Role of transesophageal echocardiography in the prediction of thromboembolism in patients with chronic nonvalvular atrial fibrillation.

The purpose of this study was to determine whether parameters derived from transesophageal echocardiography (TEE) could predict thromboembolism in patients with chronic nonvalvular atrial fibrillation (AF). Eighty-nine patients, mean age 66+/-9 years, who underwent TEE in 1996 to 1999 were studied. The clinical endpoint was a thromboembolic event, including transient ischemic attack (TIA). Sixty-seven patients (75%) were anticoagulated with warfarin after TEE. After a follow-up period of 29+/-10 months, 1 patient died suddenly, 4 had a thromboembolism, and 3 had a TIA; the annual embolic event rate was 3.3%. Left atrial appendage (LAA) thrombus (86% vs 17%, p<0.001), LAA dysfunction (LAA velocity <20 cm/s; 71% vs 25%, p=0.009), and severe LA spontaneous echo contrast (29% vs 2%, p=0.002) were more prevalent in patients with an embolic event than in those without. In patients with LAA thrombus, the annual event rate was 11% as compared with 1.2% in those without (p=0.004). On the Cox proportional hazards model analysis, LAA thrombus (chi-square 7.0, p=0.008), severe LA spontaneous echo contrast (chi-square 7.0, p=0.008), and LAA dysfunction (chi-square 5.9, p=0.015) were significantly related to thromboembolism. Multivariate analysis revealed that LAA thrombus (chi-square 5.5, p=0.019) and LAA dysfunction (chi-square 4.0, p=0.045) were the independent predictors. In conclusion, TEE parameters, particularly the presence of LAA thrombus, can be used to assess thromboembolic potential in patients with chronic nonvalvular AF.

137Cs contained in books printed during the 1960s in Japan.

Radioactivity values of 137Cs in printed pages and covers of hardbound books issued during the 1960s in Japan were measured by gamma-ray spectrometry. The result showed that the main source of 137Cs present in the books was rice straw used to make the backing board of covers. The 1965 peak of 137Cs content of the book was explained by the variation of 137Cs content of rice straw with the harvest year and a change of the kind of board.

Quantification of left atrial appendage spontaneous echo contrast in patients with chronic nonalvular atrial fibrillation.

OBJECTIVES: The left atrial (LA) appendage is the most common site of thrombus formation in patients with atrial fibrillation, and integrated backscatter allows the quantiative assessment of LA spontaneous echo contrast (SEC). Integrated backscatter was used to examine the significance of measuring appendage SEC, specifically in relation to echocardiographic variables implying thromboembolism, in patients with chronic nonvalvular atrial fibrillation. METHODS: Fifty-two patients with chronic nonvalvular atrial fibrillation and no prior anticoagulant therapy (35 men, 17 women, mean age 66 +/- 7 years) underwent transesophageal echocardiography with integrated backscatter analysis. The LA and LA appendage integrated backscatter intensity were measured with the regions of interest placed in the LA cavity and the appendage, respectively. The integrated backscatter intensity values for these two chambers (corrected "LA" and "LA appendage" integrated backscatter intensity, respectively) were corrected using values from the left ventricular cavity. RESULTS: The LA appendage integrated backscatter intensity values were available in 44 patients (85%). Overall, the corrected LA appendage integrated backscatter intensity was significantly increased compared with the corrected LA integrated backscatter intensity (2.8 +/- 2.2 vs 2.0 +/- 1.8 dB, p < 0.001). The corrected LA appendage integrated backscatter intensity was inversely correlated with the LA appendage velocity (r = -0.37, p < 0.05), but not with the LA dimension, appendage size, or left ventricular function. The corrected appendage integrated backscatter intensity (4.5 +/- 2.3 vs 2.4 +/- 1.9 dB, p < 0.01) and LA integrated backscatter intensity (3.2 +/- 2.1 vs 1.7 +/- 1.7 dB, p < 0.05) were higher in patients who had LA appendage thrombus (n = 8) than those who did not. With the corrected appendage integrated backscatter intensity set at > or = 2.5 dB, the sensitivity for the presence of appendage thrombus was 88% and the specificity was 64%. CONCLUSIONS: Patients with chronic nonvalvular atrial fibrillation had a denser SEC in the LA appendage compared with SEC in the main LA cavity. The severity of the appendage SEC was influenced by the LA appendage function rather than its size. Quantification of SEC in the appendage, rather than main LA cavity, was more valuable for assessing embolic potential.

Prediction of mean pulmonary wedge pressure using doppler pulmonary venous flow variables in hypertrophic cardiomyopathy.

We examined whether pulmonary venous flow variables, assessed by transthoracic Doppler echocardiography, could predict mean pulmonary wedge pressure in hypertrophic cardiomyopathy. Forty-four patients with no left ventricular systolic dysfunction (left ventricular fractional shortening > or =25%) were studied. Forty patients with systolic dysfunction (dilated cardiomyopathy group) served as control. Mitral and pulmonary venous flow velocity curves were recorded with the pulsed-Doppler method and were related to mean pulmonary wedge pressure obtained by right heart catheterization. In hypertrophic cardiomyopathy group, the systolic (r=-0.15, P=0.335) and diastolic (r=0.35, P=0.022) forward flow velocity were poorly related to mean pulmonary wedge pressure, whereas the velocity of atrial reversal (r=0.68, P<0.001) correlated well with mean pulmonary wedge pressure. In dilated cardiomyopathy group, the systolic (r=-0.51, P=0.001) and diastolic (r=0.60, P<0.001) forward flow velocity were strongly related to mean pulmonary wedge pressure. With the cut-off value set at the velocity of atrial reversal >30 cm/s in hypertrophic cardiomyopathy group, the sensitivity for predicting mean pulmonary wedge pressure >15 mmHg was 79% and the specificity was 73%. In conclusion, the atrial component of the pulmonary venous flow can be used to predict mean pulmonary wedge pressure in hypertrophic cardiomyopathy.

Integrated backscatter assessment of left atrial spontaneous echo contrast in chronic nonvalvular atrial fibrillation: relation with clinical and echocardiographic parameters.

Integrated backscatter (IB) provides the quantitative assessment of left atrial spontaneous echo contrast (SEC). The IB intensity of the left atrial cavity relative to the left ventricular cavity is related to atrial thrombus in patients with atrial fibrillation (AF) or sinus rhythm. However, little is known about the relation between the quantitative SEC value of the left atrial cavity and variables implying thromboembolism in nonvalvular AF. To examine this relation, we performed transesophageal echo-cardiography with IB analysis in 65 patients with chronic nonvalvular AF. The quantitative SEC value of the left atrial cavity was defined as the difference between atrial IB intensity and ventricular IB intensity (corrected IB intensity). The corrected IB intensity was correlated with the left atrial dimension (r = 0.25, P =.049), the left atrial appendage velocity (r = -0.41, P <.001), and the duration of AF (r = 0.23, P =. 023). The corrected IB intensity was higher in patients who had a history of hypertension (3.2 +/- 2.2 dB versus 2.0 +/- 1.6 dB, P =. 018), SEC (3.9 +/- 1.9 dB versus 1.4 +/- 1.1 dB, P =.002), and left atrial thrombus (4.5 +/- 2.7 dB versus 2.2 +/- 1.7 dB, P <.001) when compared with those who did not have these abnormalities. The corrected IB intensity was significantly lower in patients with significant mitral regurgitation than in those without it (1.1 +/- 1. 2 dB versus 2.7 +/- 2.0 dB, P =.036). When the cutoff value of the corrected IB intensity was set at >/=2.0 dB, the sensitivity for left atrial thrombus was 78% and the specificity was 55%. In patients with chronic nonvalvular AF, the quantitative SEC value of the left atrial cavity depends on the duration of AF as well as the left atrial dimension and appendage velocity. Although IB may be capable of identifying patients with higher risk of cardiogenic embolism, a large-scale prospective study is needed to actually establish this.

Prognostic value of left atrial appendage function in patients with dilated cardiomyopathy.

The purpose of the present study was to determine whether parameters of left atrial appendage (LAA) function, assessed by transesophageal echocardiography (TEE), could predict the clinical outcome in patients with dilated cardiomyopathy (DCM). Fifty-five patients (20 had ischemic cardiomyopathy; mean age, 56+/-14 years) who underwent TEE to evaluate LAA function from 1992 to 1996 were studied. After a mean follow-up period of 34+/-13 months, 16 patients died; the cause was cardiac in 14 and noncardiac in 2. Patients who died of cardiac cause had a lower LAA emptying velocity than survivors (38+/-18 vs 54+/-18 cm/s, p=0.01). There were, however, no significant differences between survivors and nonsurvivors with regard to the maximal LAA area (4.3+/-1.3 vs 4.5+/-0.9 cm2, p=0.55), minimal LAA area (2.4+/-1.1 vs 2.9+1.1 cm2, p=0.13), and LAA ejection fraction (46+/-16 vs 36+/-18%, p=0.05). On the Cox proportional hazards model analysis, LAA emptying velocity <50 cm/s (chi-square 5.9, p=0.02), LAA ejection fraction <43% (chi-square 5.6, p=0.02), female gender (chi-square 5.2, p=0.02), pulmonary artery wedge pressure > or =14 mmHg (chi-square 4.8, p=0.03), E/A ratio > or =1.3 (chi-square 4.6, p=0.03), deceleration time <148 ms (chi-square 4.6, p=0.03), and cardiothoracic ratio > or =54% (chi-square 4.3, p=0.04) were significantly related to cardiac death. The stepwise multivariate analysis revealed that LAA emptying velocity (chi-square 6.1, p=0.01) and gender (chi-square 5.4, p=0.02) were the independent predictors for outcome. In conclusion, the parameters of LAA function may be useful predictors of the clinical outcome in patients with DCM.

Myocardial integrated ultrasonic backscatter in patients with dilated cardiomyopathy: prediction of response to beta-blocker therapy.

BACKGROUND: Myocardial integrated backscatter (IB) imaging has been reported to be useful for ultrasonic tissue characterization and delineation of myocardial viability or fibrosis. beta-Blocker therapy has beneficial effects for patients with dilated cardiomyopathy (DCM), but there are no clear findings that indicate which patients with DCM will respond to this therapy. This study was performed to evaluate whether myocardial IB analysis can predict the response to beta-blocker therapy. METHODS AND RESULTS: We prospectively performed echocardiographic examination with IB analysis in 29 patients with DCM (20 men, 9 women) before starting bisoprolol therapy and in 15 normal subjects. Standard echocardiographic examination and IB analysis in the left ventricular wall in the 2-dimensional short-axis view were performed and the magnitude of cyclic variation (CV) of IB and calibrated myocardial IB intensity (subtracted pericardial) were obtained from the interventricular septum and the left ventricular posterior wall. Sixteen patients responded to bisoprolol therapy and 13 did not respond after 12 months of full-dose therapy. Calibrated myocardial IB intensity was lower in responders relative to nonresponders in both the interventricular septum (responders, -20.1 +/- 3.6 dB vs nonresponders, -9.8 +/- 5.1 dB, P <.0001; controls, -20.1 +/- 4.4 dB) and posterior wall (responders, -20.6 +/- 3.6 dB vs nonresponders, -14.6 +/- 4.2 dB, P =.0002; controls, -22.7 +/- 3.3 dB). Also, the lower the myocardial intensity in the interventricular septum or posterior wall, the better left ventricular systolic function improved after beta-blocker therapy. However, CV was lower in both DCM groups than in the controls, and CV in the interventricular septum was lower in nonresponders than in responders (responders, 4.0 +/- 4.1 dB vs nonresponders, -0.8 +/- 6. 1 dB, P <.02; controls, 8.3 +/- 2.4 dB). In addition, CV in the posterior wall showed no difference between the 2 DCM groups (responders, 5.6 +/- 1.3 dB vs nonresponders, 5.1 +/- 3.5 dB, P = not significant; controls, 9.6 +/- 2.5 dB). Also, the percent fibrosis on right ventricular endomyocardial biopsy specimens showed no distinctions between these 2 groups (responders, 25.1% +/- 16.1% vs nonresponders, 24.9% +/- 15.0%, P = not significant). CONCLUSIONS: These findings suggest that left ventricular myocardial IB data, especially IB intensity, provide useful information for predicting the response to beta-blocker therapy in patients with DCM. However, right ventricular endomyocardial biopsy findings do not appear to contribute to discriminating between the 2 groups.

Solitary papillary muscle hypertrophy as a possible form of hypertrophic cardiomyopathy.

Patients can present with hypertrophied papillary muscles in the left ventricle, even without hypertrophy in other segments, and they have electrocardiographic (ECG) abnormalities suggestive of hypertrophic cardiomyopathy (HCM). This study was performed to evaluate whether the solitary papillary muscle hypertrophy was related to HCM. By analyzing 6731 echocardiographic studies between 1990 and 1994, the incidence of patients with papillary muscle hypertrophy was retrospectively examined, as well as the ECG features and family history related to HCM in these patients. After the normal size of the anterolateral and posteromedial papillary muscles was obtained from echocardiographic studies in 40 healthy subjects (0.7 +/- 0.2 cm for each of the vertical and horizontal axis), papillary muscle hypertrophy was defined as follows: either the vertical or horizontal diameter of at least one of the 2 papillary muscles was more than 1.1 cm (mean+2SD in the normal subjects). Using this definition, 29 patients with papillary muscle hypertrophy were identified, of whom 14 (48%) showed high voltage QRS complexes, 10 (34%) showed T wave inversion, and 6 (21%) showed abnormal Q waves. Ten patients (34%) had a family history of HCM. In 2 patients that were followed for 18 and 11 years, respectively, the voltages of the QRS complexes and inverted T waves progressed with the hypertrophy of the papillary muscle. These findings suggest that solitary papillary muscle hypertrophy is related to HCM and that papillary muscle hypertrophy is a newly identified subtype of or an early form of HCM.

Ratio of pulmonary venous to mitral A velocity is a useful marker for predicting mean pulmonary capillary wedge pressure in patients with left ventricular systolic dysfunction.

In patients with an elevated left ventricular filling pressure, the mitral A wave is diminished while the pulmonary venous A wave is augmented because of decreased left ventricular compliance. We examined whether an increase in the ratio of pulmonary venous to mitral A velocity might be a marker for an elevated mean pulmonary capillary wedge pressure. Forty-one patients who had left ventricular systolic dysfunction underwent transthoracic Doppler echocardiography simultaneously or within 24 hours of right heart catheterization. There were 29 men and 12 women 61 +/- 12 (mean +/- SD) years of age. Underlying heart disease was ischemic cardiomyopathy in 27 and nonischemic cardiomyopathy in 14 patients. The same Doppler-hemodynamic study was performed on 8 patients after optimal management of heart failure. The ratio of pulmonary venous to mitral A velocity correlated strongly with mean pulmonary wedge pressure (r = 0.72, P < .0001). When the cutoff value of the ratio was set at 0.5 or higher, the sensitivity for predicting a pulmonary capillary wedge pressure of 15 mm Hg or more was 88%, and the specificity was 80%. The serial Doppler-hemodynamic study showed that the ratio decreased markedly after treatment of heart failure. The value was 0.84 +/- 0.29 before treatment and 0.36 +/- 0.17 after treatment (P = .001). An increased ratio of pulmonary venous to mitral A velocity is a useful marker for elevated pulmonary capillary wedge pressure among patients with left ventricular systolic dysfunction.

Effect of beta-blocker treatment in dilated cardiomyopathy with bradyarrhythmias.

This study was performed to evaluate whether beta-blocker therapy was effective in patients with nonischemic dilated cardiomyopathy (DCM) and bradyarrhythmias supported by pacemaker implantation. Beta-blocker therapy is useful for some patients with DCM, especially those with rapid heart rate or residual nonfibrotic myocardium in the left ventricle, but no data exist on whether beta-blocker therapy is useful in patients with DCM and bradyarrhythmias. The effectiveness of beta-blocker therapy was prospectively evaluated in patients with DCM and bradyarrhythmias supported by pacemaker implantation and compared with those without these arrhythmias. Beta-blocker therapy was started in 63 patients (45 men, 18 women, aged 11-83 years) with DCM, in whom 7 had bradyarrhythmias and 56 did not. These bradyarrhythmias were atrioventricular block, sick sinus syndrome and atrial fibrillation with slow heart rate. Of the 56 patients without bradyarrhythmias, 42 (75%) (group 1) responded to beta-blocker therapy, but 5 of the 7 with bradyarrhythmias (71%) (group 2) also responded. Left ventricular end-diastolic dimension was reduced (6.5 +/- 0.6 cm to 5.6 +/- 0.5 cm; p < 0.0001 in group 1; 6.6 +/- 0.8 cm to 5.5 +/- 0.2 cm; p < 0.02 in group 2) and left ventricular fractional shortening was improved (13 +/- 4% to 27 +/- 7%; p < 0.0001 in group 1; 12 +/- 4% to 29 +/- 10%; p < 0.05, in group 2) to the same degree in both groups. These results indicate that beta-blocker therapy for DCM is effective not only in patients without bradyarrhythmias but also in those with bradyarrhythmias supported with pacemaker implantation.

A case of hypertrophic obstructive cardiomyopathy with localized upper septal hypertrophy: reduction of left ventricular outflow obstruction by dual-chamber (DDD) pacing.

A patient with localized upper septal hypertrophy and medically uncontrolled severe outflow obstruction is described. His outflow obstruction was controlled by the implantation of a dual-chamber (DDD) permanent pacemaker.

Assessment of left atrial appendage function after cardioversion of atrial fibrillation: relation to left atrial mechanical function.

Although several flow patterns in the left atrial appendage have been described, mechanical determinants of its function have not been elucidated in human beings. We attempted to investigate changes in left atrial appendage function after cardioversion of atrial fibrillation and examine the potential relation between appendage function and left atrial mechanical function. Twenty patients without mitral valvular disease underwent transesophageal and transthoracic echocardiography at 24 hours and 1 week after cardioversion of atrial fibrillation. Left atrial appendage function was assessed by the pulsed Doppler measurements of left atrial appendage emptying and filling velocities corresponding to early and late ventricular diastole, respectively. Left atrial mechanical function was evaluated by the transmitral A-wave velocity, percent atrial contribution of the total left ventricular filling (percent atrial filling), and the pulmonary venous A-wave velocity. Left ventricular function was also estimated with conventional M-mode echocardiography. The late appendage emptying and filling velocities markedly increased during 1 week after cardioversion (p < 0.0001, respectively). This finding was associated with an increase in left atrial mechanical function. Changes in the late emptying and filling velocities significantly correlated with changes in the transmitral A-wave velocity (r = 0.59, p < 0.01), percent atrial filling (r = 0.61, p < 0.005), and the pulmonary venous A-wave velocity (r = 0.56, p < 0.05). In contrast, little change was observed in the early emptying and filling velocities. There was no relation between the indexes of left ventricular function and those of appendage function. In conclusion, unless there was an alteration of the loading conditions, left atrial appendage function improved over several days after cardioversion, and its function was related to left atrial mechanical function.

Influence of altered loading conditions on left atrial appendage function in vivo.

This study sought to examine the influence of heart failure treatment on left atrial (LA) appendage function in 10 patients with left ventricular dysfunction. After treatment of heart failure, LA appendage function markedly improved, less dependent on LA and left ventricular functions, which suggests that with altered loading conditions, LA appendage function changes chiefly through its intrinsic contractile property.

Reversible left atrial dysfunction possibly due to afterload mismatch in patients with left ventricular dysfunction.

Limited data are available concerning the influence of altered loading conditions on left atrial (LA) function. In addition, the underlying mechanism of the augmentation of atrial filling (A) velocity (assessed by transmitral Doppler measurement) after treatment of heart failure has been less studied. Therefore, we examined various indexes of LA function during the depression of left ventricular (LV) filling pressure resulting from treatment of heart failure. Twelve patients with LV dysfunction (ejection fraction < 50%) underwent right heart catheterization and transthoracic echocardiography before and after optimal treatment of heart failure. LV/LA volume and ejection fraction and mitral and pulmonary venous flow velocities were measured. LV stiffness (substitute for LA afterload) was assessed by the ratio of LV filling pressure to LV end-diastolic volume. After treatment of heart failure, the mitral A velocity significantly increased (38 +/- 9 to 58 +/- 16 cm/sec, p < 0.005) and there was a distinct attenuation of the difference of the pulmonary venous and mitral A-wave duration (43 +/- 29 to -8 +/- 31 msec, p < 0.005). These findings were associated with a marked decrease in LV stiffness (0.12 +/- 0.04 to 0.05 +/- 0.02 mm Hg/ml, p = 0.0001) and an increase in LA ejection fraction (27% +/- 7% to 38% +/- 8%, p < 0.005). There was a significant curvilinear relation between LA ejection fraction and LV stiffness (r = 0.63, p < 0.01). The mitral A velocity correlated positively with LA ejection fraction (r = 0.77, p < 0.0001) and inversely with LV stiffness (r = -0.52, p < 0.01). The reversible LA dysfunction suggests that the initial LA dysfunction is due to LA afterload mismatch rather than intrinsic LA disease, which also contributes to the augmentation of the mitral A velocity after heart failure treatment.

Radioactivity in books printed in Japan: its source and relation to the year of issue.

The radioactivities of the naturally occurring radionuclides (226Ra, 228Ra, 228Th and 40K) and a fallout nuclide (137Cs) in books produced in Japan in the 20th century were measured by gamma-ray spectrometry to obtain information on radiation emitted from books. The respective concentration ranges of 226Ra, 228Ra, 228Th, 40K, and 137Cs were 0.2-6.4, 0.4-11.2, 0.3-11.3, 1-112, and 0-3 Bq kg-1. X-ray diffraction spectra of the papers used in book printing showed that pyrophyllite, talc, kaolinite, and calcium carbonate were contained as fillers. A comparison of the radioactivity contents of the pulp and filler indicated that most of 226Ra, 228Ra, and 228Th in the books was present in the filler whereas 137Cs was in the pulp. The pattern of the concentration of each nuclide vs. the year of issue of the book was investigated. Patterns for the naturally occurring radionuclides were similar and were explained by the kinds of filler used. The pattern for 137Cs differed from the patterns of the naturally occurring radionuclides, having a marked peak in the mid-1960s.

A case of adult T-cell leukemia/lymphoma, histologically presenting CD30-positive large cell lymphoma.

A 48-year-old Japanese woman with adult T-cell leukemia/lymphoma (ATLL), histologically presenting CD30-positive large cell lymphoma is reported. The patient, who was from an ATLL endemic area in Japan, had cutaneous nodules in the head, trunk, and extremities, and cervical lymph node swelling; these had been found three months before her admission to our hospital. A biopsy specimen of a skin lesion showed diffuse large cell lymphoma; the lymphoma cells were positively stained with CD30 (Ki-1/Ber H-2), CD4 (helper-T), and CD25 (interleukin-2 receptor) antibodies. Anti HTLV-1 antibody (ATLA) was detected in the serum, and molecular cytogenetic studies of lymphoma cells showed both positive T-cell receptor rearrangement and HTLV-1 specific DNA sequences.