndrome analyzed by Doppler echocardiography.

Transient increase in wall thickness of the left ventricular apex after stunned myocardium: a case report.

A case of transiently increased wall thickness in the left ventricular apex after stunned myocardium due to severe attack of vasospastic angina is described. "Ace of spades" configuration, documented by left ventriculogram and increased apical wall thickness of the left ventricle, as revealed by two-dimensional echocardiograms returned to normal in 2 months. This transiently increased left ventricular mass may have been due to myocardial edema, which is occasionally seen in the recovery course of active myocarditis.

Transient segmental asynergy of the left ventricle of patients with various clinical manifestations possibly unrelated to the coronary artery disease.

Eight cases of transient reversible segmental asynergy of the left ventricle thought not to be related to coronary artery lesions are reported. Three cases were associated with inflammatory reactions of unknown origin, and one each with lactic acidosis, abdominal surgery, hypoglycemia, tetanus and pneumonia. None of the patients had symptoms suggestive of ischemic heart disease before or after these episodes. Electrocardiograms before these episodes were all normal. Two-dimensional echocardiography was performed to evaluate abnormal electrocardiograms. Coronary angiography was performed in 4 of 8 cases and was normal in all 4 cases; 2 done as emergencies and 2 non-emergencies. Two ergonovine tests were negative. Left ventricular wall motion abnormalities, present mainly at the apex of the left ventricle, returned to normal in 1 to 4 weeks. Giant negative T waves in the chest leads during this recovery period were characteristic electrocardiographic features and normalized in 6 weeks on average. We believe that these episodes were not related to ischemia due to coronary artery disease, but to some metabolic humoral factors. An excellent prognosis can be expected if these abnormal metabolic circumstances can be resolved.

A case of unusual longevity of tetralogy of Fallot confirmed by cardiac catheterization.

We describe a 61-year-old woman with tetralogy of Fallot and dextrocardia with complete situs inversus. The functional status of this patient was New York Heart Association (NYHA) class II and the systemic blood pressure was 100/54 mmHg. The hematocrit was 54.4% and the arterial partial pressure of oxygen was 53 mmHg. On cardiac catheterization, both pulmonary valvular and infundibular stenoses were of equal severity and the aorta and main pulmonary artery were of equal size. We think that this patient has survived to this unusual age for tetralogy of Fallot because of unusually low systemic pressure and a proper balance between the ventricular septal defect and the pulmonary stenosis.

[Two cases of atrial septal defect diagnosed by two-dimensional Doppler echocardiography: comparison with other methods for detecting atrial septal defect].

We describe two cases of atrial septal defect(ASD) diagnosed by chance with two-dimensional Doppler echocardiography(2DD) which was carried out for another purpose. There were no findings characteristic of ASD such as systolic murmurs in the pulmonary area, incomplete right bundle branch block pattern on electrocardiograms, increased hilar shadow on chest films or increased right ventricular chamber diameter in two-dimensional echocardiography. However, the 2DD showed blood flow crossing through the atrial septum. Cardiac catheterization confirmed the presence of a small ASD. ASD diagnosed by 2DD alone without other classical characteristic signs of ASD indicates that the ASD is small and clinically insignificant as it is with Doppler valvular heart disease.

Progressive restrictive cardiomyopathy--a case report.

We present a case of restrictive cardiomyopathy which progressed over a 10 month period. A 69-year-old female was admitted because of acute inferior myocardial infarction; hemodynamically, she was in Forrester subset I. Cardiac catheterization performed 4 weeks post-infarction showed markedly increased left ventricular end-diastolic and pulmonary wedge pressures. Left ventricular ejection fraction was 66% with postero-basal akinesis and minimal mitral regurgitation. The right coronary artery was completely occluded with good collateral circulation from the intact left coronary artery. Doppler echocardiography 4 weeks post-infarction showed pseudo-normalization of the A/E ratio of peak mitral flow velocity in atrial systole (A) to peak mitral flow velocity in early diastole (E). Preload reduction by nitroglycerin increased the A wave. Ten months post-infarction, the patient was re-admitted due to congestive heart failure. The A/E ratio was unchanged, however the A wave no longer increased after the same dose of nitroglycerin. We have hypothesized that dehydration and/or the vigorous use of a nitrate, in the acute phase of myocardial infarction, masked an underlying restrictive cardiomyopathy which progressed in the 10 months post-infarction.

Native valve infective endocarditis in adults--analysis of 32 consecutive cases over a ten-year period from 1980 to 1989.

Thirty-two patients with native valve infective endocarditis who presented over a 10-year period at our hospital were analyzed retrospectively. The presenting symptom was a persistent fever in 22 patients. In 30 patients, the New York Heart Association functional class was less than II before the development of endocarditis. Blood cultures were positive on all occasions in 24 out of 29 culture-positive patients. All of the viridans streptococci, accounting for 79% of the isolated pathogens, were highly susceptible to ampicillin. Treatment consisted of a 6 week course of antibiotics, usually ampicillin, at a dose of 12 grams/day. In 9 cases, we had to change or stop the antibiotics because of severe side effects. The longer the period before making a diagnosis, the more severe were the symptoms of congestive heart failure and the more frequent was the incidence of cerebral hemorrhage. To initiate treatment as early as possible, in order to minimize valve destruction and to reduce the risk of cerebral hemorrhage, serial blood cultures are recommended in patients with valvular heart disease or congenital heart disease and a persistent fever, with minimal cardiac symptoms.

[Congestive heart failure in the elderly: severe tricuspid regurgitation by two-dimensional Doppler echocardiography].

We studied five cases of atrial fibrillation in the elderly showing severely decreased exercise tolerance (NYHA III) and normal left ventricular function. There were no signs of classical tricuspid regurgitation. Both atria were enlarged and right ventricular sizes were shown by two-dimensional echocardiography to have mildly increased. Two-dimensional Doppler echocardiography revealed severe tricupid regurgitation but at a maximal velocity less than 2.3 m/sec, meaning that right ventricular pressure was not increased. Cardiac output (CO) and circulating blood volume (BV), measured by radiocardiography showed CO to have decreased and BV to have increased. No intracardiac shunt was detected. The cause of this decreased exercise tolerance in the group in our study is thought to be right ventricular dysfunction due to the aging process. This also occurs in a similar pattern in younger people who have arrhythmogenic right ventricular dysplasia (ARVD), Uhl's disease, or right ventricular dilated cardiomyopathy.

Left ventricular filling pattern in congestive heart failure patients with normal sinus rhythm--a decreased ratio of peak mitral flow velocity in atrial systole relative to that in early diastole may reflect markedly increased left ventricular end-diastolic pressure.

The left ventricular filling pattern was studied by pulsed Doppler echocardiography in 13 congestive heart failure patients with normal sinus rhythm. The first study was done when congestive heart failure was present; the second after the signs and symptoms of congestive heart failure disappeared. In 12 of the 13 patients, the peak mitral flow velocity in atrial systole (PFVA) increased after the congestive heart failure disappeared (mean increase from 50.5 cm/sec to 74.8 cm/sec : p = 0.0001, paired t test), and the peak mitral flow velocity in early diastole (PFVE) decreased significantly in all 8 patients in whom secondary mitral regurgitation became less severe after improvement of congestive heart failure (mean decrease from 90.8 cm/sec to 52.0 cm/sec : p = 0.0001, paired t test). The ratio of PFVA to PFVE (PFVA/PFVE) increased in all cases after the congestive heart failure improved (mean increase from 0.59 to 1.33 : p = 0.0001, paired t test). The PFVA/PFVE is a simple index of left ventricular diastolic function. A PFVA/PFVE greater than one indicates disturbed left ventricular diastolic function. However, when the PFVA/PFVE is in a normal range for the patients' age ("pseudo-normalization") and is accompanied by impaired left ventricular systolic function in congestive heart failure, markedly increased left ventricular end-diastolic pressure must be considered.

Reversible left ventricular wall motion impairment caused by pheochromocytoma--a case report.

Excessive catecholamine levels can cause myocardial damage in experimental animals. Similar observations have been made in humans following autopsy for pheochromocytoma. However, whether catecholamine crises are reversible or not remains uncertain. We report here a case in which pheochromocytoma manifested as acute pulmonary edema during an operation. Serial echocardiograms revealed that the depressed motion of the left ventricular wall was reversed after tumor removal. The plasma catecholamine level was extraordinarily high during the episode of acute pulmonary edema, and it seems that catecholamines in high concentration can directly damage the myocardium.

[Selenium deficiency and cardiomyopathy in a patient on long-term parenteral nutrition].

A 28 year-old Japanese male with Crohn's disease maintained on total parenteral nutrition for 5 consecutive years showed congestive cardiomyopathy. His symptoms (palpitation and precordial pain), arrhythmia on ECG and cardiomegaly on chest X-ray film were progressive. By intravenous selenium supplementation of 100 micrograms/day (selenite) his symptoms disappeared dramatically and plasma selenium level, erythrocyte selenium level and glutathione peroxidase activity improved to normal ranges. It is suggested that this myocardial damage was caused by selenium deficiency.

Evaluation of local blood flow velocity in proximal and distal coronary arteries by laser Doppler method.

A high resolution laser Doppler velocimeter using an optical fiber was developed to evaluate detailed characteristics of phasic blood flow in the coronary artery. Local blood flow velocities were measured in the proximal (0.27 +/- 0.05 cm i.d.) and the distal portion (0.09 +/- 0.02 cm i.d.) of the left circumflex coronary artery of anesthetized, open-chest dogs. The velocity waveform in the central axial region of the vessel and the velocity profile across the vascular lumen were compared in the proximal and the distal portions.

Engineering approaches to the evaluation of cardiac function in future.

The present and future impact of engineering technology on observing and evaluating cardiac function is discussed, with particular reference to the development of cardiac measurements. Several new topics in cardiac imaging, manometers, and blood flow velocity measurements are briefly reviewed. The effectiveness of cardiac models in the evaluation of cardiac function is emphasized, although there are many unsolved basic problems concerning muscle mechanics of the heart. Overall, comprehensive studies in cooperation with clinical cardiology, cardiac physiology, and engineering are necessary to accelerate further progress in the evaluation of cardiac function.

Measurement of point velocity in the canine coronary artery by laser Doppler velocimeter with optical fiber.

A laser Doppler velocimeter with an optical fiber was developed to investigate point blood velocity in the arteries and was applied to the measurement of blood velocity in the canine coronary artery. Fundamental experiments revealed that the accuracy of this method was satisfactory, since an excellent linear relation was found between the known blood velocity and the Doppler shift frequency (r = 0.998). The fiber tip (0.1 mm diam.) was inserted into the proximal portion of the left circumflex coronary artery and was traversed across the vascular lumen to measure the point velocity at each sampling point. Detailed velocity profiles were than reconstructed sequentially in three dimensional coordinates, i.e., velocity, diameter and time. In general the velocity waveform showed a diastolic dominant pattern which is characteristic of coronary arterial flow. One peak in early systole and two peaks in early and in late diastole were commonly observed in the velocity waveform near the center-line of the vessel. The velocity profiles were flat in the axial region and declined abruptly near the vessel wall. These results indicate that the laser Doppler velocimetry with an optimal fiber proved to be an accurate and feasible method of evaluating the point velocity of coronary artery flow.