Relationship between the angiotensin converting enzyme gene polymorphism and the effects of enalapril on left ventricular hypertrophy and impaired diastolic filling in essential hypertension: M-mode and pulsed Doppler echocardiographic studies

OBJECTIVE

To investigate the relationship between the angiotensin converting enzyme (ACE) gene polymorphism and the effects of the ACE inhibitor enalapril on left ventricular hypertrophy and impaired diastolic filling.

DESIGN AND METHODS

Enalapril (5-10 mg/day) was administered for 12 months to 60 previously untreated patients with essential hypertension. M-mode and pulsed Doppler echocardiography were performed before and after treatment, and changes in various parameters after treatment with enalapril were examined. ACE gene polymorphism was examined by the polymerase chain reaction method and the patients were classified as having the 190 bp deletion homozygous (DD) genotype, the 490 bp insertion homozygous (II) genotype or the 490 bp insertion 190 bp deletion heterozygous (ID) genotype.

RESULTS

The DD genotype was observed in 10 patients (17%), the ID genotype in 24 patients (40%) and the II genotype in 26 patients (43%). Plasma ACE activity before treatment with enalapril was significantly higher in seven patients with DD genotype than it was in 18 patients with ID genotype and in 14 patients with II genotype. In all of the 60 patients, the left ventricular mass index, the peak atrial systolic velocity:early diastolic velocity ratio and the deceleration time from the peak of the early diastolic wave to the baseline in transmitral flow velocity were decreased significantly after treatment with enalapril. The changes in left ventricular mass index and atrial systolic velocity:early diastolic velocity ratio after enalapril administration were significantly greater in the DD genotype group than they were in the other two genotype groups.

CONCLUSION

Enalapril-induced regression of left ventricular hypertrophy and improvement in left ventricular impaired diastolic filling were significantly greater in the DD genotype group than they were in the ID and II genotype groups, suggesting that the circulating and tissue renin-angiotensin systems, particularly the former system, are most active in hypertensive patients with the DD genotype.

The effect of oral 1 alpha-hydroxycalciferol treatment on bone mineral density in hemodialysis patients

We have studied the effect of different doses of 1 alpha-hydroxycalciferol (1 alpha [OH]D3) on bone mineral density (BMD) of 165 male hemodialysis patients (ages from 24 to 71 years) using dual X-ray absorptiometry (DXA) in a one-year follow-up study. There were no fractures in their lumbar spine participated in the study. 1 alpha (OH)D3 was administered orally at a low dose (0.25 microgram/day, n = 56, Group L) or at a higher dose (0.5 to 1.0 microgram/day, average 0.58 +/- 0.02 microgram/day, n = 65, Group H), and the absolute BMD values and the percent annual changes of BMD were compared with those who took no 1 alpha (OH)D3 (n = 44, Group N). BMD was measured three ways at the start and the end of the study; 1) lumbar spine BMD at anterior-posterior view (AP-BMD), 2) lumbar spine BMD at lateral view (Lat-BMD), and 3) 1/3 distal radius BMD. Plain spinal radiographs indicated no bone fracture before nor during the study. Although there were no detectable changes in the absolute values of BMD during the one-year period, significant differences were observed in the percent annual changes of lumbar spine BMD among the three groups. The annual changes of lumbar spine BMD among the three groups. The annual changes of AP-BMD were -0.4 +/- 0.7%, +0.1 +/- 0.6%, and +2.4 +/- 0.8% in Group N, Group L and Group H, respectively. These changes were statistically significant (p = 0.011 by one-way ANOVA). The positive effect of 1 alpha (OH)D3 on Lat-BMD was also significant (p = 0.028 by one-way ANOVA), while the treatment did not affect the change of BMD at 1/3 distal radius. There was no significant difference among the three groups in the initial or final levels of biochemical parameters including serum calcium, phosphorus, alkaline phosphatase, osteocalcin and parathyroid hormone. These results indicate, in male hemodialysis patients, that oral 1 alpha (OH)D3 treatment is effective in the prevention of lumbar spine BMD loss which is frequently observed in hemodialysis patients.

Influence of left atrial pressure on left atrial appendage flow velocity patterns in patients in sinus rhythm

To examine changes in left atrial appendage flow velocity patterns in relation to left atrial pressures during sinus rhythm, transesophageal echocardiography and cardiac catheterization were performed in 31 patients with myocardial diseases in sinus rhythm and 20 control subjects without cardiovascular disease. The 31 patients were divided into two groups according to mean pulmonary capillary wedge pressure: the group with high wedge pressure (19.9 +/- 5.8 mmHg) and the group with low wedge pressure (8.6 +/- 2.9 mmHg). The left atrial appendage peak early emptying velocity was decreased significantly in the groups with both high and low wedge pressure compared with the control group. The left atrial appendage peak late emptying velocity was significantly greater in the group with low wedge pressure compared with the control group, whereas it was decreased significantly in the group, with high wedge pressure compared with the control group. The left atrial appendage peak late emptying velocity had a significant negative correlation with wedge pressure. The maximum left atrial appendage area at end systole in the group with high wedge pressure was significantly greater than that in both the group with low wedge pressure and the control group. There was a significant positive correlation between the maximum left atrial appendage area and the wedge pressure, as well as a significant negative correlation between the left atrial appendage ejection fraction during atrial contraction and the wedge pressure. In the group with high wedge pressure, one patient had evidence of left atrial appendage thrombi and two had spontaneous echo contrast. These results suggest that even in patients in sinus rhythm, a marked elevation in the left atrial pressure is likely to reduce the left atrial appendage peak early and late emptying velocities. These changes may be accompanied by an increased incidence of thrombus formation in the left atrial appendage compared with individuals with normal or only slightly elevated left atrial pressures.

Relationship between pulmonary capillary wedge V wave and transmitral and pulmonary venous flow velocity patterns in various heart diseases

BACKGROUND

A large V wave in a pulmonary capillary wedge pressure (PCWP) tracing is characteristic of mitral regurgitation. However, the V wave is often increased in patients without or with no significant mitral regurgitation.

METHODS AND RESULTS

The V wave was in the PCWP tracing investigated in 65 patients using transmitral flow (TMF) and pulmonary venous flow (PVF) velocity patterns obtained by transesophageal pulsed Doppler echocardiography. A large V wave was defined if the peak V wave minus the mean PCWP (V-mPCWP) was greater than 7 mmHg. Three study groups were formed: 15 patients with large V waves and significant mitral regurgitation, 15 patients with large V waves with no significant mitral regurgitation, and 35 patients with small V waves. The mPCWP and left ventricular end-diastolic pressure were greatest in the group with large V waves and no significant mitral regurgitation. Peak early diastolic TMF and PVF velocities were significantly greater in the two groups with large V waves. The peak second systolic PVF velocity was lowest in the group with large V waves and significant mitral regurgitation, followed by the group with large V waves and no significant mitral regurgitation. The V-mPCWP was positively correlated with the peak early diastolic TMF and PVF velocities and negatively correlated with the peak second systolic PVF velocities. Additionally, mitral regurgitation severity in patients with large V waves and significant mitral regurgitation was positively correlated with the peak early diastolic TMF and PVF velocities and negatively correlated with the peak second systolic PVF velocity.

CONCLUSIONS

These results suggest that large V waves in PCWP tracings appear not only in severe mitral regurgitation, but also in any condition with markedly elevated left ventricular end-diastolic pressure. Combined analysis of the TMF and PVF velocity patterns is helpful in determining the etiology of these hemodynamic abnormalities.

[A case of gastric cancer with peritoneal dissemination and malignant biliary stenosis treated by loco-regional cancer therapy]

A 68-year-old male diagnosed as Borrmann 2 type gastric cancer (T3N3P3H0M0: Stage IVb) was treated by distal gastrectomy and administration of CDDP 50 mg+MMC 10 mg intraperitoneally. After operation intraperitoneal chemotherapy was continued until adhesional ileus occurred four months later. At reoperation peritoneal dissemination was not found either macroscopically or microscopically. After four months, and expandable metallic stent (Wallstent) was applied for malignant biliary stenosis due to lymph node metastasis. Although the patient died 23 months after the first operation, our loco-regional cancer therapy seemed effective for support of quality of life.

Possible mechanisms of mitral regurgitation in dilated hearts: a study using transesophageal echocardiography

HYPOTHESIS

This study was undertaken to clarify the mechanisms of mitral regurgitation (MR) in dilated hearts.

METHODS

In all, 68 patients with dilated heart and MR, including 26 patients with dilated cardiomyopathy (DCM), 24 with prior anterior myocardial infarction (A-MI), and 18 with prior posteroinferior myocardial infarction (I-MI), as well as 25 normal subjects were examined by transesophageal two-dimensional and color Doppler echocardiography.

RESULTS

The maximum area of the MR signal in the DCM group correlated positively with the anteroposterior diameter of the mitral annulus at late systole. Although the coaptation edge length of the anterior and posterior mitral leaflets appeared shorter in dilated hearts than in the hearts of controls, a significant difference did not exist. The length of the coaptation edge correlated negatively with the maximum area of the MR signal in all dilated hearts, and characteristic systolic displacement of the coaptation point of both mitral leaflets occurred. The MI groups demonstrated anterior and posterior displacement in the direction of the short axis of the left ventricle in the A-MI and I-MI groups, respectively. However, the DCM group demonstrated inferior displacement toward the long axis of the left ventricle; its magnitude correlated positively with the maximum area of the MR signal.

CONCLUSION

A major cause of MR in dilated hearts is mitral malcoaptation due to displacement of the coaptation point of the mitral leaflets along the long or short axis of the left ventricle. This is caused by left ventricular enlargement and/or asynergy of the left ventricular wall, rather than by a decrease in mitral coaptation edge length due to mitral annular dilation.

Renovascular hypertension with massive proteinuria

A 65-year-old woman with renovascular hypertension and massive proteinuria is reported. Her urinary protein ranged from 3 to 5 g/day. Serum potassium was 2.9 mEq/l. Plasma renin activity and plasma aldosterone concentration were very high. A CT scan disclosed atrophy of the left kidney. Renogram showed a non-functioning pattern of the left kidney. An abdominal aortogram showed complete occlusion of the left renal artery at its ostium. After left nephrectomy, her high blood pressure and urinary protein were normalized. It seemed that the massive proteinuria was mainly due to some endocrinological effect of the left kidney.

Detour factors in water and plastic phantoms and their use for range and depth scaling in electron-beam dosimetry

Average penetration depths and detour factors of 1-50 MeV electrons in water and plastic materials have been computed by means of analytical calculation, within the continuous-slowing-down approximation and including multiple scattering, and using the Monte Carlo codes ITS and PENELOPE. Results are compared to detour factors from alternative definitions previously proposed in the literature. Different procedures used in low-energy electron-beam dosimetry to convert ranges and depths measured in plastic phantoms into water-equivalent ranges and depths are analysed. A new simple and accurate scaling method, based on Monte Carlo-derived ratios of average electron penetration depths and thus incorporating the effect of multiple scattering, is presented. Data are given for most plastics used in electron-beam dosimetry together with a fit which extends the method to any other low-Z plastic material. A study of scaled depth-dose curves and mean energies as a function of depth for some plastics of common usage shows that the method improves the consistency and results of other scaling procedures in dosimetry with electron beams at therapeutic energies.

Peculiar patterns of aortic regurgitation and carotid pulse due to dysfunction of a Medtronic Hall prosthetic valve: a case report

We describe a patient with dysfunction of a Medtronic Hall prosthetic valve showing peculiar patterns of aortic regurgitation and carotid pulse caused by valvular thrombosis. The aortic regurgitation was considered to be caused by a significant delay in prosthetic valve closure, manifested by a peculiar regurgitation pattern limited to early diastole, in association with widely split closing clicks and an abnormally low dicrotic notch in the carotid pulse. At surgery, fibrin thrombi were noted just below the prosthetic ring in the minor outflow region which restricted disc movement. The fibrin thrombi were removed and the valve was rotated 90 degrees. Following reoperation, all abnormalities disappeared.

Influence of aging on left atrial appendage flow velocity patterns in normal subjects

Transesophageal pulsed Doppler echocardiography was performed to examine changes with age in the left atrial appendage flow velocity patterns in 50 normal subjects (15 to 80 years) in sinus rhythm. There was a significant negative correlation between the peak early diastolic forward and backward left atrial appendage flow velocities and age, as well as a significant positive correlation between the peak early diastolic forward left atrial appendage flow velocity and the peak early diastolic transmitral and pulmonary venous flow velocities. Although there was a significant positive correlation between the peak atrial systolic transmitral flow velocity and age, there was a negative correlation between the peak atrial systolic forward and backward left atrial appendage flow velocities and age. There was a positive correlation between both the maximum left atrial diameter and the amplitude of the interatrial septal motion during atrial systole and age. There was a significant negative correlation between the left atrial appendage ejection fraction during atrial systole and age. Left atrial appendage thrombi and spontaneous echo contrast were detected in two subjects with low peak early diastolic and atrial systolic left atrial appendage flow velocities. In conclusion, both peak early diastolic and atrial systolic left atrial appendage flow velocities decreased with age. A decrease in the peak atrial systolic flow velocity appeared to be an important sign of left atrial appendage thrombus formation even in normal elderly subjects in sinus rhythm.

Systolic and diastolic mitral regurgitation in a patient with annulo-aortic ectasia demonstrated by color Doppler flow imaging

A rare case of annulo-aortic ectasia is reported in a 65-year-old man who had aortic and mitral regurgitation during systole and diastole. He was hospitalized for further examination of the heart due to cardiomegaly and heart murmurs. Aortography revealed severe aortic regurgitation. On color Doppler flow imaging, we could detect red aortic regurgitant signals in the left ventricular cavity during diastole, and mosaic and blue mitral regurgitant signals in the left atrial cavity during systole and diastole associated with a relatively long R-R interval, respectively. The unique observation of diastolic mitral regurgitation is discussed.

Assessment of left atrial pressure and volume changes during atrial systole with transesophageal pulsed Doppler echocardiography of transmitral and pulmonary venous flow velocities

To determine whether transmitral and pulmonary venous flow velocity patterns can be used to evaluate left atrial pressure and volume changes during atrial systole, we performed transesophageal pulsed Doppler echocardiography and right heart catheterization in 85 patients (20 with hypertrophic cardiomyopathy, 20 with dilated cardiomyopathy, 30 with prior myocardial infarction, and 15 with mitral regurgitation), and 35 normal subjects. Pulsed Doppler variables from transmitral and pulmonary venous flow velocities during atrial systole were compared with mean pulmonary capillary wedge pressure (mean PCWP), pressure rise during atrial systole (PCWP-A), and left atrial volume change during atrial systole (delta LAV). The mean PCWP correlated significantly with the peak atrial systolic transmitral flow (r = -0.38, p < 0.05) and pulmonary venous flow (r = 0.40, p < 0.05) velocities in all patients. The PCWP-A correlated significantly with the peak atrial systolic transmitral flow (r = -0.39, p < 0.05) and pulmonary venous flow (r = 0.68, p < 0.0001) velocities in all patients. There was a particularly close correlation between the PCWP-A and the peak atrial systolic pulmonary venous flow velocities. The sum of the time-velocity integral of the atrial systolic transmitral and pulmonary venous flow velocities (TAI) correlated closely with the delta LAV (r = 0.70, p < 0.0001) in all patients. Thus, the peak atrial systolic pulmonary venous flow velocity correlated well with left atrial pressure changes during atrial systole. Furthermore, the sum of the time-velocity integral of the atrial systolic transmitral and pulmonary venous flow velocities correlated well with left atrial volume changes during atrial systole. Therefore, transesophageal echocardiographic measurements of atrial systolic transmitral and pulmonary venous flow velocities are reasonable indicators of left atrial pressure and volume changes during atrial systole.

Differences in IgM synthesis to gut bacterial peptidoglycan polysaccharide after burn injury and gut ischemia

Both burn injury and intestinal ischemia have been proven to induce bacterial translocation from the gut. It is still unknown, however, whether the bacteria induces immune response in these different models. To assess this, we measured in vitro IgM synthesis to peptidoglycan polysaccharide (PGPS), a ubiquitous gut bacterial antigen, after burn injury or gut ischemia-reperfusion in a mouse model. Eighty-five BALB/c mice were divided into four groups. Gut ischemia was produced by placing a vessel loop around the superior mesenteric artery at celiotomy (group Isc; n = 31). After 45 minutes, the abdomen was reopened, and the vessel loop removed. All animals had visible gut ischemia. Control mice (group Isc-C; n = 15) underwent two sham operations. Burn injury was 25% body surface area full-thickness to the dorsum (group B; n = 27). Another control group (B-C; n = 12) was also used. Animals were euthanized 24 hours after recirculation or 5 days after the burn injury. All spleens were removed, and cell suspensions prepared. Cells were cultured in 2.5 micrograms/ml lipopolysaccharide for 5 days, and anti-PGPS IgM level in the supernatant was measured by an enzyme-linked immunosorbent assay. Intestinal ischemia produced a significant rise in in vitro anti-PGPS IgM synthesis per 10(5) lymphocytes, which is the principal immunoglobulin response to infection. However, anti-PGPS IgM in mice after burn injury was significantly decreased. This decreased IgM synthesis after burn injury compared to gut ischemia may represent continued immune impairment from the burn wound, and may account for organ dysfunction related to bacterial translocation after burn injury.

Transient and sustained depolarization of retinal ganglion cells by Ih

1. Using whole cell patch-clamp methods, we have identified an inward cationic current activated by hyperpolarization (Ih) in somata of goldfish retinal ganglion cells. 2. Ih activated at test potentials between -70 and -105 mV, and did not appear to inactivate during prolonged hyperpolarizations under voltage clamp. During step hyperpolarizations from holding potentials between -70 and -40 mV, apparent activation was faster at more negative test potentials. On repolarization from -105 mV to holding potentials between -75 and -55 mV, Ih deactivated exponentially at rates showing no marked voltage dependence (tau = approximately 100 ms). 3. Ih tail currents reversed at membrane potentials consistent with a relative permeability to Na+ and K+ of roughly 0.5, when pipette and bath solutions both contained Na+ and K+. 4. Ih was readily blocked by extracellular Cs+ (3 mM), but was resistant to block by tetraethylammonium (30 mM), Ba2+ (1 mM), or Co2+ (2.4 mM). 5. Time-dependent voltage rectification developed during injection of hyperpolarizing current under current clamp. After current injection ceased, membrane potential depolarized beyond resting potential, often leading to anode-break-like spikes. Both voltage rectification and voltage overshoot were suppressed by extracellular Cs+. 6. Voltage-clamp measurements in the presence and absence of Cs+ were used to model membrane potential changes produced by exogenous current injections, by hyperpolarizing synaptic inputs, and by termination of both. Modeled responses resembled membrane potential changes measured under current clamp when terms for activation and deactivation of Ih were included. 7. The voltage rectification and anode-break-like spikes observed in isolated cells resemble those recorded during and after light-evoked hyperpolarizations of retinal ganglion cells in situ. Ih may transiently augment retinal ganglion cell excitability after termination of hyperpolarizing light stimuli, and thus promote encoding of stimulus timing.

[A study of surgical treatment in lung cancer over 75 years of age-effect of epidural anesthesia for protection of postoperative coughing disturbance]

29 patients over 75 years of age in 221 patients undergoing resection of lung cancer from January of 1990 through December of 1994 were studied for the occurrence of expectoration disturbance (atelectasis), the effect of epidural anesthesia for protection of it. Atelectasis was observed in 8 (27.6%) of 29. In a group received epidural anesthesia (EA) during the early postoperative phase, 1 of 5 patients developed atelectasis. In 192 patients below 75 years of age, atelectasis was observed in 40 (20.8%) of them, so in a group received epidural anesthesia (EA) during the early postoperative phase, only 2 of 42 patients (4.8%) developed atelectasis. This value was significantly lower than that value (25.3%) in a group without EA. In conclusion, in the group below 75 years of age, EA during the early postoperative phase may be useful in inhibiting the occurrence of atelectasis, an important one of the postoperative lung complications.

Omega-conotoxin-MVIID blocks an omega-conotoxin-GVIA-sensitive, high-threshold Ca2+ current in fish retinal ganglion cells

Reduction of Ca2+ current amplitude by the Conus peptide omega-conotoxin-MVIID (omega-CTx-MVIID) was measured in voltage-clamped, goldfish retinal ganglion cells. Effects of depolarizing shifts in holding potential, and sequential applications of omega-CTx-MVIID, omega-CTx-GVIA, and BAY-K-8644, together with effects of Ni2+ and omega-Aga-IIIA, indicated that omega-CTx-MVIID may target Ca2+ channels differing from those termed T, L, N, P < Q and R.

Hepatitis C biochemical remission and viral replication in haemodialysis patients

The natural course of non-A, non-B (type C) hepatitis was studied in 62 haemodialysis patients. From the onset of the disease, serum alanine aminotransferase levels were monitored monthly for 9-218 mon (median 115). After fluctuation of aminotransferase levels for 1-206 mon (median 39), 57 (92%) patients showed normalization of these levels lasting until the end of the follow-up, which was for > 2 yr in 31 (50%) cases and for > 5 yr in 15 (24%) cases. At the end of follow-up, hepatitis C viraemia was assessed by reverse transcription-polymerase chain reaction (RT-PCR) and branched DNA (bDNA) assay. Viraemic levels were significantly lower in the 15 patients with normal aminotransferase for > 5 yr (median RT-PCR + ve/bDNA-ve, range RT-PCR-ve to 10(6.7) Eq/mL) than in the 47 cases with normal levels for < 5 yr (median 10(6.6), range RT-PCR + ve/bDNA-ve to 10(7.6) Eq/mL) (P < 0.01). Moreover, a significant inverse relation was observed between viraemic levels and the duration of aminotransferase normalization (r = -0.46, P < 0.01). These findings indicate that biochemical remission of hepatitis C may be frequent in haemodialysis patients and may be related to viral attenuation.

Transesophageal pulsed Doppler echocardiographic study of pulmonary venous flow in mitral stenosis

For evaluation of pulmonary venous flow (PVF) in mitral stenosis, transthoracic and transesophageal echocardiography were performed in 33 patients with mitral stenosis and 20 normal controls. The peak systolic flow velocity of the PVF was significantly lower in patients with mitral stenosis and atrial fibrillation. The peak diastolic flow velocity of the PVF was significantly lower in the patients with mitral stenosis than in normal controls. The diastolic wave recorded as laminar flow in the mitral stenosis group showed a peak in the rapid filling phase with a gradually descending slope of velocity during mid to late diastole. There was a significant negative correlation between the peak diastolic flow velocity of the PVF and the pressure half time from transmitral flow obtained by continuous wave Doppler in the mitral stenosis group. These results demonstrate that evaluation of the PVF is helpful in understanding hemodynamic events between the left atrium and left ventricle in patients with mitral stenosis.

Changes in transmitral and pulmonary venous flow velocity patterns after cardioversion of atrial fibrillation

To examine the recovery time of left atrial mechanical function after electrical cardioversion of atrial fibrillation, we recorded transmitral flow, pulmonary venous flow velocities, and interatrial septal motion during atrial systole within 24 hours (16 +/- 5 hours) and 10 days after cardioversion in 25 patients with atrial fibrillation, including 6 patients with hypertension, 4 with ischemic heart disease, 2 with alcoholic heart disease, 5 with dilated cardiomyopathy, and 8 with no evidence of underlying heart disease. With the exception of the five patients with dilated cardiomyopathy, the peak atrial systolic transmitral and pulmonary venous flow velocities, peak first systolic velocity of pulmonary venous flow, duration of both atrial systolic waves, and amplitude of the interatrial septal motion during atrial systole decreased markedly within 24 hours after cardioversion and increased 10 days after cardioversion. These results suggest that active atrial systolic and relaxant variables obtained from transmitral and pulmonary venous flow velocities may reflect left atrial mechanical function after cardioversion of atrial fibrillation.

Clinical significance of the apical late systolic ejection murmur: a new phonocardiographic sign indicating dynamic mid-left ventricular obstruction

Systolic ejection murmurs of the left heart usually have their peak during early to mid-systole. Few reports have addressed ejection murmurs with their peak at late systole. We evaluated the clinical significance of an apical systolic ejection murmur with a peak intensity during late systole using Doppler and two-dimensional (2-D) echocardiography and phonocardiography. The apical late systolic ejection murmur was observed in 9 of 13 consecutive patients with mid-left ventricular obstruction. We investigated the ejection flow velocity and the timing of maximum velocity at the three different sites of the left ventricle, the left ventricular cavity shape, and the timing of the peak murmur intensity in these nine patients (late-murmur group). The same parameters were also examined in 8 consecutive patients with mid-systolic ejection murmurs (mid-murmur group), 10 with early systolic ejection murmurs (early-murmur group), and 7 controls without murmurs. Patients with aortic stenosis were excluded. The mid-ventricular ejection flow velocity was significantly higher in the late-murmur group than in the other three groups; that of the outflow tract was markedly higher in the mid-murmur group. The ejection flow velocity at the aortic orifice of patients in the early-murmur group was significantly high compared with that of the controls. The timing of the peak murmur intensity in each group correlated with that of the peak flow signal at the corresponding site with maximum velocity. In all patients in the late-murmur group, 2-D echocardiography revealed a systolic narrowing of the cavity at the mid-ventricle. Amyl nitrite inhalation induced a marked increase in the intensity of the murmur without evidence of appearing or increasing mitral regurgitation. It was concluded that the apical ejection murmur with a late systolic peak intensity is a new phonocardiographic sign indicative of dynamic, mid-left ventricular obstruction. This murmur should be differentiated from the mitral regurgitant murmur.

Parturition in six renal allograft recipients

Between 1983 and 1994, we studied renal function and neonatal conditions for eight pregnancies and births to six women who had received renal transplants in order to assess the effect of an allograft on pregnancy and its outcome. The gestation period was 34 to 39 weeks (mean 36 weeks and 4 days), and four pregnancies ended before term. All eight babies were delivered by cesarean section. Intrauterine growth retardation (IUGR) was found in both babies of one woman who had been treated with conventional (without cyclosporin) immunosuppression. The serum creatinine level did not change during gestation in any of the women but was elevated after delivery in four. Four mothers suffered from proteinuria (25-364 mg/dl) during gestation, but the proteinuria disappeared after delivery in all but one case. The one exception, persistent proteinuria of 100-200 mg/dl, was assumed to result from the recurrence of the original renal disease (lgA nephropathy). The reduction of creatinine clearance and hydronephrosis of one graft noted during gestation were later reversed. None of the eight babies (four females and four males) was congenitally malformed, and their Apar scores were 6 to 9 (median 8). They are now 3 months to 11 years old, and seven of them are healthy and show good growth. One of the two IUGR babies has not grown well; her weight and height are more than 1 SD below the mean for her age, and she is mentally retarded and suffers from muscle weakness. Compared with dialysis patients, female renal allograft recipient have a better quality of life because they can safely deliver a child if they observe the criteria for pregnancy established for renal allogaft recipients.

[Evaluation of myocardial sympathetic nerve function in patients with mitral valve prolapse using iodine-123-metaiodobenzylguanidine myocardial scintigraphy]

Mitral valve prolapse (MVP) is closely related to myocardial sympathetic nerve function. This study evaluated the presence of impaired myocardial sympathetic nerve function by Iodine-123-metaiodobenzylguanidine (MIBG) scintigraphy in nine patients with MVP. For comparison, 15 healthy subjects without heart disease were investigated (control group). Single photon emission computed tomography (SPECT) and anterior planar myocardial scintigraphy were performed 15 min (initial images) and 3 hours (delayed images) after injection of MIBG (111 MBq). The location and degrees of reduced tracer uptake were evaluated. Myocardial MIBG uptake was quantified by uptake ratio of the heart (H) to upper mediastinum (M) on the anterior planar images (H/M). Percentage washout of MIBG in nine sectors of all oblique slices along the short-axis was calculated. The washout rates were higher at the inferoposterior and septal segments in patients with anterior leaflet prolapse, and at inferoposterior and lateral segments in patients with posterior leaflet prolapse. The bull's eye map showed increased washout rate in the apical and posteroseptal basal segments. There was no significant difference in the H/M ratio between MVP patients and the control group. These results indicate that MIBG can be used to evaluate localized myocardial sympathetic nerve function in MVP.