Left recurrent laryngeal nerve palsy associated with primary pulmonary hypertension and patent ductus arteriosus.

Two patients with left recurrent laryngeal nerve paralysis in association with pulmonary artery hypertension are described. One had primary pulmonary hypertension and the other had patent ductus arteriosus. The greatly dilated pulmonary artery in these patients resulted in compression of the left recurrent laryngeal nerve and produced a cardiovocal (Ortner's) syndrome. The pathogenesis of the vocal cord palsy was documented by cross-sectional computed tomography. In conclusion, computed tomography is of great help in differentiating this syndrome from other diseases such as mediastinal mass or lymphadenopathy whenever hoarseness is complicated by pulmonary hypertension.

Effect of left ventricular hypertrophy secondary to systemic hypertension on left coronary artery flow dynamics.

STUDY OBJECTIVE: The aim was to clarify the characteristics of the phasic blood velocity pattern and their possible causes in left ventricular hypertrophy secondary to systemic hypertension. DESIGN: Measurements of blood velocities in the left anterior descending coronary artery were made with a 20 MHz Doppler catheter with a top mounted annular crystal. All patients had normal coronary arteriograms. PATIENTS: 23 hypertensive patients [systolic/diastolic pressure: 181(SD 15)/100(4) mm Hg)] with left ventricular hypertrophy, and 13 atypical chest pain patients without left ventricular hypertrophy or any abnormal haemodynamic findings (normal controls) entered the study. MEASUREMENTS AND MAIN RESULTS: The left anterior descending coronary artery blood velocity waveform in pressure overloaded left ventricular hypertrophy was characterised by delayed early diastolic inflow. The diastolic rise time of coronary flow (TDR), ie, the time from the beginning of diastole to peak velocity, was higher in patients with hypertensive left ventricular hypertrophy than in normal controls, at 145(56) v 66(15) ms, p less than 0.001. In patients with hypertensive left ventricular hypertrophy, TDR correlated well with the degree of hypertrophy (r = 0.83, p less than 0.01) and also with peak left ventricular systolic pressure (r = 0.62, p less than 0.01). The coronary flow reserve, calculated from the ratio of the diastolic mean velocity after intracoronary injection of papaverine to the resting flow velocity, decreased with prolongation of TDR (r = 0.58, p less than 0.02). CONCLUSIONS: (1) Impairment of early diastolic coronary arterial inflow is the most remarkable characteristic in pressure overloaded left ventricular hypertrophy; (2) preceding systolic vascular compression and impaired left ventricular relaxation correlate with the delayed early diastolic inflow; (3) the delayed inflow is an important possible cause of the decreased coronary flow reserve in the hypertensive left ventricular hypertrophy.

Thallium-201 imaging with color display computer system in old myocardial infarction.

In 13 patients with old myocardial infarction diagnosed with use of the electrocardiogram, coronary angiogram and left ventriculogram and in 11 patients without infarction, thallium-201 imaging with a color display computer system was carried out. In the group without infarction the average ratio of activities in two regions of interest within the myocardial wall, excluding the apex, was 1.14 (1.08 to 1.23). In the group with infarction the average ratio of noninfarcted to infarcted areas was 1.44 (1.23 to 1.78). Objective detection of infarction was possible in 12 patients (92 percent) in the group with infarction. In two patients, the earlier electrocardiographic pattern of infarction had resolved by the time of imaging. These results suggest that the sensitivity of thallium-201 imaging in the diagnosis of old myocardial infarction may be greatly enhanced by objective and quantitative analysis using a color display computer system.

Significant coronary artery disease detected by amyl nitrite and systolic time intervals.

The relation between changes in left ventricular systolic time intervals with amyl nitrite (AN) inhalation and the severity of coronary artery disease (CAD) was evaluated in 77 patients who underwent catheterization because of chest pain. In 25 subjects with normal coronary angiograms (control group), AN inhalation increased the ejection time (ET), shortened the preejection period (PEP) and increased the ET/PEP markedly. In the 52 patients with CAD (CAD group), the ET/PEP changed insignificantly after AN. The difference between the 2 groups was significant (p less than 0.001). At cardiac catheterization, the increase of left ventricular dP/dt after AN in the control group was significantly larger than that in the CAD group. Although a positive correlation between changes in ET/PEP with AN and ejection fraction at rest was noted in patients with 1-vessel CAD, no such correlation was noted in those with multivessel CAD. This suggests that factors in addition to pump function, such as the degree of CAD, influence the effect of AN inhalation on systolic time intervals. When an increase of less than 30% in ET/PEP occurs with AN inhalation, the presence of significant CAD can be detected with a sensitivity of 92%, a specificity of 84% and the predictive value of 92%. The AN inhalation test is safe and simple, and thus could serve as a stress test for evaluating the presence and severity of significant CAD.

[Exercise induced precordial T wave normalization associated with U wave inversion in detection of left anterior descending artery stenosis].

Although normalization of inverted T wave is not an uncommon finding during exercise tests, it's clinical significance is still unclear. Exercise 12-lead electrocardiograms (ECGs) were recorded by using Master's 2-step or ergometer. T wave normalization in the anterior chest leads was found in 20 patients with, and 14 patients without coronary artery disease (CAD). Coronary angiography and/or exercise Tl-201 myocardial imaging were also performed in every patient. Exercise-induced T wave normalization was defined as "inverted T wave at rest becoming upright during exercise". ST segment, T and U wave amplitudes were measured before and immediately after exercise. 1) All of the 20 patients (100%) with CAD demonstrated critical stenosis of the left anterior descending artery (LAD). 2) ST deviation was noted in none of the 14 patients (0%) without CAD, and in only 4 of the 20 patients (20%) with CAD. 3) T wave amplitude increased equally in patients both with and without CAD. 4) Exercise-induced U wave inversion was found in 16 of the 20 patients (80%) with CAD, whereas it was found in only 1 of the 14 patients (7%) without CAD. 5) The sensitivity of "U wave inversion" in detection of LAD stenosis was 80%, and the specificity was 93%. We conclude that exercise-induced T wave normalization associated with U wave inversion in anterior chest leads is highly indicative of the specific presence of critical LAD stenosis.

[Long-term follow-up of clinical features and ECG changes in 50 patients with HCM].

We studied the relation of ECG changes during the clinical course in patients with hypertrophic cardiomyopathy (HCM). Fifty patients with HCM were categorized in two groups; 20 patients with, and 30 patients without signs of deterioration of clinical state. The changes between the first and the final ECG were compared in these two groups. The average follow-up period was 7.6 years. Twenty patients with clinical deterioration presented increase in QRS intervals (0.06----0.071 sec, p less than 0.025), decrease in voltage of RV5 (2.81----2.38 sec, p less than 0.025), increase in newly developed abnormal Q waves, and P wave changes. In contrast to these cases, 30 patients without clinical deterioration presented no significant ECG changes. Amplitudes of the negative T wave were unchanged in both groups. We conclude that electrocardiographic observations proved to be useful for predicting clinical features in patients with HCM.

[Acute and chronic effects of bunazosin in patients with congestive heart failure].

The acute hemodynamic effect (right atrial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, heart rate, blood pressure) and neurohumoral response (alpha-ANP, plasma renin activity, aldosterone, angiotensin II) of Bunazosin, oral alpha 1 blocker, was investigated in 28 patients with congestive heart failure at rest and immediately after exercise. Bunazosin reduced alpha-ANP, but, other neurohumoral factors did not change. Bunazosin produced significant hemodynamic improvements both at rest and after exercise. Its chronic effect was also investigated in 11 patients in 28 days after taking oral Bunazosin. Improvement of hemodynamics at acute phase was also preserved at chronic phase without deterioration of neurohumoral factors. It is concluded that Bunazosin may be an effective Balanced vasodilator both at acute and chronic phases in patients with congestive heart failure.

[Severe hyponatremia associated with captopril therapy in dilated cardiomyopathy: a case report].

A 47-year-old man, with dilated cardiomyopathy developed severe hyponatremia and hypoosmolarity during captopril therapy. He also had an inappropriate elevation of antidiuretic hormone and urine osmolarity, but no evidence of dehydration, renal or suprarenal disturbances. The hyponatremia and hypoosmolarity improved after withdrawal of captopril alone, and recurred after readministration of captopril. We conclude that the hyponatremia may be caused by high secretion of prostagrandin and bradykinin associated with captopril therapy.

[A case of acute pericarditis secondary to mediastinitis].

A 45-year-old man who complained of swallowing disturbance and chest pain in inspiration phase was admitted for evaluation of "pericarditis". A chest X-ray film on admission disclosed a wide mediastinal shadow and pleural effusion on the right side. Bilateral tonsils were swollen, and covered with pus. A Computed tomogram of the chest showed a shadow of exudate contained with air in the mediastinum. Mediastinal drainage, tonsillectomy and drainage of fistula from pre-tracheal space to upper mediastinum were immediately performed. Staphylococcus aureus was confirmed from the sputum and mediastinal effusion. Thus, acute mediastinitis was confirmed as an etiological diagnosis of "pericarditis" in this patient.

[Two cases of primary artery dissection].

We experienced two cases of primary coronary artery dissection. (Case 1) 55-year-old man had frequent episodes of chest oppression at early morning and midnight. During chest oppression, electrocardiogram showed transient ST-segment elevation in leads II, III, and a VF. Then, he was diagnosed as having angina pectoris. This diagnosis was based on the fact that he presented coronary spastic syndrome. Right coronary angiogram demonstrated an intimal flap and false lumen at segment 3, and primary coronary dissection was confirmed. (Case 2) A 27-year-old woman complained of back pain while taking a bath. Electrocardiogram showed ST-segment elevation and abnormal Q in leads V2, V3 and V4. She was diagnosed as having acute anterior wall myocardial infarction. Presence of coronary artery dissection at segment 6 was identified by left coronary angiogram. Primary coronary artery dissection is clinically diagnosed by coronary angiogram very rarely. Only 27 such cases have been reported. It was speculated that, in case 1, vasospastic angina may be associated with primary coronary artery dissection. Case 2 had primary coronary artery dissection at segment 6 of the left anterior descending artery. Thus, her clinical picture was similar to those of previously reported cases.

[A case of silent posterior myocardial ischemia/left circumflex artery obstruction detected by prominent U-wave in right precordial leads].

A 64-year-old woman with a history of hypertension for ten years and of syncope 18 month previously visited our Division of Cardiology on 12 June, 1989. The S4 and mitral regurgitation were audible at the apex, and her electrocardiogram showed ST-depression in leads II, aVF, V5-6 and prominent U-wave (PU) in V1-3 when first seen. Then, she was thought to have a posterior myocardial ischemia. PU in V1-3 diminished whereas T-wave increased after nitrate and Ca++ blocker. Ergometer exercise ECG showed ST-depression in II, III, aVF, V4-6 and PU with decreased T-wave in V2-3 with no apparent symptoms. Simultaneously, Tl-201 myocardial imaging demonstrated a transient posterior defect. A silent posterior myocardial ischemia was, therefore, confirmed. Coronary arteriograms demonstrated subtotal obstruction of the proximal left circumflex artery, and the peripheral site was filled by collaterals from the right coronary artery. Angina-induced PU in the right precordial leads proved to be useful in detection of posterior myocardial ischemia, and this marker may also improve the possibility of detection of silent posterior ischemia.

[Treadmill exercise test in patients with hypertrophic cardiomyopathy with and without coronary artery disease].

We studied whether the treadmill exercise test can discriminate between normal and significant narrowing of coronary arteries in patients with hypertrophic cardiomyopathy (HCM) accompanied with chest pain, and we compared the extent of myocardial ischemia during exercise. Thirty one patients with HCM were divided into two groups; 21 with normal coronary arteries and 11 with significant narrowing of coronary arteries. The treadmill exercise test was carried out in both groups. The following parameters were more frequently seen in the group with coronary stenosis. (1) short treadmill time (338, sec vs 542, p less than 0.05). (2) delta SBP less than or equal to 60 mmHg (delta: end point minus rest, 10 cases vs 12, 0.05 less than p less than 0.1). (3) significant delta ST depression (0.17 mV vs 0.05, p less than 0.05). (4) large delta ST/delta HR (3.3 microV.min/beats vs 0.7). delta ST/delta HR greater than or equal to 2.0 was the most useful for differentiating the two groups, and it was 90% in index both sensitivity and specificity for diagnosis of HCM with significant narrowing of the coronary arteries. It was concluded that treadmill exercise induced more severe myocardial ischemia in patients with HCM who had significant narrowing of the coronary arteries than in patients with HCM who had angiographically normal coronary arteries. The delta ST/delta HR was the most useful index for diagnosis of HCM with significant narrowing of the coronary arteries.

[Autonomic function and severity of hypertrophic cardiomyopathy by power spectrum analysis on heart rate variability].

To examine the relation of autonomic function and severity of hypertrophic cardiomyopathy (HCM) with and without ventricular tachycardia (VT) and poor blood pressure response on Treadmill exercise, 30 patients with HCM and 10 healthy controls were selected. Autonomic function was assessed by heart rate variability (HRV) on 24hr-Holter monitoring. The power spectrum analysis was classified into LF component, HF component and ratio of LF/HF. (1) Night time HF and LF decreased, and LF/HF increased in HCM compared with healthy controls. (2) HF decreased more in HCM with VT. (3) LF/HF also decreased in HCM with poor blood pressure response on exercise. These results suggest that autonomic function may be altered in HCM, and severity of HCM proved to be able to be assessed by power spectrum analysis of HRV.

[Effect of heart rate on cardiac hemodynamics in patients with aortic regurgitation].

We evaluated the effects of heart rate on cardiac hemodynamics in 10 patients with aortic regurgitation (AR, mean regurgitant fraction: 64.3%). Cardiac catheterization was performed in all patients, and the hemodynamic parameters were obtained by increasing heart rate (80.100.120.140) using right atrial pacing. Regurgitant fraction and total systemic resistance were improved up to 100/min, but aggravated on further increase in heart rate. Cardiac function curve was remarkably improved up to 100/min, but aggravated on further increase in heart rate. LV end-diastolic pressure-volume relation was moved toward the left lower direction up to 100/min, but toward the left upper direction on further increase in heart rate. Thus, it was concluded that in severe AR, cardiac function was improved up to 100/min, but aggravated on further increase in heart rate.

[The effect of bunazosin vs captopril on hemodynamic and neurohumoral parameters in patients with congestive heart failure].

The hemodynamic parameters (right atrial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, heart rate, blood pressure) and neurohumoral responses (alpha-ANP, plasma renin activity, aldosterone, angiotensin II) of Captopril, oral ACE inhibitor, and Bunazosin, oral alpha 1-blocker, were investigated in 28 patients with congestive heart failure at rest and after exercise. These data were analysed in both acute and chronic phases. 1) Acute effect. Captopril produced significant improvement of neurohumoral factors at rest and also after exercise. Bunazosin reduced alpha-ANP, but other neurohumoral factors did not change. Bunazosin produced significant hemodynamic improvement both at rest and after exercise. 2) Chronic effect. Captopril produced significant hemodynamic improvement both at rest and after exercise. Improvement of neurohumoral factors in acute phase was also preserved at chronic phase. On Bunazosin, improvement of hemodynamics at acute phase was also preserved at chronic phase without deterioration of neurohumoral factors.

[Significance of decreased washout rate in hypertrophic cardiomyopathy by exercise Tl-201 myocardial scintigraphy].

UNLABELLED: A clinical significance of decreased washout rate (WR) in hypertrophic cardiomyopathy by exercise thallium-201 myocardial scintigraphy was evaluated. Thirty-six patients with hypertrophic cardiomyopathy and normal coronary angiogram were categorized into 3 groups according to initial distribution (ID) and WR: decreased ID group (17 patients, ID group), normal ID but decreased WR group (9 patients, WR group) and normal ID and normal WR group (10 patients, N group). RESULTS: (1) Cardio-thoracic-ratio and left ventricular end-diastolic pressure were higher in WR group than in other 2 groups. (2) Resting ejection fraction and left ventricular end-diastolic volume index did not differ in three groups. (3) Exercise ejection fraction was increased in N group, whereas it was not increased in ID or WR groups. It was increased in 47% of ID group, but were decreased or not changed in all patients of WR group. In conclusion, decreased WR in patients with hypertrophic cardiomyopathy may strongly suggest left ventricular myocardial damage.

[Right pulmonary artery obstruction and pulmonary hypertension secondary to aortitis syndrome].

A 56-year-old woman with aortic arch syndrome and finally right pulmonary artery obstruction secondary to Takayasu's aortitis was presented. She had had a history of visual disturbance and dizziness when she looked upward since 1983. On admission in July, 1984, aortography showed obstruction of the right innominate artery and of the left subclavian artery. Pulmonary arterial pressure, pulmonary perfusion and ventilation images seemed to be normal at that time. After discharge from our hospital, she began in 1987, to be aware of dyspnea on effort. Because of this symptom, she was admitted again in March, 1988. The pulmonary perfusion images showed complete lack of perfusion in the right lung, and arterial blood gas showed hypoxia with 62 mmHg in PaO2, 39 mmHg in PaCO2. Cardiac catheterization confirmed pulmonary hypertension with pulmonary artery pressure of 56/18 mmHg. In conclusion, pulmonary perfusion and ventilation scintigraphy proved to be the best way to clarify the nature of a lesion of the pulmonary artery in aortitis syndrome.

[Usefulness for evaluation of the left ventricular disorders by apexcardiographic A-wave ratio in patients with hypertrophic cardiomyopathy].

Usefulness for evaluation of left ventricular disorders by apexcardiographic A-wave ratio was studied in 48 patients with hypertrophic cardiomyopathy. These subjects were divided into 3 groups: A-wave ratio less than or equal to 15% (group 1), 16% less than or equal to A-wave ratio less than or equal to 29% (group 2), and A-wave ratio greater than or equal to 30% (group 3). A-wave ratio was found to have a positive correlation with Time constant T (r = + 0.71), left ventricular end-diastolic pressure (r = +0.46), and left ventricular atrial kick (r = +0.55). During exercise, ejection fraction decreased significantly (p less than 0.05) in group 3 as compared to group 1. During treadmill exercise test, rise of systolic blood pressure was significantly (p less than 0.05) poor, and there was a large number of ST depression (p less than 0.05) in group 3. It was recognized by exercise thallium-201 myocardial scintigraphy, that the frequency of perfusion defect was 30% in group 3. In conclusion, high A-wave ratio may strongly suggest impaired left ventricular diastolic function, and, there was correlated to abnormal hemodynamic state during exercise. Apexcardiographic A-wave ratio proved to be useful in patients with hypertrophic cardiomyopathy. It is useful for evaluation of left ventricular disorders.

[A marked Hegglin syndrome in pheochromocytoma].

A 46-year-old man was hospitalized with paroxysmal headache and chest discomfort. His blood pressure varied, occasionally being up to 300/160 mmHg. Cardiac examination revealed a decrescendo type of diastolic murmur (aortic regurgitation) and S4 gallop. Both blood and urine catecholamine levels were extremely high. Electrocardiogram and echocardiogram showed severe left ventricular hypertrophy pattern presenting hypertrophic cardiomyopathic changes. The phonocardiogram showed marked Hegglin syndrome (QT; 450 msec and QII; 310 msec). Right adrenal tumor, pheochromocytoma was found on the abdominal CT scanning and 131I-metaiodobenzylguanidine (MIBG). In the post-operative period, Hegglin syndrome was completely abolished (QT; 360 msec and QII; 345 msec,), and also electrocardiographic left ventricular hypertrophy pattern improved immediately after surgical removal of the pheochromocytoma.