Imatinib plasma concentrations during long-term effective treatment of metastatic gastrointestinal stromal tumor

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Background: Imatinib concentrations at one month after the start of imatinib have shown an association with clinical benefit in pts with gastrointestinal stromal tumors (GISTs) and a significant decrease of 30% within twelve months. This retrospective study investigated imatinib plasma concentrations in pts with metastatic GISTs in a long-term (≥2 years) effective treatment. Methods: 31 metastatic GIST pts, who had been treated with imatinib for two or more years in our hospital, were enrolled in this study. 11 pts were excluded because of adjuvant setting (n=5) and rejection to concentration testing (n=6). 20 pts were included in this study. GISTs were immunohistochemically diagnosed, and radiologically assessed as effective GIST by Choi’s criteria without relapse. Results: 10 pts were male, median age was 63 years (range, 31-84), and median imatinib exposure time was 3.5 year (range, 2-12). The median plasma concentration was 1093 ng/ml (range, 417-2091) and minimal level after at least five years was 789 ng/ml. imatinib concentration has no significant correlation with age, gender, gastrectomy, leukocyte count, platelet count, serum albumin, serum creatinine, cholesterol, and duration of imatinib exposure. Body surface area (BSA) isn’t directly associated with imatinib dose; median BSA of pts taking 300mg imatinib was 1.560 m2 and that of 400mg 1.595 m2, but minimal BSA of 400mg imatinib was 1.560 m2, which is higher than the minimum of 300mg. Conclusions: Plasma concentrations of long-term (≥2 years) response pts was scattered, but one of longer-term (≥5 years) response pts were more than 789 ng/ml. Effective imatinib plasma level might be more than 789 ng/ml and 400mg imatinib may be recommended for a pt with BSA(≥1.56 m2).

Cyclooxygenase-2 expression is related to prognosis in patients with esophageal squamous cell carcinoma

AIM

Esophageal carcinoma is one of the most aggressive malignancies. Many studies have examined various biological factors associated with the malignant potential of esophageal carcinoma. Cyclooxygenase (COX)-2 is overexpressed in various types of human malignancies, including esophageal carcinomas. Although some groups have described COX-2 expression in esophageal adenocarcinoma, few studies have reported COX-2 expression in esophageal squamous cell carcinoma (ESCC).

METHODS

We immunohistochemically investigated relationships between COX-2 overexpression in surgical specimens of primary tumors in 228 patients with ESCC. Relationships between COX-2 expression and clinicopathological factors, including prognosis, were analyzed. COX-2 expressions were classified into 4 criteria: Score 0, no staining; Score 1, <10% staining; Score 2, 10-90% staining; and Score 3, >90% staining.

RESULTS

Scores of COX-2 immunoreactivity in 228 patients were as follows: Score 0, 21 of 228; Score 1, 71of 228; Score 2, 117 of 228; and Score 3, 19 of 228, respectively. COX-2 expression was significantly correlated with depth of invasion and tumor stage (p=0.03 and p=0.04, respectively). The 5-year survival rate of patients decreased significantly with increased expression of COX-2 (p=0.005). Multivariate regression analysis indicated COX-2 expression as an independent prognostic factor for ESCC.

CONCLUSIONS

COX-2 overexpression was significantly correlated with depth of invasion, tumor stage and survival in ESCC. Evaluation of COX-2 expression should be useful for determining tumor properties, including prognosis, in patients with ESCC.

Randomized controlled study on preoperative chemoradiotherapy followed by surgery versus surgery alone for esophageal squamous cell cancer in a single institution

The purpose of the present study was to compare the clinical results between preoperative chemoradiotherapy followed by surgery (CRT group) and surgery alone (Surgery group) by a randomized controlled study. Twenty-two patients were assigned to the CRT group and 23 to the Surgery group. A total radiation dose of 40 Gy was applied and in the same period, intravenous chemotherapy was performed using cisplatin (7 mg over 2 h) and 5-fluorouracil (5-FU; 350 mg over 24 h). Surgical treatment was performed in 20 patients in the CRT group except for two patients with bone metastasis after CRT. According to histological effects of primary tumors, the number of patient with Grades 1, 2 and 3 was 11, 7 and 3, respectively. Frequency of lymphatic and venous invasion was significantly lower in the CRT group than in the Surgery group. The 5-year survival rate was 57% in the CRT group and 41% in the Surgery group (P = 0.58). According to the histological effect in the CRT group, 5-year survival was 30% for Grade 1, 83% for Grade 2 and 100% for Grade 3 (P = 0.0069). This randomized trial did not demonstrate a statistically significant survival difference between the CRT group and the Surgery group.

Expression of osteopontin in oesophageal squamous cell carcinoma

Osteopontin is a multifunctional 34 kDa extracellular matrix protein with a cell-binding domain. It is involved cell adhesion and cell migration and is therefore considered to influence tumorigenesis and/or metastasis. The purpose of the present study was to evaluate the clinical significance of Osteopontin expression in oesophageal squamous cell carcinoma (ESCC). In the present study, we immunohistochemically investigated the relationship between Osteopontin expression and clinicopathological factors including prognosis in surgical specimens of primary tumours in 175 patients with ESCC. Osteopontin was expressed in 48% of 175 patients. Osteopontin expression was significantly correlated with lymph node metastasis, lymphatic invasion, and stage (P=0.0015, 0.037 and 0.033, respectively). Tumours with expressing Osteopontin exhibited more lymph node metastasis, lymphatic invasion and advanced stage than the tumour with negative Osteopontin expression. Five-year survival rate was better in patients with negative Osteopontin expression than in those with positive Osteopontin expression (P=0.035). However, multivariate analysis revealed that Osteopontin expression was not an independent prognostic factor. As our findings suggest that Osteopontin may play an important role in progress of ESCC, the evaluation of Osteopontin expression is useful for predicting the malignant properties of ESCC.

The role of salvage surgery for recurrence of esophageal squamous cell cancer

AIM

A consensus treatment strategy for recurrent esophageal squamous cell cancer (ESCC) has not been established. The purpose of the present study was to analyse the mode of recurrence, and evaluate the role of surgical salvage treatment in recurrence of ESCC.

METHODS

Recurrence was detected in 131 of 367 consecutive patients with ESCC. We retrospectively analysed the mode of recurrence and treatment for recurrence. Recurrence was divided into four types; lymph node, hematogeneous, mixed and local. Treatments were classified into four groups; chemotherapy alone (C group), radiation therapy +/- chemotherapy (R group), surgery +/- other therapy (S group), and no therapy (N group).

RESULTS

Of the 131 recurrences, the number of patients with lymph node, hematogeneous, mixed and local recurrence was 43, 44, 40 and 4, respectively. The number of patients in the C, R, S, N groups was 35, 35, 24 and 37, respectively. Of the 24 patients who received surgical treatment for recurrence, the number of patients with lymph node, hematogeneous, mixed and local recurrence was 11, 6, 6 and 1, respectively. The number of lesions in hematogeneous recurrence was 2 or less. The survival rate from recurrence to death in the C, R, S and N groups was 0, 3.9, 6.7 and 0%, respectively. A statistically significant difference was found in these groups (p < 0.0001).

CONCLUSIONS

Salvage surgery is one of the useful treatment tools for resectable metastatic lesions. In such cases, the number of lesions, recurrent sites and effectiveness of chemotherapy and/or radiotherapy should be carefully evaluated.

Effect of tolerance induction to immunodominant T-cell epitopes of Sendai virus on gene expression following repeat administration to lung

Sendai virus (SeV) is able to transfect airway epithelial cells efficiently in vivo. However, as with other viral vectors, repeated administration leads to reduced gene expression. We have investigated the impact of inducing immunological tolerance to immunodominant T-cell epitopes on gene expression following repeated administration. Immunodominant CD4 and CD8 T-cell peptide epitopes of SeV were administered to C57BL/6 mice intranasally 10 days before the first virus administration with transmission-incompetent F-protein-deleted DeltaF/SeV-GFP. At 21 days after the first virus administration, mice were again transfected with DeltaF/SeV. To avoid interference of anti-GFP antibodies, the second transfection was carried out with DeltaF/SeV-lacZ. At 2 days after the final transfection lung beta-galactosidase expression, T-cell proliferation and antibody responses were measured. A state of 'split tolerance' was achieved with reduced T-cell proliferation, but no impact on antiviral antibody production. There was no enhancement of expression on repeat administration; instead, T-cell tolerance was, paradoxically, associated with a more profound extinction of viral expression. Multiple immune mechanisms operate to eradicate viruses from the lung, and these findings indicate that impeding the adaptive T-cell response to the immunodominant viral epitope is not sufficient to prevent the process.

Endoscopic quadrantectomy for breast cancer with sentinel lymph node navigation via a small axillary incision

A great deal of clinical experience has firmly established the concept of the sentinel lymph node (SN) in breast cancer. SN biopsy allows treatment without axillary lymphadenectomy and has made it possible to perform a surgical intervention via just a small skin incision. In partial resection of the breast (quadrantectomy), we use a double retractor to form a workspace under the skin via a small axillary incision. Resection does not require a large incision even in cases in which the cancer lesion is located in the upper inner or lower inner quadrant of the breast, as the endoscope allows the surgeon to see the workspace formed by the double retractors.

A study of relationship between multifocal VEF responses and binocular disparity

Multifocal visual evoked magnetic field (mfVEF) is useful for shortening the measurement time and/or improving the signal-to-noise ratio of recording, in investigating cortical activities elicited by multiple stimulus patches across the visual field. To record the whole-head mfVEF, we previously developed custom software to deliver multifocal stimuli and to analyze the acquired data, and we applied it to investigation of stereopsis. In the present study, relationship between mfVEF responses and binocular disparity was investigated. Subjects were instructed to fixate a nonius line in the center of a screen, and they were presented with rapid alteration of random-dot (RD) patches. The experiments consisted of a luminance change condition (condition L) and seven binocular disparity conditions (condition BDs) ranging from a crossed disparity of 1 deg to an uncrossed disparity of 1 deg. Each response evoked by one of the RD patches was obtained with the multifocal technique. Although all subjects showed obvious responses in the condition L, only one of the subjects showed obvious responses in condition BDs. The sources of the responses recorded in condition BDs were mainly localized around calcarine sulci according to the known retinotopic cortical representation. The responses obtained in condition BDs showed dependence on binocular disparity in the magnitude and the latency. These results would be the basis for further analysis of brain magnetic responses related to stereopsis.

The ultrasonic coagulating and cutting system injures nerve function

BACKGROUND

Although, many surgeons have used ultrasonic coagulating and cutting systems and shears (LCS) when carrying out endoscopic thyroidectomies and parathyroidectomies, in our experience some patients had temporary paralysis of the recurrent laryngeal nerve (RLN) after these operations. We had sometimes noticed that the heat of the blade of the LCS was increased just after use; therefore, we designed an RLN model, and investigated the damage to the RLN which could be attributed to the heat of the LCS.

METHODS

We investigated the effects of the heat of the LCS blade on rat femoral and sciatic nerves, using temperature measurement, histological examination and evoked electromyography.

RESULTS

The temperature of the LCS blade exceeded 150 degrees C after 30 seconds when it was not used for cutting. When we used the LCS to cut rat muscle or fat tissue, the temperature of the blade exceeded 100 degrees C after 20 seconds. There was no damage to the nerve histologically when the LCS was used for less than 20 seconds at a distance of 3 mm. Electrophysiological study showed that touching the nerve with the LCS blade after only 5 seconds of use resulted in damage to the nerve.

CONCLUSIONS

Our results suggest that the RLN should not be touched directly with the blade just after it has been used, and that it is possible to use the LCS at a distance of 3 mm from the RLN for less than 20 seconds at level 3. In order to maintain these distances, the RLN must be endoscopically visualized during surgery of the neck.

Endothelial cells potentiate phagocytic killing by macrophages via platelet-activating factor release

The immunomodulatory function of endothelial cells (EC) includes the initiation of leukocyte margination, diapedesis, and activation through the upregulation of various cell surface-associated molecules. However, the effect that EC have on the phagocytic function of neighboring monocytes and macrophages is less well described. To address this issue, microvascular EC were cocultured with murine peritoneal macrophages, first in direct contact, then in a noncontact coculture system, and macrophage phagocytosis and phagocytic killing were assessed. The presence of increasing concentrations of EC resulted in a dose-dependent increase in macrophage phagocytic killing. This stimulatory effect was inhibited in a dose-dependent manner by the pretreatment of macrophage/EC cocultures with WEB-2086 or CV-6209, specific platelet-activating factor (PAF)-receptor antagonists, but not by anti-tumor necrosis factor-alpha, anti-interleukin (IL)-1alpha, or anti-IL-1beta. Furthermore, the effect was reproduced in the absence of EC by the exogenous administration of nanomolar concentrations of PAF. Microvascular EC potentiate macrophage phagocytic killing via the release of a soluble signal; PAF appears to be an important component of that signal.

Automated determination of 5-fluorouracil and its metabolite in urine by high-performance liquid chromatography with column switching

We report a quantitative assay of 5-fluorouracil (FU) and its metabolite, 5-fluorodihydrouracil (FDHU) in human urine by used a column-switching high-performance liquid chromatographic method. The analyses were carried out using a molecular exclusion column for sample purification, and a cation-exchange column for separation. Each sample required only 40 min to analyze, and required no preparation other than filtration. Linearity was verified up to 1000 nmol/ml (r > 0.993). The recovery of FU was 96-101%; recovery of FDHU was 96-105%. The imprecision (RSD) for FU (10-100 nmol/ml) was < 1.5%, same-day (n = 5), and < 1.8%, day-to-day (n = 5). The imprecision (RSD) for FDHU (10-100 nmol/ml) was < 3.2%, same-day (n = 5), and < 4.0%, day-to-day (n = 5). The detection limits were, respectively, 0.1 nmol/ml. We measured FU and FDHU in urine of seven cancer patients after oral administration of FU. The cumulative quantity ratio of the FDHU and FU (FDHU/FU) excreted in their urine within 120 min after FU administration was a constant value in all seven patients. Based on these results, we believe that our method provides a useful tool for evaluating FU metabolism.

Endothelial cells potentiate oxidant-mediated Kupffer cell phagocytic killing

Phagocytosis and killing of circulating organisms by Kupffer cells (KCs) are discrete, important components of host defense. However, the killing mechanism(s) are not fully understood, and the potential role of adjacent nonparenchymal cells such as hepatic endothelial cells has not been defined. Rat KCs -/+ an hepatic endothelial cell enriched cellular fraction (HECEF) were incubated with Candida parapsilosis and assayed for phagocytosis and phagocytic killing by validated fluorochromatic vital staining. The role of reactive oxygen metabolites in KC phagocytic functions was examined by inhibition with superoxide dismutase and/or catalase. Diphenyleneiodonium and allopurinol were used to examine the potential roles of NADPH oxidase and xanthine oxidase, respectively, in generating these toxic oxidants. Coculture with HECEF increased KC phagocytic activity (from 75% to 88%) and candidacidal activity (from 20% to 31%). Superoxide dismutase, catalase, diphenyleneiodonium, or allopurinol caused inhibition of candidacidal activity, but did not affect phagocytosis, and did not block the potentiation of phagocytosis or of killing caused by coculture with HECEF. Reactive oxygen intermediates generated by both NADPH oxidase and xanthine oxidase-dependent pathways are important in KC killing of Candida parapsilosis. In vitro, KC phagocytosis and killing are potentiated (via a non-oxidant-mediated mechanism) by coculture with a preparation of hepatic non-parenchymal cells composed primarily of endothelial cells.

Study of needlestick accidents and hepatitis C virus infection in healthcare workers by molecular evolutionary analysis

In the five-year period between 1989 and 1993, 87 needlestick accidents occurred among healthcare workers at our hospital. Thirty-seven (43%) of these needlestick accidents involved blood contaminated with hepatitis C virus (HCV), and two of them (5.4%) led to the occurrence of hepatitis C infection. Case 1 was a 43-year-old nurse who was accidentally injured by a needle contaminated with blood from a patient who had cirrhosis and hepatocellular carcinoma due to hepatitis C. Acute hepatitis C occurred after five weeks and HCV RNA was positive after eight weeks. Case 2 was a 33-year-old nurse who was injured by a needle contaminated with blood from a patient who had chronic hepatitis C. Liver function was normal at 11 days after the accident. However, hepatitis C was diagnosed 21 months later after she had successfully given birth to her baby. The nucleotide sequence of the HCV E2/NS1 region was determined in the two patients and the needlestick victims, and phylogenetic trees were constructed by molecular evolutionary analysis. On the basis of these trees, transmission of HCV could be confirmed in both cases. This method of analysis may be useful for confirming the transmission of HCV even long after the event.

[7 years of annual mass screening for colorectal cancer in office workers--usefulness of 3-day RPHA method]

Immunological fecal occult blood test have been proved to be useful in the mass screening for colorectal cancer. Since 1986, we have started annual mass screening by the use of 3-day RPHA method and medical questionnaire for office workers over 40 yr old. During 7 yr, 261 out of 5386 examinees were testing positive for fecal occult blood, a test positive rate was 4.8% and 12 colorectal cancer (7: early, 5: advanced) were found. Among 12 cases, 10 were detected by positive results of RPHA test and 2 by questionnaires of symptoms or family history. The sensitivity and specificity of this method were calculated at 83.3% and 95.3% respectively. But as for advanced cancers, the sensitivity of this method was 100%. 75% of patients with colorectal cancer were over 55 yr old. The predictive value of positive test (PV) were much more higher in subjects with 2 or 3 times test positive (high risk group: PV = 14.3%) than in subject with only 1 time test positive (low risk group: PV = 0.6%). So it is considered to be reasonable that the high risk group (24% of total test positive) should be immediately undergone further examinations (Ba. enema or colonoscopy), and the low risk group should be undergone re-examinations of 3-day RPHA method. By this system, almost 50% of further examinations will be reduced. In conclusion, 3-day RPHA method with this further examination system is reasonable and efficient for screening of colorectal cancer in office workers, considering the high reliability in cancer detection and decreased further examinations.

Clinical application of transvenous mitral commissurotomy by a new balloon catheter

A new balloon catheter was developed which allows mitral commissurotomy without thoracotomy. The procedure has been successful in five of the six patients with mitral stenosis so treated. In the remaining patient, the procedure could not be performed because of technical difficulties. The balloon is reinforced with a nylon micromesh and its shape changes in three stages, depending on the extent of inflation. It is inserted from the saphenous vein into the mitral orifice transseptally, fixed across the mitral orifice with partial inflation, and finally inflated to full its extent, separating the fused commissures by its expansile force. After the procedure, catheterization revealed a significant reduction in the mean diastolic pressure gradient across the mitral valve without resultant mitral regurgitation in each patient. Two-dimensional echocardiograms showed a marked to moderate degree of dilatation of the mitral orifice in each patient. All five patients are well with remarkable clinical improvements 2 to 16 months after the procedure.

[Noninvasive evaluation of cardiac involvements and left ventricular function in schoolchildren with the history of mucocutaneous lymph node syndrome]

Mucocutaneous lymph node syndrome (MCLS) in the young has been known to have coronary aneurysms, and then it has been recently suspected as a cause of premature atherosclerosis and cardiomyopathy. Thirty-three schoolchildren who suffered from MCLS were studied to evaluate cardiac involvements and left ventricular function using two-dimensional (2-D) echocardiograms and submaximal stress test. Fifteen normal schoolchildren were studied as normal control. All these MCLS children were asymptomatic and had no significant findings in routine chest X-ray and electrocardiographic examinations. According to submaximal stress test, 8 cases showed a J type ST depression of only 0.5--1.0 mm, and there were no positive cases. Using 2-D echocardiograms, the left coronary artery was detected in 85% and the right coronary in 27%. One case showed an aneurysm of the left coronary artery. However, none of them showed abnormal left ventricular wall motion or the wall motion abnormality compatible with cardiomyopathy. There were no significant differences between MCLS and normal control in ejection fraction, mean VCF, diastolic descent rate of the anterior mitral valve, D/S ratio of the left ventricular wall, and Weissler's index (PEP/ET). These findings suggested that 1) most of MCLS schoolchildren do not have obvious cardiac involvement and their left ventricular function is within normal limits, 2) because of its low sensitivity, submaximal stress test is not so useful in screening coronary lesions, and 3) the 2-D echocardiogram works not only in detecting coronary aneurysms but also in evaluating left ventricular function.

[Tricuspid valve motion and tricuspid valve ring size in normals and patients with atrial septal defect (author's transl)]

To investigate the normal configuration of the tricuspid valve and the normal size of the tricuspid valve ring, 17 normals, 20 patients with atrial septal defect, 4 patients with tricuspid valve prolapse, and 41 patients with various diseased conditions were studied by cross-sectional echocardiography. The tricuspid valve ring diameter in atrial septal defect was judged to be increased in comparison with that of normals. All the patients with tricuspid valve prolapse exhibited an excessive systolic ballooning of the leaflets toward the right atrium. However, a systolic ballooning of the leaflets alone was frequently observed in normals and many other conditions. Therefore, we conclude that cross-sectional echocardiography has some clinical limitations in the differential diagnosis between tricuspid valve prolapse and normals.

[Cross-sectional and M-mode echocardiographic diagnosis of vegetative endocarditis in the right-sided heart (author's transl)]

M-mode and cross-sectional echocardiograms of 3 cases with vegetative endocarditis in the right-sided heart were reported. The location of vegetative lesions was the tricuspid valve in one, the parietal band of the right ventricle and chordae tendinae in one, and the pulmonary artery wall in the remaining patient. Ruptured chordae tendinae were observed in the patient with tricuspid valve vegetation. M-mode echocardiography detected vegetative lesions in all patients. However, the precise size and location of these lesions, and a complication of the destructive process were not evaluated by M-mode echocardiography. On the other hand, cross-sectional echocardiography not only documented the presence but also assessed the morphologic characteristics of the lesions, since this technique provides spatial orientation concerning moving structures. Furthermore, ruptured chordae tendineae in the patient with tricuspid valve vegetation was correctly estimated. However, the lesions should be differentiated from other conditions including a localized calcified lesion, abscess and thrombus. In conclusion, cross-sectional echocardiography in combination with M-mode echocardiography is recommended in diagnosing vegetative lesions in the right-sided heart.

Cross-sectional echocardiographic diagnosis of coronary artery aneurysms in patients with the mucocutaneous lymph node syndrome

Real-time cross-sectional echocardiographic studies revealed the presence of coronary artery aneurysms in five patients with mucocutaneous lymph node syndrome. These lesions appeared as circular echo-free spaces with clearly-defined borders in sites corresponding to angiographically proven aneurysms. In 15 normal subjects who were studied only by noninvasive methods, and in 17 who had normal coronary arteriograms (including eight with the mucocutaneous lymph node syndrome), we found no similar echo findings. The aneurysms were in both right and left coronary arteries in three patients, and were confined to the left side in two. The mucocutaneous lymph node syndrome is an increasingly common condition in Japan which may be fatal due to myocardial infarction occurring in a setting of coronary aneurysm with thrombosis. Therefore, the ability to demonstrate coronary aneurysms noninvasively is of prognostic and potentially therapeutic value in this inadequately understood syndrome.

Noninvasive diagnosis of pseudoaneurysm of the left ventricle

The echocardiographic, scintigraphic, angiocardiographic and autopsy correlations in a patient with left ventricular pseudoaneurysm are presented. Interruption of the echo of the left ventricular wall and radioisotope image of pseudoaneurysm and its communication channel are demonstrated for the first time. The striking similarity of the radioisotope image to the angiographic image is noted. This study suggests that echocardiography has capability to visualize left ventricular wall defects, such as the perforation seen in this case and radioisotope ventriculography is equivalent to the invasive contrast technique. Both of the methods seem to be safe and specific for the diagnosis of left ventricular pseudoaneurysm.

Cross-sectional echocardiographic diagnosis of large left atrial tumor and extracardiac tumor compressing the left atrium. Limitation of M mode echocardiography in distinguishing the two lesions

A case of a left atrial fibrosarcoma arising from the posterior left atrial wall and two cases of an extracardiac tumor compressing the left atrium were studied with M mode and cross-sectional echocardiography. In all three cases, M mode echocardiography revealed a mass of echoes just behind the aorta and did not distinguish a left atrial from an extracardiac tumor. By contrast, cross-sectional echocardiography allowed direct visualization of the location, size and movement of the tumor in all three cases and contributed to distinguishing the two lesions. This study indicates that cross-sectional echocardiography is more accurate than M mode echocardiography in the differential diagnosis of a large left atrial tumor and extracardiac tumor compressing the left atrium.

Ultrasonic features of anomalous origin of the left coronary artery from the pulmonary artery

Two cases of anomalous origin of the left coronary artery from the pulmonary artery with and without marked dilatation of the right coronary artery were studied by M-mode echocardiography and cross-sectional echocardiography. The M-mode echocardiogram obtained from the case with the dilated right coronary artery demonstrated an abnormal structure anterior to the aortic root. The cross-sectional echocardiogram of the same case visualized the origin of the dilated right coronary artery. In addition, echocardiographic abnormalities suggesting the ischemia of the left ventricle were observed in both cases. Although many of the ultrasonic features are nonspecific, the combination of ultrasonic technique provides useful clues to the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

Echocardiographic features of congenital pulmonary regurgitation

Eight patients with congenital pulmonary regurgitation documented by cardiac catheterization and angiography were studied by echocardiography. Echocardiographic features of the pulmonary valve observed in this condition included a) diastolic fluttering (5 cases), b) diastolic separation (2 cases), and c) increase of posterior motion during atrial systole (a wave). Maximum a wave depth exceeded the upper limit of the normal value in 2 cases and averaged 6.1 +/- 0.7 (standard error of the mean) mm. In addition, d) diastolic fluttering of the anterior tricuspid valve was seen in 5 cases and e) abnormal interventricular septal motion in 2 cases (one, paradoxical and the other, flat). Of these findings, the diastolic fluttering of the pulmonary valve, which results from the turbulent stream of blood in the outflow of the right ventricle striking the pulmonary valve, is pathognomonic for pulmonary regurgitation. Although the other findings are nonspecific, all patients had at least 1 of these 5 findings. Echocardiography, therefore, provides useful clues to the diagnosis of pulmonary regurgitation. Furthermore, echocardiography should be of use in differentiating congenital from functional pulmonary regurgitation and from aortic regurgitation.

Reappraisal of jugular phlebogram in the diagnosis of tricuspid regurgitation. Relationship between echocardiographic interventricular septal motion and jugular phlebogram

Little information is available concerning the relationship between the pattern of the jugular phlebogram and interventricular septal motion. We studied 250 patients with various conditons. Abnormal septal motion was observed in only 33% of the patients with tricuspid regurgitation. All the patients having abnormal septal motion and 66% of those having normal septal motion had the jugular pattern of tricuspid regurgitation. After cardiac operation with the incision of cardiac chambers and pericardiotomy, abnormal septal motion was seen from 40 to 89% at early postoperative period. Of the patients studied approximately 1 year after operation, there was reduced incidence of septal abnormality. Septal motion was normal in all the patients who had ligation of a patent ductus arteriosus and who underwent Blalock's operation. Of these, all having paradoxical motion which occurred in the mid-septum at least had the jugular pattern of tricuspid regurgitation. On the other hand, only 20 to 30% of the patients whose septal motion was normal had the jugular pattern of tricuspid regurgitation. Furthermore, all of the 3 patients with coronary artery disease having paradoxical motion of the entire septum had the jugular pattern of tricuspid regurgitation, as well. We conclude that the jugular pattern of tricuspid regurgitation and echocardiographic septal motion abnormality are related to each other and that tricuspid regurgitation should not be diagnosed by jugular phlebogram unless echocardiographic septal motion is examined.

Cord-like aortic valve vegetation in bacterial endocarditis. Demonstration by cardiac ultrasonography. Report of a case

The ultrasonic features in a case of bacterial endocarditis in which a highly mobile, cord-like vegetation, attached to the noncoronary cusp of the aortic valve, are reported. The echocardiogram demonstrated abnormal echo patterns in the left ventricular outflow tract in diastrole which were continuous with similar echoes in the aortic root. While these findings did not differ from the previously reported manifestations in cases of flailing aortic valve leaflets, the cardiac ultrasonogram distinguished this vegetative growth. Cardiac ultrasonography revealed a cord-like characteristic, showed the movement of the entire growth into the left ventricular outflow tract in diastole and into the aorta in systole, and allowed estimation of the size of the vegetation. We conclude that cardiac ultrasonography can help in differentiating aortic valve leaflet flail and vegetations in endocarditis.

Study of posterior left atrial wall motion by echocardiography and its clinical application

Echocardiographic tracings of posterior left atrial wall motion were examined in 30 normal subjects, 17 patients of mitral stenosis with sinus rhythm and 31 coronary patients with elevated left ventricular end-diastolic pressure. Because of the plane of the posterior left atrial wall motion and the angle of the sound beam, usually the postero-inferior portion of the left atrial wall was recorded. In normal subjects, there were 3 positive waves (A,C,V waves) and 2 negative waves (X and Y waves). The A wave during atrial contraction period occurred in the closing motion of the mitral valve and was initiated by a slight negative wave. The fourth heart sound was consistent with the ascending limb of the A wave. The C wave coincided with the first heart sound followed by the pronounced negative depression (X wave). The X trough coincided with the beginning of the mitral valve opening in early diastole and was the deepest point in the motion curve. The V wave was a peaked anterior motion during rapid filling period and followed by the third heart sound. The Y wave was a slight negative depression following the V wave, and its trough occurred when the both leaflets of the mitral valve assumed a semiclosed position. In both mitral stenosis and coronary artery disease, significant increase (p less than 0.01) of the A wave excursion and significant decrease (p less than 0.01) of the V wave excursion were observed, resulting in marked increase (p less than 0.01) of the A/V ratio. The slope of the ascending limb of the V wave was also decreased apparently in both conditions. These findings might reflect increased resistance to left atrial emptying in mitral stenosis and decreased left ventricular filling rate in coronary artery disease. This study shows that echocardiographic examination of the posterior left atrial wall motion is feasible and useful in estimating the presence of either mitral stenosis or decreased left ventricular filling rate.

Ultrasonic diagnosis of ventricular aneurysm

Fifteen patients with ventricular aneurysm were selected based on the following 3 criteria: 1) electrocardiographic evidence of old myocardial infarction, 2) presence of abnormal precordial impulse, 3) presence of dyskinesis or akinesis with diastolic bulging of the ventricular cavity by angiocardiogram. Eight patients had anterior left ventricular aneurysm and 7 apical aneurysm. The characteristic abnormal precordial impulse was diminished or absent A wave, pre-upstroke retraction, late systolic bulge, and diminished rapid filling wave, all of which were recorded over the restricted area of the broad precordial impulse. M-mode echocardiogram revealed increased or normal excursion of the posterior left ventricular wall. However, abnormal motion of the anterior left ventricular wall was detected in all, if the transducer was located over the abnormal precordial impulse or slightly inside of it. Compound M-mode echocardiographic scan toward the abnormal precordial impulse was able to detect asynergy of the anterior left ventricular wall and the apex, and distinguish it from motions of the interventricular septum and the anterior right ventricular wall. Abnormal motion of the anterior left ventricular wall was paradoxical in 13 patients and flat in the others. Systolic posterior mortion of the posterior left ventricular wall was detected in 2 patients with apical aneurysm. Cardiac ultrasonogram scanning over the abnormal precordial impulse demonstrated the bulging of the ventricular cavity in either systole or diastole depending on the site of lesion. There was a good correlation between cardiac ultrasonography and angiocardiography with respect to the site of lesion. Our study indicates that this method is useful in the diagnosis of anterior and apical aneurysm which ordinary technique failed to detect.

Echocardiographic diagnosis of endocardial cushion defects

Sixteen patients with endocardial cushion defects were studied by echocardiography and ultrasonocardiotomography. Three characteristic findings, common to both complete and partial forms, were observed. They were the ostium primum defect of the interatrial septum, the left ventricular outflow narrowing and the atrioventricular valve abnormalities which are the anatomic bases of endocardial cushion defects. Several additional findings were observed in patients with complete form. Most strikingly, the anterior leaflet echo locating in the left ventricle had the direct connection to that in the right ventricle without the interposition of the interventricular septum by echocardiogram. Ultrasonocardiotomogram, on the other hand, demonstrated beautifully the common anterior leaflet and the high inteventricular septal defect. There were, in addition, the absence of the paradoxical motion of the interventricular septum and the diffuculty in detecting the interatrial septum. The intact interatrial septum continuous with the anterior mitral leaflet was demonstrated in patients with the interventricularseptal defect of atrioventricular canal type, in which there were the typical abnormalities in the atrioventricular valves and the left ventricular outflow narrowing as well. This study indicates that ultrasonic examination may provide a direct, yet noninvasive method in the diagnosis of various types of endocardial cushion defects.