[Surgical treatment of iatrogenic cardiac injury induced by pericardiocentesis; report of a case].

We reported a case of surgical treatment of iatrogenic cardiac injury. A 67-year-old man with cardiac tamponade was treated by pericardiocentesis. At night he was transferred to our hospital for emergent treatment of shock state. We found the pericardiocentesis drainage tube perforated left ventricle on computed tomography (CT). This perforation was repaired on the beating heart state using 5-0 monofilament mattress sutures reinforced by felt pledgets. Fatal complications might not occur when appropriate procedures are followed during the placement of a catheter for pericardiocentesis. Iatrogenic cardiac injury is rare but nevertheless requires caution.

[Is delayed surgical repair admitted for the thrombosed aortic dissection?].

The initial treatment for the thrombosed aortic dissection is still controversial. Accordingly, we sought to evaluate the strategy of its surgical repair. Ninety-six (35 type A and 61 type B) acute thrombosed aortic dissection were studied retrospectively. Initially all of them were treated medically. The ratio of the false and the true lumen (F/T ratio) was calculated on the onset. The uncontrollable cardiac tamponade, recanalization, large ulcer-like projection (ULP) and enlargement of the dissected aorta had a delayed surgical repair during the follow-up period. Eighteen of the type A and 14 of the type B were surgically treated and showed good result. The 1- and 5-year survival rates and the event-free survival rates for the type A and the type B were almost equal with no statistical difference. The mean F/T ratio for the type A was 31% for the operative and 51% of the nonoperative cases (p = 0.007). The maximum size of the initial aorta of the operative cases was larger than that in the nonoperative for the type B. The conservative therapy for the thrombosed aortic dissection decreased the number of the unnecessary operation and the strategy of the delayed surgical repair was justified properly.

[Surgical management of papillary muscle rupture following acute myocardial infarction].

Papillary muscle rupture is a rare but severe complication of acute myocardial infarction. Two cases successfully underwent mitral valve replacement and concomitant coronary artery bypass grafting (CABG) for acute myocardial infarction with the anterior papillary muscle rupture in cardiogenic shock. Each of them needed preoperative massive inotropic infusion, respiratory support and intraaortic balloon pumping assist. The first case was a 76-year-old female. Double vessel disease (seg 7 : 90%, seg 11 : 100%) was revealed by coronary angiography and rupture of the papillary muscle was confirmed by transesophageal echocardiography. The second case was a 69-year-old female. Double vessel disease (seg 2 : 90%, seg 11 : 100%) was revealed and severe mitral regurgitation due to prolapse of the anterior leaflet was confirmed by transthoracic echocardiography. To assess the diagnosis of postinfarction papillary muscle rupture, transthoracic and/or transesophageal echocardiography is mandatory. Coronary angiography is also desirable because concomitant myocardial revascularization may improve the prognosis.

[Aortic root replacement with free-style stentless valve for aorto-left and right ventricular communication due to infective endocarditis; report of a case].

Aortic root abscess remains a major determinant of both early and late results of surgical treatment of endocarditis. This complication rarely progresses to intracardiac shunt followed by cardiac failure. We report a surgical case of a 40-year-old man, who had been diagnosed as prosthetic valve endocarditis with aortic root abscess ruptured into left and right ventricle creating aorto-left and right ventricular communication. Because of complete debridment of infective and/or dead tissue, aortic root replacement was required. We used free-style stentless valve, xenograft, since homograft was not available at the time of operation. We believe that this prosthesis has easier handling and is more resistant to infection, therefore, it might be an option for infective endocarditis with aortic root abscess.

Improved survival of idiopathic dilated cardiomyopathy in the 1990s.

To analyze the recent change in the long-term survival of patients with dilated cardiomyopathy (DCM), the present study comprised consecutive 111 patients with ejection fraction <50% and left ventricular end-diastolic diameter >58 mm. who were admitted to hospital from January 1983 to December 1994. The patients were divided into 2 groups: group A who were diagnosed before 1989 and group B diagnosed after 1990. Basic characteristics at diagnosis, including age, NYHA functional class, left ventricular end-diastolic diameter and ejection fraction, were similar between these 2 groups. Calculated survival rate at 5 years was 90.0% in group B in contrast to 62.3% in group A. Event-free survival also improved in group B. In group B, beta-blockers and angiotensin converting enzyme inhibitors were more frequently used than in group A (p<0.0001) whereas digitalis and other positive inotropic agents were significantly less used. Left ventricular ejection fraction was significantly improved during the follow-up period in patients treated with beta-blockers compared with those not treated with beta-blockers. These data indicate a significant improvement in the survival of patients with dilated cardiomyopathy after 1990, which may be explained by the change of medical treatment, especially the use of beta-blockers.

[Aneurysm of the nonpatent ductus arteriosus in the adult--a report of the case and review of the literature].

Aneurysm of the ductus arterious in adult in rare. 28 cases have been previously reported in the Japanese literature. A new 73-year-old male case, preoperatively diagnosed and successfully repaired, are presented. The patient with hoarseness was admitted to our hospital. Contrast-enhanced CT scans and aortograms made a diagnosis for the aneurysm of the ductus arteriosus. Operation was done through left thoracotomy with the aid of partial cardiopulmonary bypass. The pulmonary arterial end of the ductus arteriosus was closed and a Ligamentum arteriosus was identified. A 3 by 2.7 cm saccular aneurysm was resected and segmental replacement of the aorta with woven dacron graft was performed. Because of it's critical location and the high incidence of complications, aneurysm of the ductus arteriosus in the adult should be surgically corrected when diagnosed.

[Early and long-term outcome for surgical treatment of acute aortic dissection].

This study was undertaken to determine the factors that influence the final outcome after the operation of acute aortic dissection. Twenty-one patients, the median age was 59 years (range 44 to 81), were operated at acute phase in 92 admitted into our hospital during the 13-year period between May 1985 and Jan. 1998. Preoperative complications included cardiac in 5 and ruptured with shock in 7, myocardial ischemia in 3 and stroke in 4. The ascending aortic reconstruction (9, 43%), ascending aorta and arch reconstruction (7, 33%) and other procedures (4, 19%) were performed using cardiopulmonary bypass with deep hypothermia and circulatory arrest or selective cerebral perfusion. The 30-day operative deaths were 6 (29%) and 5 (24%) late death occurred. Three out of 5 were aneurysm related deaths. The cause specific survival rates were 61% at 5 years and 51% at 8 years. The multivariably determined risk factors for death were as follows (p < 0.05): preoperative FDP; bleeding volume; postoperative renal complications; postoperative stroke.

[Clinical evaluation of 123I-BMIPP myocardial SPECT in patients with hypertensive heart disease and hypertrophic cardiomyopathy: comparison with the findings of 201Tl SPECT and Gd enhanced magnetic resonance imaging].

123I-BMIPP SPECT (123I-BMIPP), 201Tl SPECT (201Tl), and Gd-DTPA enhanced magnetic resonance myocardial imaging (MR) were performed in patient groups with hypertensive heart disease (HHD), apical hypertrophic cardiomyopathy (APH), and hypertrophic cardiomyopathy without APH(HCM). SPECT was divided into 20 segments and each segment was scored as one of 4 grades (0 = normal; 1 = mildly decreased; 2 = severely decreased; and 3 = defect) according to the RI uptake. Gd enhancement in MR was interpreted visually. A decreased in the uptake of 123I-BMIPP showed in 54 of 141 hypertrophic (> 13 mm, measured by ultrasonic cardiography) segments in HHD, in 32 of 66 in APH and in 103 of 207 in HCM respectively. Whereas 201Tl SPECT showed decreased uptake in 18 of 141 hypertrophic segments, in 18 of 66 in APH, and in 27 of 207 in HCM, respectively. 123I-BMIPP showed a higher incidence of these scintigraphic abnormalities than did 201Tl in the hypertrophic segments. And also in the hypertrophic segments, decreased in the uptake of 123I-BMIPP occurred more frequently in HCM than in HHD. In HCM, decreased 123I-BMIPP uptake appeared more frequently in segments 1, 2, 9, and 10 (antero-septal junction) than in other segments, but in APH, such decreases occurred more often in segments 17, 18, 19, and 20 (apex). Enhanced signal intensity with Gd-DTPA appeared in more segments in the HCM group than in the APH or HHD groups. We concluded that HCM had the most extensive and severe structural changes--including metabolic and ischemic changes--among three groups, and that the combination of these three examinations was useful for evaluating the characteristics of hypertrophic myocardium.

Acute necrotizing eosinophilic myocarditis with giant cell infiltration after remission of idiopathic thrombocytopenic purpura.

Acute necrotizing eosinophilic myocarditis is characterized by acute onset, fulminant congestive heart failure, and extensive necrosis of myocytes with striking eosinophilic infiltration. However, multinucleated giant cells sometimes appear in the fulminant phase of severe myocarditis. This is the first case of a patient with a 1 year previous history of idiopathic thrombocytopenic purpura, who presented with acute necrotizing eosinophilic myocarditis with giant cell infiltration.

Abnormal myocardial uptake and clearance of 123I-labeled metaiodobenzylguanidine in patients with chronic renal failure and autonomic dysfunction.

BACKGROUND: Patients with chronic renal failure were evaluated with 123I-labeled metaiodobenzylguanidine (MIBG) myocardial scintigraphy to investigate the relationship between abnormal findings on MIBG scintigrams and autonomic dysfunction. METHODS AND RESULTS: Eleven control subjects and 20 patients with chronic renal failure (CRF) (serum creatinine level > 8 mg/dl) were evaluated by MIBG myocardial scintigraphy and power spectral analysis (PSA) of the R-R fluctuations of the electrocardiogram. Subjects with CRF were divided into two groups: without (CRF1; nine patients) or with (CRF2; 11 patients) autonomic neuropathy. From MIBG images, the heart/mediastinum mean count rate, defect score, which was scored visually, and clearance rate were calculated. Percent low-frequency power and high-frequency power were obtained from PSA. MIBG scintigrams showed decreased heart/mediastinum mean count rate, a high defect score in both initial and delayed images, and rapid clearance rate in the CRF2 group. PSA showed an abnormally low percent low-frequency power and high-frequency power in the CRF2 group. In addition, there was a weak but significant inverse correlation between percent low-frequency power and defect score. CONCLUSION: Alterations in MIBG scintigrams are seen in patients with autonomic dysfunction in CRF and may be useful for evaluating cardiac sympathetic dysfunction in those patients.

Clinical usefulness of 123I-metaiodobenzylguanidine myocardial scintigraphy in diabetic patients with cardiac sympathetic nerve dysfunction.

To assess the clinical utility of 123I-metaiodobenzylguanidine (MIBG) scintigraphy in evaluating cardiac sympathetic nerve disturbance in diabetic patients, we performed MIBG scintigraphy in 18 diabetic patients and 11 normal controls. Diabetic patients with symptomatic neuropathy (DM2) had a significantly lower heart to mediastinum uptake ratio than did those without neuropathy or normal controls in initial and delayed images (initial image, 1.90 +/- 0.27 vs 2.32 +/- 0.38, 2.41 +/- 0.40, p< 0.01; delayed image, 1.80 +/- 0.31 vs 2.48 +/- 0.35 2.56 +/- 0.28, p < 001, respectively). Defect score, assessed visually, were higher in DM2 patients than in patients in the other two groups (initial image, 7 +/- 2.6 vs 1.5 +/- 1.9, 0.7 +/- 0.9; delayed image 10.6 +/- 3.3 vs 4.0 +/- 2.5, 1.7 +/- 1.6 p < 0.01, respectively). The maximum washout rate in DM2 patients was also higher than those in patients in the other two groups. The findings of these indices obtained from MIBG scintigraphy coincided with the % low-frequency power extracted from heart rate fluctuations using a power spectral analysis and the results of the Schellong test, which were used to evaluate sympathetic function. These results suggest that MIBG scintigraphy may be useful for evaluating cardiac sympathetic nerve disturbance in patients with diabetes.

[Transthoracic Doppler color imaging of the blood flows in the left coronary septal branches].

This study characterized blood flow signals derived from the left coronary septal branches by transthoracic Doppler color flow imaging. In the anterior ventricular septum, the signal was detected in 7 of 13 patients with aortic stenosis, 8 of 34 with hypertrophic cardiomyopathy, and 5 of 144 patients with other diseased states. The peak diastolic flow velocity assessed by a pulsed Doppler technique ranged 21-115 cm/s (mean 57). Systolic signal was depicted in 13 of the 20 with the diastolic signal, indicating retrograde flow direction in all of them. The peak negative systolic component ranged 11-80 cm/s (mean 40). Peak diastolic flow velocity of the left anterior descending artery was higher in patients with the septal branch flow signal than in those without the signal (53 +/- 24 vs 31 +/- 11 cm/s). Patients with the signal showed larger transvalvular pressure gradient in aortic stenosis, and greater septal thickness in hypertrophic cardiomyopathy than in those without the signal. In conclusion, transthoracic visualization of the septal branch flow signal by Doppler color flow mapping is attributable to increased coronary blood flow at rest which is probably due to excessive load and/or septal hypertrophy. Augmented systolic retrograde flow may play additional role in the diastolic high velocity flow in the septal perforator.

[A case of unusually muscle localization of 99mTc-hydroxy methylene diphosphonate scintigraphy in a patient with acute rhabdomyolysis].

A 85-year-old man was admitted with a history of right upper arm pain following trauma. Laboratory studies included an initial CPK level of 5,385 IU/liter. Other laboratory values were GOT, 114 IU/L; LDH, 701 IU/L; myoglobin, 1,100 ng/ml; aldolase, 13.8 IU/L. The patient was presumed to have have rhabdomyolysis. A 99mTc-hydroxy methylene diphosphonate (99mTc-HMDP) scan revealed an increased uptake in the right shoulder area. 99mTc-HMDP scan is a sensitive indicator of local skeletal muscle injury in rhabdomyolysis.

Serum calcium increases the incidence of arrhythmias during acetate hemodialysis.

We investigated the occurrence of arrhythmias during maintenance acetate hemodialysis (HD) using a 24-hour continuous electrocardiogram recording system. Three of 22 patients showed augmented increases in both ventricular premature beats and supraventricular premature beats during HD. When we changed the dialysate from one with a Ca2+ concentration of 1.75 mmol/L (3.5 mEq/L), to one with a Ca2+ concentration of 1.25 mmol/L (2.5 mEq/L), the elevation of serum Ca2+ concentration during HD was abolished and the increases in both ventricular premature beats and supraventricular premature beats were significantly decreased. The elevation of serum Ca2+ concentration during HD might induce either extracellular or intracellular increase in Ca2+ concentration in the heart and elicit either reentry- or triggered-activity types of arrhythmias during HD. The present results indicate that the dialysate with a lower Ca2+ concentration is advisable to use in patients with underlying cardiac diseases.

[Apical sequestration in hypertrophic cardiomyopathy: its clinical features and pathophysiology].

The clinical and pathophysiological significance of apical sequestration, in which an apical cavity was sequestered from the remainder of the left ventricle by cavity obliteration was investigated in patients with hypertrophic cardiomyopathy (HCM). Among 196 consecutive patients, 24 with apical sequestration and 70 control subjects proven to have no sequestration with left ventriculography were selected for this study using echocardiography combined with Doppler color flow imaging. Various cardiac disorders occurred significantly more frequently in patients with apical sequestration than in the 70 controls: NYHA > or = II, 83% vs 51%; thromboembolism, 17% vs 3%; ventricular tachycardia, 47% vs 11%; and apical asynergy, 75% vs 4%. Continuous Doppler ultrasound revealed that all 24 patients with sequestration had a high systolic blood flow velocity across the obliterated cavity (2.7 +/- 0.9 m/s). During isovolumic relaxation or early diastolic filling or both, 21 of them had paradoxical jet flow directed toward the basal cavity away from the apex, with the peak flow velocity ranging from 1.0 m/s to 3.5 m/s (mean 1.9 +/- 0.7). The maximal diastolic pressure gradient across the obliterated cavity ranged between 4 mmHg and 49 mmHg using the simple Bernoulli's equation, which suggested a significantly higher pressure in the sequestered apical chamber during early diastole. Patients with sequestration were classified into 2 groups; 17 with (group A) and 7 without (group B) apical hypertrophy. The time interval from the closing of the aortic valve to the onset of filling into the sequestered cavity was longer in group A than in group B (401 +/- 191 vs 131 +/- 145 ms, p < 0.01) as assessed by the pulsed Doppler technique. Angiographic asynergy of the apex was more frequent in group A than in group B (100 vs 29%, p < 0.01). In group B, the midventricular cavity was incompletely obliterated throughout the cardiac cycle; whereas, in group A, it was obliterated completely in systole and partially in diastole. Apical sequestration is not uncommon in HCM; it is accompanied by abnormal segmental wall motion, which may be related to ventricular arrhythmias and thromboembolism. Prolonged cavity obliteration with a higher systolic apical pressure and a persistent diastolic intraventricular gradient may play a pathogenic role in apical aneurysmal formation in the absence of fixed coronary artery disease, particularly in patients with apical hypertrophy.

[Long-term follow-up of electrocardiographic changes in patients with asymmetric apical hypertrophy].

The serial electrocardiographic (ECG) changes of 20 patients with asymmetric apical hypertrophy (AAH) were retrospectively reviewed relative to their clinical symptoms, echocardiography and Doppler echocardiography, and thallium-201 perfusion scintigraphy. These patients were followed 4-18 years (mean 8 years). Patterns of the serial ECG changes were as follows: Seven patients (group Ia) had an increase of 10 mm or greater in the highest R wave amplitude in the precordial leads, with newly-developed giant T wave inversion. Five patients (group Ib) had relatively stable ECGs and the changes in the R wave amplitudes of less than 10 mm. Six patients (group IIa) had a decrease of 10 mm or greater in the highest R wave amplitude with mild decreases of negative T wave amplitudes. In the remaining two patients (group IIb) right bundle branch block developed. At the last follow-up study, group IIa had lower R wave amplitudes and longer QTc than did those in group I. The follow-up periods and their mean age did not differ among the groups. At the initial evaluation, exercise limitation was rare in group I; whereas, most of the patients in group II presented symptoms such as palpitation, chest pain or exertional dyspnea. These cardiac symptoms developed slowly but progressively during the follow-up period, and their incidence increased both in groups I and II at the final observation. Left ventricular (LV) wall thickness at the chordal level showed normal values and did not differ between the two groups, but apical wall thickness was greater in group II than in group I. Two-dimensional echocardiography showed a spade-like deformity of the LV in group II. In group I, the LV deformity was less marked and was not noted at the initial examination. Color Doppler echocardiography frequently revealed "paradoxical flow" expelled from the obliterated apex to the base in the early diastolic filling period in group II. Left ventriculography confirmed asynchronous contraction, hyperkinesis in the basal segment and dyskinesis at the apical segment, resulting in this abnormal intraventricular blood flow profiles. Serial studies by thallium-201 (TL) perfusion scintigraphy disclosed that four of the eight patients in group II developed localized hypoperfusion at the apex where a high and homogeneous uptake of TL was previously noted.(ABSTRACT TRUNCATED AT 400 WORDS)

[Intraventricular flow dynamics in hypertrophic cardiomyopathy with midventricular obstruction investigated by Doppler echocardiography].

Seven patients with hypertrophic cardiomyopathy having midventricular obstruction (MVO) were examined using two-dimensional, conventional Doppler and color Doppler echocardiography to investigate intraventricular flow conditions. The controls were 35 patients with hypertrophic cardiomyopathy without MVO. All MVO patients had "hour-glass" LV cavities during systole, resulting from either hypertrophy at the midventricular level or hypertrophied papillary muscles, where systolic mosaic signals originated. Systolic peak flow velocities at the midventricle ranged from 2.5 to 4.2 m/s, proving the presence of a pressure gradient between the apex and the base of the LV. In fact, a pressure drop of 15-30 mmHg was demonstrated in four patients who underwent cardiac catheterization. These high velocity jet flows were not detectable at the midventricle in the control subjects. Peak ejection velocities in the outflow tracts were significantly lower in patients with MVO compared to those with hypertrophic cardiomyopathy and subaortic stenosis (129 +/- 29 vs 384 +/- 111 cm/s; p less than 0.001). As midventricular obliteration became severe, systolic jets at the midventricle increased in velocity. Waveforms changed from single- to double-peaked, and lasted until the isovolumic relaxation or the rapid filling phase beyond the second heart sound. Consequently, isovolumic relaxation waveforms at the midventricle using the apical approach changed the direction; from "the base to apex" to "the apex to base". An isovolumic signal away from the transducer was only observed in two patients without MVO. Diastolic color reversal and mosaic signals at the midventricle were also seen in five of the seven patients with MVO. Peak flow velocities in the rapid filling phase were significantly higher at the papillary muscle level than at the mitral valve level, indicating that MVO continues up to early diastole. It was suggested that MVO disturbs intraventricular flow dynamics during both systole and diastole. Color Doppler echocardiography is particularly useful in determining the site of obstruction and allows further evaluation by pulsed and continuous wave Doppler techniques to precisely measure pressure gradients. With routine, careful use of Doppler echocardiography, MVO may prove to be a more common entity than was previously believed.

[Value of exercise echocardiography in evaluating left ventricular systolic function in mitral stenosis].

Exercise echocardiography was performed for 34 patients with mitral stenosis (MS) to evaluate left ventricular (LV) systolic function. The patients were categorized in three groups according to the work loads attained: Group I, 14 patients who attained 25 watts; Group II, 10 patients, 50 watts; and Group III, 10 patients, 75 watts. Among these groups, there were no statistical differences between the resting echocardiographic LV systolic function and their cardiac catheterization data. Resting LV end-diastolic and end-systolic dimensions (EDD and ESD) did not differ by group. During exercise, EDD and ESD decreased significantly in all groups, but ESD at the maximum exercise in Group I was greater than those of the other groups. The percent fractional shortening of the left ventricle (%FS) decreased significantly with exercise in Group I, while it increased significantly in the other groups. The mean velocity of circumferential fiber shortening (mean Vcf) increased significantly in all groups, but the extent was least in Group I. The exercise-induced changes in %FS (delta %FS) and mean Vcf (delta mean Vcf) correlated closely with exercise duration (r = 0.80, r = 0.73), but this was not the case in the mitral valve area. Postoperatively, exercise echocardiography was also performed for 14 patients with mitral stenosis; two of seven patients in Group I, four of five in Group II, and two in Group III showed significant improvement in exercise tolerance after surgery. However, the other six patients showed no change in their exercise tolerance. The former patients had positive values in delta %FS and more than 0.5 circ/sec in delta mean Vcf during pre-operative evaluations, while except one patient, those who did not improve had negative delta %FS values and less than 0.5 circ/sec in delta mean Vcf. It was concluded that the change in LV systolic function during exercise echocardiography reflects LV functional reserve in patients with MS, and provides valuable information for evaluating the severity of, indications for and benefits from surgery for MS.