Effects of enalapril on left ventricular mass and diastolic function in essential hypertension: special reference to duration of hypertension.

Using M-mode and pulsed Doppler echocardiography, the effects of enalapril on left ventricular (LV) hypertrophy and diastolic dysfunction in essential hypertension and the relation between improvement in these two parameters and duration of hypertension were evaluated. The subjects, 30 previously untreated hypertensive patients, were divided into nonhypertrophy (18 patients) and hypertrophy (12 patients) groups. All patients received enalapril at a daily dose of 5 to 10 mg for 6 months. Left ventricular mass by M-mode echocardiography and LV inflow (LVIF) velocity by transthoracic pulsed Doppler echocardiography were measured before and after enalapril therapy. In the nonhypertrophy group, enalapril significantly increased peak early diastolic LVIF (E) velocity (P < .05), slightly lowered peak atrial systolic LVIF (A) velocity, significantly decreased their ratio (A/E) (P < .01), and significantly shortened both the deceleration time, from the peak of the early diastolic wave, and isovolumic relaxation time (P < .05 and P < .01, respectively). In the hypertrophy group, enalapril significantly increased E (P < .05), slightly lowered A, significantly decreased A/E (P < .05), slightly shortened the deceleration time and isovolumic relaxation time, and slightly decreased LV mass. The administration of enalapril correlated significantly and positively with the duration of hypertension and the rates of change in A/E and LV mass in all of the hypertensive patients (P < .01 and P < .05, respectively). These results suggest that long-term administration of enalapril to hypertensive patients improves LV diastolic hemodynamics regardless of the presence or absence of LV hypertrophy and that the effects are most remarkable in patients with the shortest duration of hypertension.

[Diastolic right ventricular hemodynamics in right ventricular overloads assessed by pulsed Doppler echocardiography].

To assess right ventricular (RV) filling dynamics, RV inflow velocity patterns of pulsed Doppler echocardiograms and jugular pulse tracings were analyzed in 59 patients with various types of RV overloads and in 20 normal subjects. The patients were classified as (1) RV volume overload group (RVVO) consisting of 25 patients with atrial septal defect (ASD) without pulmonary hypertension (PH), (2) RV pressure overload group consisting of 26 patients including 12 with primary pulmonary hypertension (PPH), eight with mitral stenosis, three with pulmonary stenosis and three with cor pulmonale, and (3) RV volume and pressure overload group consisting of eight patients with ASD and PH. The acceleration time (AT), deceleration time (DT) and the A/D ratio were measured from the RV inflow velocity patterns, and v-y interval and the y/H ratio were measured from jugular pulse tracings. The results were as follows: 1. AT was significantly prolonged in groups with pressure overload as well as pressure and volume overload compared with that of the normal controls. 2. DT was significantly prolonged in all overload groups compared with that of the normal controls except for PPH, and was particularly prolonged in the group with pressure overload. 3. The A/D ratio was significantly increased in all overload groups, particularly in the groups with pressure overload. 4. In patients with volume overloads, the v-y interval was longer and the y/H ratio was higher than in the normal controls. RVVO shifted to the right and superiorly. The reverse was true in the pressure overload group, and the high ratios were observed in the remainder. 5. In 12 patients with ASD evaluated pre- and postoperatively, AT, DT and the A/D ratio were restored to normal after surgery. These findings suggest that RV volume overload was characterized not only by increased inflow velocity during the rapid filling period, but prolongation of this period and compensatory increase of atrial inflow velocity. However, the pressure overload group had disturbed rapid filling and a decrease in end-diastolic RV compliance. The group with both pressure and volume overloads was between the two. In conclusion, the mode of RV filling in patients with RV overload showed various patterns depending on the type of overload. The RV inflow velocity pattern recorded by pulsed Doppler echocardiography is of use in discriminating these varieties.

[Mitral regurgitation in mitral valve prolapse: its mechanisms and time course].

To clarify the mechanisms and time course of mitral regurgitation (MR) in mitral valve prolapse (MVP), the relationship between the timing of MR flow patterns on pulsed Doppler echocardiography and phase of mitral valve prolapse on two-dimensional echocardiography was investigated. 1. Thirty-seven patients with MVP were followed by pulsed Doppler echocardiography for one to six years with an average of 2.5 years. At the initial examination, the patients were classified in five subsets on the basis of the presence or timing of MR: 10 without MR, five with early systolic MR, one with mid-systolic MR, 15 with late systolic MR and six with pansystolic MR. During the follow-up period, the timing of MR did not change in 21 patients (three with no MR, five with early systolic MR, seven with late systolic MR and six with pansystolic MR). Various changes were observed in 16 patients, i.e., developments of late systolic MR from no MR in four, of pansystolic from no MR in three, from late systolic MR in five and from mid-systolic MR in one, and disappearing late systolic MR in three. 2. Mitral annular diameter and the prolapsing phase of 118 patients with MVP (44 without MR, eight with early systolic MR, 30 with late systolic MR and 36 with pansystolic MR) were examined by long-axis two-dimensional echocardiography. The mitral annular diameter in patients with early systolic MR was significantly less than that of other MR groups, and the diameter in patients with pansystolic MR was markedly increased. The timing of MR was determined according to the prolapsing phase and the grade of the prolapse and the systolic size of the mitral annulus. Six of the eight patients with early systolic MR first had early systolic prolapse of either mitral leaflet, and then the regurgitant gap of the mitral valve orifice was plugged by the prolapsing leaflet and/or the narrowed mitral annulus during mid-to-late systole. In 18 of the 30 patients with late systolic MR, the grade of prolapse of the mitral valve during mid-to-late systole was more severe, compared with that of early systole. The results of the present study indicated that the occurrence of MR in MVP is various in timing (early, mid-, late or pansystole) and shows various changes the during follow-up study, and that pulsed Doppler echocardiography allows phase analysis of MR in MVP.

[Correlations between the features of first heart sound and opening snap and the shape and motion of the anterior mitral leaflet in patients with mitral stenosis].

To evaluate the relationship between the motion pattern and degree of organic change of the anterior mitral leaflet (AML) and the features of the mitral component of the first heart sound (M1) or the opening snap (OS), 37 patients with mitral stenosis (MS) were studied by auscultation, phonocardiography and echocardiography. Based on the features of M1 and OS according to auscultation and phonocardiography, the patients were categorized as group I, 18 patients with loud and snappy M1 and OS; group II, 12 patients with snappy M1 but small and dull OS; and group III, seven patients with small and dull M1 and OS. Intensities of M1 and OS were calculated by the ratios of their amplitudes to the aortic component of the second heart sound on the high frequency phonocardiograms recorded at points of the maximum intensities, respectively. Echocardiographic parameters related to productions of M1 and OS were obtained from M-mode and two-dimensional echograms of the AML; they were amplitudes and velocities on closing and opening, M1 area defined as that between end-diastolic and systolic echoes, OS area between systolic and early diastolic echoes, the doming area between the trailing edge of an early diastolic echo and a line projected from the anterior annulus to the tip of the leaflet, and the degree of systolic ballooning. Results were as follows: 1. Significant differences in the area of the mitral valve orifice were found among three groups. The area was maximum in group II, minimum in group III and intermediate in group I. 2. In group I, the body of the AML was pliable, resulting in a ballooning into the left atrium in systole and a marked doming toward the left ventricle in early diastole. Various parameters related to the production of M1 and OS in group I were significantly increased as compared with those of the other two groups. 3. In group II, the body of the AML was not pliable in spite of mild organic changes in the valve. The degree of early diastolic doming was mild. Compared to group III, the intensity of M1 in group II was significantly larger, but no significant difference was observed in the parameters related to the production of M1 between the two groups.(ABSTRACT TRUNCATED AT 400 WORDS)

[Mitral component of the first heart sound in complete left bundle branch block: the mechanism of the decreased intensity].

To clarify the mechanism of the reduced intensity of the mitral component of the first heart sound (IM) in complete left bundle branch block (LBBB), electrocardiograms, phonocardiograms, apexcardiograms and mitral valve echograms of 12 patients with LBBB (LBBB group) and 13 normal subjects (normal group) were simultaneously recorded. The first derivative of the apexcardiogram was also studied. One of the 12 patients had an intermittent LBBB. There was no significant difference in the P-Q interval between the two groups. The following results were obtained: 1. In the LBBB group; 1) The intensity of the IM, expressed as a ratio of the amplitude of the IM to that of the aortic component of the second heart sound (IIA) on the apical phonocardiograms, was significantly reduced except in one patient who had a relatively short P-Q interval. 2) The timings of the onset of the upstroke of the apexcardiogram and mitral valve closure were significantly and equally delayed. 3) The amplitude of the mitral valve echogram at the onset of the upstroke of the apexcardiogram (end-diastolic amplitude of the mitral valve) was significantly decreased. The closing velocity of the mitral valve was also decreased. 4) The amplitude ratio (H2/H1) and the rate of rise (A) of the apexcardiogram at the onset of the IM were significantly decreased. 2. The intensity of the IM, H2/H1 and A of the apexcardiogram at the onset of the IM were compared for three cases with nearly equal end-diastolic mitral valve amplitudes in each group. The intensity of the IM was apparently reduced in the LBBB group, compared with that of the normal group, and its intensity correlated inversely with H2/H1 and A. These results indicate that the reduced intensity of the IM in LBBB is caused mainly by the decreased amplitude of the mitral valve excursion at the onset of left ventricular contraction. An additional cause is the decreased tension on the closed mitral valve resulting from the slow rate of left ventricular pressure rise at the onset of the IM.

[Mode of left ventricular diastolic filling in hypertrophic cardiomyopathy as studied by pulsed Doppler echocardiography and multigated blood pool scan].

The clinical significance of the mode of left ventricular (LV) diastolic filling in hypertrophic cardiomyopathy was studied by the LV inflow velocity patterns (LVIF) of pulsed Doppler echocardiography and LV early diastolic filling rates (V2) of radionuclide (RI) angiography. The relationship between the deceleration time (DT) obtained from LVIF and the V2 was evaluated in 34 patients with nonobstructive hypertrophic cardiomyopathy (HCM) and in nine with obstructive hypertrophic cardiomyopathy (HOCM), and the results were compared with those of 10 patients with dilated cardiomyopathy (DCM), of two with restrictive cardiomyopathy (RCM), and of 19 normal subjects. HCM was subdivided into the following groups according to V1-DT relationships: Group 1 with prolonged DT and decreased V1, Group 2 with normal or short DT and normal V1, and Group 3 with normal or short DT and decreased V1. There were significant negative correlations between V2 and DT in Groups 1 and 2 of HCM, normal and HOCM. However, there were significant positive correlations in Group 3 of HCM, DCM and RCM. Nearly all patients in Group 3 had decreased LV ejection fraction and % fractional shortening, distinct B-B' step formation of the mitral valve echogram, and huge A wave of the apexcardiogram. These findings suggested that the LV rapid filling interval gradually became shorter because the LV contraction is decreased as myocardial fibrosis develops in HCM, and that we must pay attention to the diagnosis of such abnormalities, similar to those of DCM or RCM.

[Primary pericardial malignant mesothelioma associated with constrictive pericarditis: a case report].

A case of primary pericardial malignant mesothelioma was presented, which initially had a relatively large quantity of pericardial fluid, followed by constrictive pericarditis. The patient was a 43-year-old woman whose chief complaint was dyspnea and admitted to our hospital in March, 1984. Because of a relatively large quantity of pericardial fluid was observed. In April, drainage of the fluid and pericardiotomy were performed with marked relief of symptoms. She was discharged, but her dyspnea recurred in August, and she was readmitted. After the second admission, the chest radiograph showed a cardiothoracic ratio of 62%, and her electrocardiogram showed low voltage. A pericardial knock was recorded, and the timing of this sound coincided with that of the peak of the early distolic wave of the mitral flow velocity pattern. A jugular pulse tracing showed a deep and sharp y descent. The diastolic pressure curve of the right ventricle revealed a dip and plateau pattern. The echocardiographic finding was characterized by abnormal systolic motion and an early diastolic dip of the interventricular septum, multiple abnormal echoes and thickening of the pericardium, and an abnormal mass echo in the left atrial cavity. Based on the above examinations, pericardiotomy was performed, but the tumor was not entirely resected. The histological diagnosis was malignant mesothelioma.