Prognostic impact of heart mate risk score among elderly heart failure patients with non-responder for cardiac resynchronization therapy

Background

For patients with severe heart failure (HF) who are not eligible for transplantation, there is destination therapy (DT) that uses a continuous flow left ventricular assist device (LVAD). Implantation of LVAD improves HF and can be expected to improve the prognosis of life. Elderly refractory HF patients with non-responders for cardiac resynchronization therapy (CRT) may benefit from LVAD as DT. In considering indications of LVAD as DT for the elderly in Japan, conditions such as a low risk of Heart Mate Risk Score (HMRS) have been raised. HMRS has been shown to correlate with mortality in the cohort of LVAD patients enrolled in the Heartmate II trials.

Purpose

Because elderly CRT non-responder refractory HF patients are not indicated for transplantation and may benefit from LVAD as DT in Japan, we aimed to investigate the HMRS and prognosis among elderly CRT non-responders.

Methods

Of 467 patients underwent CRT implantation between 2000 and 2015, 157 were aged 65–75 years old. Of which 59 patients who could be determined to be non-responders based on echocardiographic data were included in this study. The primary endpoint was all-cause mortality, the secondary was readmission for HF and appropriate implantable cardioverter defibrillator (ICD) therapy.

Results

The patients' mean age was 68 years, males were 71%. The mean serum creatinine value was 1.1 mg/dl, albumin was 3.8 mg/dl, and BNP was 383 pg/ml. The mean left ventricular ejection fraction (LVEF) was 26%. The subjects were divided into 3 groups according to HMRS. The average of HMRS was 2.2, the low-risk group included 17 (29%) patients, the medium was 22 (37%), and the high was 20 (34%). There was no significant difference in age, LVEF, BNP, and NYHA functional classification at the time of CRT implantation between three groups. In the low-risk group, creatinine and INR were significantly lower, and albumin was significantly higher compared to the high-risk group. BNP tended to be lower in the low-risk group, but there was no significant difference. The mortality rate by HMRS was 12% in the low-risk group, 36% in the medium-risk group, and 50% in the high-risk group. On the Kaplan-Meier analysis, the low-risk group had a significantly lower mortality rate than the high-risk group (Figure). Furthermore, focusing on HF readmission, the rate of readmission was 59% in the low-risk group, 86% in the medium -risk group, and 65% in the high-risk group, and there was no significant difference between three groups. There was also no significant difference in appropriate ICD therapy between three groups.

Conclusion

Approximately 30% of elderly non-responders of CRT are in the low-risk group by HMRS and their mortality was lower than that of the other two groups. These elderly CRT non-responder patients might be considered a candidate for DT in Japan.

Funding Acknowledgement

Type of funding sources: None.

P3359Myocardial flow reserve using 13N ammonia PET for detection of cardiac allograft vasculopathy in heart transplant patients

Purpose

Risk stratification and early detection of cardiac allograft vasculopathy (CAV) are essential in heart transplantation patients. CAV is associated with poor outcome in the chronic phase after heart transplantation. CAV presents a diffuse vascular involvement and has been difficult to noninvasively diagnose by the lack of a sensitive method to detect developing vascular pathology in the allograft. The present study investigates the ability of 13N-ammonia PET for detection of CAV in heart transplant patients.

Methods

Data of adenosine-stress 13N-ammonia PET imaging for thirty-one patients (mean age, 39 years-old) after 11 + 7 years from transplant was analyzed. Five patients had undergone percutaneous coronary intervention (PCI), and the remaining 26 patients had no history of definite myocardial ischemia. Myocardial flow was generated from the time activity curve of left ventricle input and myocardial uptake using 3-compartment model and the first 2 minutes' dataset of list-mode acquisition. Global - myocardial flow reserve (MFR) was calculated by stress to rest flow ratio. Patient with global-MFR <2.0 was defined as significant decrease. Summed difference score (SDS) was used as an estimate for the extent of ischemia, and the patient showing SDS >2 was identified as those having significant ischemia.

Results

The mean Global-MFR of our subjects were 2.3 (1.2 to 3.9). MFR using 13N-ammonia PET significantly decreases in one third of heart transplant patients in chronic stage. Eleven patients with Global-MFR <2.0 (35%) were observed, and eight of them had no history of clinical myocardial ischemia. The proportion of patients with a history of PCI is 18% in patients with Global-MFR <2.0 (vs 5%, p=0.210). Moreover, there were eight patients with SDS >2 (26%) including three patients having a history of PCI. The proportion of patients with a history of PCI tends to be high with SDS >2 (38% vs 9%, p=0.056).

Conclusion

This modality using 13N ammonia PET is useful for easily detection of CAV before manifestation of symptomatic myocardial ischemia in heart transplant patients.

Common carotid intima-media thickness is predictive of all-cause and cardiovascular mortality in elderly community-dwelling people: Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

Several cohort studies have examined the association of carotid intima-media thickness (IMT) with the risk of stroke or myocardial infarction in apparently healthy persons. We investigated the predictive value of IMT of cardiovascular mortality in elderly community-dwelling people, beyond the prediction provided by age and MMSE, assessed by means of a multivariate Cox model. Carotid IMT and plaque were evaluated bilaterally with ultrasonography in 298 people older than 75 years (120 men and 178 women, average age: 79.6 years). The LILAC study started on July 25, 2000. Consultations were repeated every year. The follow-up ended on November 30, 2004. During the mean follow-up span of 1152 days, 30 subjects (21 men and nine women) died. Nine deaths were attributable to cardiovascular causes (myocardial infarction: two men and three women; stroke: two men and two women). The age- and MMSE-adjusted relative risk (RR) and 95% confidence interval (95% CI) of developing all-cause mortality was assessed. A 0.3 mm increase in left IMT was associated with a RR of predicted 1.647 (1.075-2.524), and a similar increase in right IMT with a RR of 3.327 (1.429-7.746). For cardiovascular mortality, the corresponding RR values were 2.351 (1.029-5.372) and 2.890 (1.059-7.891), respectively. Carotid IMT assessed by ultrasonography is positively associated with an increased risk of all-cause and cardiovascular death in elderly community-dwelling people.

Depressive mood is independently related to stroke and cardiovascular events in a community

By means of a multivariate Cox model, we investigated the predictive value of a depressive mood on vascular disease risk in middle-aged community-dwelling people. In 224 people (88 men and 136 women; mean age: 56.8 +/- 11.2 years) of U town, Hokkaido (latitude: 43.45 degrees N, longitude: 141.85 degrees E), a chronoecological health watch was started in April 2001. Consultations were repeated every 3 months. Results at the November 30, 2004 follow-up are presented herein. 7-day/24-h blood pressure (BP) and heart rate (HR) monitoring started on a Thursday, with readings taken at 30-min intervals between 07:00 h and 22:00 h and at 60-min intervals between 22:00 h and 07:00 h. Data stored in the memory of the monitor (TM-2430-15, A and D company, Japan) were retrieved and analyzed on a personal computer with a commercial software for this device. Subjects were asked to answer a self-administered questionnaire inquiring about 15 items of a depression scale, at the start of study and again after 1-2 years. Subjects with a score higher by at least two points at the second versus first screening were classified as having a depressive mood. The other subjects served as the control group. The mean follow-up time was 1064 days, during which four subjects suffered an adverse vascular outcome (myocardial infarction: one man and one woman; stroke: two men). Among the variables used in the Cox proportional hazard models, a depressive mood, assessed by the Geriatric Depression Scale (GDS), as well as the MESOR of diastolic (D) BP (DBP-MESOR) and the circadian amplitude of systolic (S) BP (SBP-Amplitude) showed a statistically significant association with the occurrence of adverse vascular outcomes. The GDS score during the second but not during the first session was statistically significantly associated with the adverse vascular outcome. In univariate analyses, the relative risk (RR) of developing outcomes was predicted by a three-point increase in the GDS scale (RR = 3.088, 95% CI: 1.375-6.935, P = 0.0063). Increases of 5 mmHg in DBP-MESOR and of 3 mmHg in SBP-Amplitude were associated with RRs of 2.143 (95% CI: 1.232-3.727, P = 0.0070) and 0.700 (95% CI: 0.495-0.989, P = 0.0430), respectively. In multivariate analyses, when both the second GDS score and the DBP-MESOR were used as continuous variables in the same model, GDS remained statistically significantly associated with the occurrence of cardiovascular death. After adjustment for DBP-MESOR, a three-point increase in GDS score was associated with a RR of 2.172 (95% CI: 1.123-4.200). Monday endpoints of the 7-day profile showed a statistically significant association with adverse vascular outcomes. A 5 mmHg increase in DBP on Monday was associated with a RR of 1.576 (95% CI: 1.011-2.457, P = 0.0446). The main result of the present study is that in middle-aged community-dwelling people, a depressive mood predicted the occurrence of vascular diseases beyond the prediction provided by age, gender, ABP, lifestyle and environmental conditions, as assessed by means of a multivariate Cox model. A depressive mood, especially enhanced for 1-2 years, was associated with adverse vascular outcomes. Results herein suggest the clinical importance of repetitive assessments of a depressive mood and the need to take sufficient care of depressed subjects. Another result herein is that circadian and circaseptan characteristics of BP variability measured 7-day/24-h predicted the occurrence of vascular disease beyond the prediction provided by age, gender, depressive mood and lifestyle, as assessed by means of a multivariate Cox model. Earlier, we showed that the morning surge in BP on Mondays was statistically significantly higher compared with other weekdays. Although a direct association between the Monday surge in BP and cardiovascular events could not be demonstrated herein, it is possible that the BP surge on Monday mornings may also trigger cardiovascular events. We have shown that depressive people exhibit a more prominent circaseptan variation in SBP, DBP and the double product (DP) compared to non-depressed subjects. In view of the strong relation between depression and adverse cardiac events, studies should be done to ascertain that depression is properly diagnosed and treated. Chronodiagnosis and chronotherapy can reduce an elevated blood pressure and improve the altered variability in BP and HR, thus reducing the incidence of adverse cardiac events. This recommendation stands at the basis of chronomics, focusing on prehabilitation in preference to rehabilitation, as a public service offered in several Japanese towns.

Arterial stiffness independently predicts cardiovascular events in an elderly community — Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

We investigated the predictive value of arterial stiffness to assess cardiovascular risk in elderly community-dwelling people by means of a multivariate Cox model. In 298 people older than 75 years (120 men and 178 women, average age: 79.6 years), brachial-ankle pulse wave velocity (baPWV) was measured between the right arm and ankle in a supine position. The LILAC study started on July 25, 2000, consultation was repeated yearly, and the last follow-up ended on November 30, 2004. During this follow-up span of 1227 days, there were nine cardiovascular deaths, the cause of death being myocardial infarction for two men and three women or stroke for two men and two women. In Cox proportional hazard models, baPWV as well as age, Mini-Mental State Examination (MMSE), Hasegawa Dementia Scale Revised (HDSR) and the low-frequency/high-frequency (LF/HF) ratio showed a statistically significant association with the occurrence of cardiovascular death. A two-point increase in MMSE and HDSR score significantly protected against cardiovascular death, the relative risk (RR) being 0.776 (P = 0.0369) and 0.753 (P = 0.0029), respectively. The LF/HF ratio also was significant (P = 0.025), but the other indices of HRV were not. After adjustment for age and HDSR, a 200 cm/s increase in baPWV was associated with a 30.2% increase in risk (RR = 1.302, 95% CI: 1.110-1.525), and a 500 cm/s increase in baPWV with a 93.3% increase in risk (RR = 1.933, 95% CI: 1.300-2.874, P = 0.0011), whereas the LF/HF ratio was no longer associated with a statistically significant increase in cardiovascular mortality. In elderly community-dwelling people, arterial stiffness measured by means of baPWV predicted the occurrence of cardiovascular death beyond the prediction provided by age, gender, blood pressure and cognitive functions. baPWV should be added to the cardiovascular assessment in various clinical settings, including field medical surveys and preventive screening. The early detection of risk by chronomics allows the timely institution of prophylactic measures, thereby shifting the focus from rehabilitation to prehabilitation medicine, as a public service to several Japanese towns.

Fractal analysis of heart rate variability and mortality in elderly community-dwelling people — Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

AIM

Fractal analysis of heart rate (HR) variability (HRV) has been used as a new approach to evaluate the risk of mortality in various patient groups. Aim of this study is to examine the prognostic power of detrended fluctuation analysis (DFA) and traditional time- and frequency-domain analyses of HR dynamics as predictors of mortality among elderly people in a community.

METHODS

We examined 298 people older than 75 years (average age: 79.6 years) and 1-h ambulatory ECG was monitored. During the last 10 min, deep respiration (6-s expiration and 4-s inspiration) was repeated six times in a supine position. Time-domain and frequency-domain measures were determined by the maximum entropy method. Scaling exponents of short-term (<11 beats, alpha 1) and longer-term (>11 beats, alpha 2) were determined by the DFA method. Six estimates, obtained from 10-min segments, were averaged to derive mean values for the entire recording span. These average values were denoted Alpha 1 and Alpha 2, estimates obtained during the first 10-min segment Alpha 1 S and Alpha 2 S, and those during the last 10-min segment Alpha 1E and Alpha 2E, respectively. The LILAC study started on July 25, 2000 and ended on November 30, 2004. We used Cox regression analysis to calculate relative risk (RR) and 95% confidence interval (CI) for all-cause mortality. Significance was considered at a value of P < 0.05.

RESULTS

Gender, age and Alpha 2E showed a statistically significant association with all-cause mortality. In univariate analyses, gender was significantly associated with all-cause mortality, being associated with a RR of 3.59 (P = 0.00136). Age also significantly predicted all-cause mortality and a 5-year increase in age was associated with a RR of 1.49 (P = 0.01809). The RR of developing all-cause mortality predicted by a 0.2-unit increase in Alpha 2E was 0.58 (P = 0.00390). Other indices of fractal analysis of HRV did not have predictive value. In multivariate analyses, when both Alpha 2E and gender were used as continuous variables in the same model, Alpha 2E remained significantly associated with the occurrence of all-cause mortality (P = 0.02999). After adjustment for both gender and age, a 0.2-unit increase in Alpha 2E was associated with a RR of 0.61 (95% CI: 0.42-0.90, p = 0.01151).

CONCLUSION

An intermediate-term fractal-like scaling exponent of RR intervals was a better predictor of death than the traditional measures of HR variability in elderly community-dwelling people. It is noteworthy that the longer-term (alpha 2) rather than the short-term fractal component (alpha 1) showed predictive value for all-cause mortality, which suggests that an increase in the randomness of intermediate-term HR behavior may be a specific marker of neurohumoral and sympathetic activation and therefore may also be associated with an increased risk of mortality.

Positive impact of social intervention on disturbed neurobehavioral function in an elderly community-dwelling population: Longitudinal investigation for longevity and aging in Hokkaido county (LILAC)

Several kinds of health consultation and rehabilitation for functional disorders aimed at stroke prevention and maintenance of cognitive function in an elderly population in Hokkaido county, Japan. Changes in cardiovascular and neurobehavioral endpoints between 2000 and 2002 were assessed in 72 of 115 subjects over 75 years of age. Direct social intervention, including lifestyle modification can have a positive impact, notably on subjects with cardiovascular disorders.

Tricuspid valve replacement after cardiac transplantation

Tricuspid regurgitation, a fairly common finding after cardiac transplantation, is generally mild or moderate, and is not clinically significant. The etiology of tricuspid regurgitation is not entirely understood, and experience with valve replacement after cardiac transplantation is limited. We describe a case of progressively severe tricuspid regurgitation ultimately requiring tricuspid valve replacement. At operation, the ruptured chordae of the posterior part of anterior and septal leaflet with resulting partially flail leaflets were found. Examination of the papillary muscle showed origins of several of the ruptured chordae. Damage to the tricuspid subvalvular apparatus at endomyocardial biopsy appeared to be a possible cause. A 31-mm Carpentier-Edwards porcine valve was implanted. This was because replacement with a mechanical prosthesis would prevent future right-side heart catheterization and endomyocardial biopsy and in valve repair, the patient remains exposed to the risk of the recurrence of chordal rupture. We discuss proposed causes and choices in surgical technique.

Points to note from indications for heart transplantation to post-heart transplant care: from the care of patients with refractory heart failure and overseas heart transplantation

To examine important points surrounding the indications for heart transplantation (HTX) to care after HTX, we reviewed 22 patients with refractory heart failure aged less than 60 years who had been observed for the past 6 years. Sixteen patients had dilated cardiomyopathy; 1, dilated hypertrophic cardiomyopathy; 3, restrictive cardiomyopathy; and 2, ischemic cardiomyopathy; there were 15 males and 7 females, and 6 of the 22 patients were children. The 22 patients were divided into two groups according to their response to tailored medical therapy. Group 1 (n = 6) consisted of those whose cardiac function improved to New York Heart Association (NYHA) status 2 from NYHA status 3 or 4. Group 2 (n = 16) still exhibited refractory heart failure. Seven of these 16 patients went on to have successful HTX. Survival in groups 1 and 2 combined was significantly lower than actuarial survival post-HTX cited in the registry of the International Society for Heart and Lung Transplantation, and group 2 had an even lower survival than the total groups 1 and 2 survival. Survival in children was much lower than that in adults. Seven of the 16 patients in group 2 showed a genetic link, but there was no genetic link in group 1 patients. One patient in group 2 had a panel reactive antibody (PRA) value of 46% and died while awaiting HTX. Post-HTX care in terms of immunosuppressant therapy, was modified for each patient. It is particularly necessary to consider the time a patient will wait on the list for candidates for HTX who are children, have a genetic link, or are positive for PRA. A genetic approach is helpful to determine indications for HTX. Sensitive monitoring of post-HTX immunosuppression is needed.

[Assessment of Japanese patients receiving heart transplants overseas]

No heart transplants have been performed in Japan due to various obstacles since the only operation performed in 1968. Since 1981, a number of patients requiring heart transplants have been accepted by foreign transplantation centers in England, the U.S.A., and Germany. This report describes an investigation of the postoperative course of these Japanese heart transplant patients and discusses the problems regarding transplantation in Japan. Of the 21 transplant patients, the diagnosis was dilated cardiomyopathy in 17, restrictive cardiomyopathy in 1, hypertrophic cardiomyopathy in 2, and congenital muscle dystrophy in 1. All patients survived surgery but three died in the long-term period. The causes of death were acute rejection (after 3 months), chronic rejection (after 50 months) and infection (after 30 months). The actuarial survival curve of these patients was 95.0% for one-year survival and 86.4% for three-year survival. The postoperative functional class was NYHA classification I in all patients (100%). Ninety-three percent of patients returned to work. Immunosuppressive therapies included triple drug therapy in 14 patients (66.7%), double drug therapy in 4 (19.0%), ciclosporin alone in 2 (9.5%) and FK506 in 2 (5.0%). The incidence of acute rejection was 1.56 episodes per patient per year within 3 months and 2.9 episodes per patient per year within 1 year. The postoperative courses of Japanese patients who underwent heart transplantation at foreign transplantation centers were satisfactory. These results will encourage heart transplantation in Japan.

Genotype and phenotype of severe mitochondrial cardiomyopathy: a recipient of heart transplantation and the genetic control

Comprehensive analyses of mitochondrial (mt)DNA of a recipient of heart transplantation at age 7 because of severe cardiomyopathy revealed three germ line point mutations, each one in the 12S rRNA gene, in the CO1 gene and in the cytochrome b gene, respectively. As the somatic mutation, extensive fragmentation of mtDNA associated with 212 kinds of deletions was detected in contrast to 5 kinds in an age-matched negative control. A recipient's positive control having almost the same base-substitutions and mutations with the recipient except one in the CO1 gene also developed severe cardiomyopathy died at age 20. The close relation between phenotype and mtDNA genotype provides the basis of our understanding of cell death and premature ageing.

The first pediatric Japanese case to undergo heart transplantation in the Utah Cardiac Transplant Program in the United States

A seven-year-old girl underwent heart transplantation because of progressive congestive heart failure resulting from familial dilated cardiomyopathy. Her parents were second cousins to each other and her brother had died of dilated cardiomyopathy. Her symptoms of congestive heart failure began four months before the transplantation and became gradually worse. Left ventricular ejection fraction was 10 to 20% echocardiographically, and mitral and tricuspid valve regurgitation were present. Her condition of NYHA IV was not improved by treatment with dobutamine infusion and isosorbide dinitrate. She was transported to the Primary Children's Medical Center in Utah, USA, on July 22, 1991 in critical condition to undergo heart transplantation. Despite treatment with amrinone and additional catecholamines, she became semicomatose due to ischemic liver injury on July 24, 1991. A donor became available on July 25, 1991, and the transplantation was performed. Cardiac ischemic time was 97 min. Although she had transient OKT3 monoclonal antibody-related encephalopathy on her fifth postoperative day, she recovered normally. She had moderate rejection on the 20th postoperative day and mild rejection on the 79th and 149th postoperative days. She has had no significant infectious diseases. The baseline examination performed three months after heart transplantation revealed no abnormal findings on her coronary arteriogram. She returned to Japan and has been attending elementary school. The annual examination of her transplanted heart showed neither stenosis nor occlusion in her coronary angiogram. She has been receiving cyclosporine, azathioprine, and a low dose of prednisone as an immunosuppressive regimen. If she does not exhibit rejection, the use of steroids will be decreased or discontinued.

Endomyocardial biopsy findings in cases with pericarditis or perimyocarditis

In order to determine the presence or absence of myocarditis in cases with viral or idiopathic pericarditis, a study was conducted as one of our series on endomyocardial biopsy. There were two groups of patients, pericarditis cases (n = 8), and patients with perimyocarditis (n = 6). In the former group, it was confirmed that cardiac sarcoplasmic enzymes were not released during the acute stage of the disease. In the latter, there was positive evidence of the enzyme release. Also, employing our method of categorizing the possibility of myocarditis at the histopathological level, we found that the category 'highly suggestive' of myocarditis was absent in all eight cases with pericarditis. However, in cases with perimyocarditis, this category was assigned in four out of six cases (67%), indicating a high incidence. The category, 'slightly suggestive', was seen in three cases of the former (38%) and two cases of the latter group (33%). It is concluded that in patients with pericarditis, the release of cardiac sarcoplasmic enzyme is an important diagnostic element in the diagnosis of perimyocarditis even if the clinical features reveal a predominance of pericarditis. In patients with perimyocarditis, progression to residual cardiac disease, such as conduction disturbance or congestive heart failure, is likely.

A case of hypereosinophilic syndrome with asymmetric septal hypertrophy

A case of idiopathic hypereosinophilic syndrome (HES) with asymmetric septal hypertrophy (ASH) is described: this is a very rare association. The patient was a 56-year-old male with hypereosinophilia lasting for 10 years. The white blood cell count was 11200/mm3, with 22% eosinophils, and eosinophilic hyperplasia (7.2%) was noted in the bone marrow. A peripheral blood smear showed vacuolated eosinophils with a reduced content of granules. An ultrastructure study of the eosinophils revealed reduced numbers of crystalloid granules which appeared to be dissolving with reversal of normal staining. An echocardiogram and a biventriculoglam indicated ASH with the interventricular septal wall thickness of 2.4 cm and the left ventricular posterior wall thickness of 1.5 cm. Right ventricular endomyocardial biopsy revealed no eosinophilic infiltration, but endocardial thickening, subendocardial fibrosis, hypertrophy, myocytolysis, and fragmentation of muscle bundles were observed.

Sheehan's syndrome with hypomagnesemia and polymorphous ventricular tachycardia

A 40 year old woman with Sheehan's syndrome demonstrated polymorphous ventricular tachycardia and hypomagnesemia. The diagnosis of Sheehan's syndrome was based on her history, physical examination and endocrinological data. Serum magnesium level was 1.5 mg/dl. After the treatment of polymorphous ventricular tachycardia by lidocaine, an electrocardiogram showed low voltage, T-wave inversion or flattening and QT-prolongation, and these electrocardiographic abnormalities gradually improved after the initiation of cortisone therapy. A chest roentgenogram, an echocardiogram, thallium-201 scan of the myocardium and hemodynamic parameters indicated no abnormal findings. It is suspected that hypomagnesemia caused polymorphous ventricular tachycardia. However, the cause of hypomagnesemia and its relation to Sheehan's syndrome in the present case were not determined, although, hypomagnesemia was improved after the administration of cortisone.

Coronary angiographic characteristics in Japanese patients with heterozygous familial hypercholesterolemia

Coronary angiographic findings were analyzed in 51 consecutive patients (36 males and 15 females) with heterozygous familial hypercholesterolemia (FH) and 279 consecutive patients (216 males and 63 females) without FH (non-FH). The coronary stenosis index and over 75% stenosis vessel subset were almost three times as high in the FH group. The incidence of myocardial infarction was almost twice as high in the FH group. Levels of total cholesterol and its lipoprotein fractions, except HDL-cholesterol, were almost twice as high in the FH group. In the FH group aged under 50 years, the two parameters of coronary angiogram and the incidence of myocardial infarction were significantly higher in males than in females. However, in the group aged over 50 years, all three parameters were not significantly different between those in males and females. The level of HDL-cholesterol was significantly lower in males than in females. A significantly higher incidence (18%) of coronary ectasia was observed in the FH group compared with the incidence (2%) in non-FH. All patients with coronary ectasia were males, except one female with FH. On comparison of the males among the FH patients with those among the non-FH patients matched for total cholesterol, age and other risk factors, the FH patients were associated with a significantly higher degree of coronary atherosclerosis and lower level of HDL-cholesterol. Seven FH patients with a normal coronary angiogram were observed. However, any factors as regards age, total cholesterol, HDL-cholesterol and Achilles tendon thickness failed to distinguish between the FH patients with a normal coronary angiogram and those without.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical studies on diabetic myocardial disease using exercise testing with myocardial scintigraphy and endomyocardial biopsy

Nine diabetics without significant coronary stenosis participated in an exercise testing protocol with thallium-201 myocardial scintigraphy. Endomyocardial biopsy of right ventricle was also obtained. There were 4 patients with abnormal perfusion (positive group) and 5 patients with normal perfusion (negative group). All cases of the positive group were familial diabetics and there was only one case of dietary treatment, whereas in the negative group, there were only 2 cases of familial diabetics and 3 cases receiving dietary treatment. No statistical differences between the positive and negative groups were observed for the data of exercise performance and hemodynamic parameters in cardiac catheterization at rest. However, the mean ejection fraction in the positive group (62 +/- 13%) was significantly lower than in the negative group (77 +/- 4%). In both groups, the mean diameter of myocardial cells and the mean percent fibrosis of biopsy specimens showed significant increases compared with the control group. The mean percent fibrosis in the positive group (24.1 +/- 8.5%) compared with that in the negative group (16.5 +/- 5.9%) showed a tendency to increase. It is suggested that the abnormal perfusion of thallium-201 in the positive group indicates subclinically a pathological change of microcirculation caused by diabetes mellitus.

[Left ventriculography and serial ECG changes in hypertrophic cardiomyopathy with special reference to the negative T wave]

To clarify the correlation between the configuration of the left ventriculogram and serial ECG changes, 16 patients with hypertrophic cardiomyopathy (HCM) associated with asymmetrical septal hypertrophy were examined. In the right oblique view at end-diastole, the configurations were classified by form as round (R, n = 7), round with inferior concavity (R-i, n = 2), spade (S, n = 4) and spade with inferior concavity (S-i, n = 3). These patients were divided into two groups according to serial T wave changes; nine with marked changes (A group) and seven without (B group). Furthermore, group A was separated into two subgroups; seven with increasing negativity or appearance of the negative T wave (A-1 group) and two with decreasing negativity or disappearance of the negative T wave (A-2 group). The results were as follows: Five (71%) of the seven cases with the S and S-i form belonged to the A group. Their apical walls showed marked hypertrophy and their ECGs showed deep negative T waves. The other two cases (29%) belonged to the B group, and did not show marked apical hypertrophy. Four (44%) of the nine cases with the R and R-i form belonged to the A group. They showed mild apical hypertrophy, and initially did not show deep negative T waves. A deep negative T wave appeared in three during observation. The initial depth of the maximum negativity of T wave correlated significantly with apical wall thickness, SV1 + RV5, and the total depth of the negative T wave in precordial leads. During the observation, the A-1 group showed a marked increase of SV1 + RV5. The A-2 group showed a decrease of SV1 + RV5. In conclusion, HCM with deep negative T waves has a tendency to present wide changes in the T wave during serial ECG observation and to show apical hypertrophy on left ventriculography. Cases of increasing negativity of the T wave showed marked increase in voltage of SV1 + RV5. However, cases of decreasing negativity of the T wave showed decreasing SV1 + RV5. These ECG changes, especially the negative T wave changes are reputed to be related to apical wall thickness.

An adult case of mixed connective tissue disease associated with perimyocarditis and massive pericardial effusion

We report the case of a 55-year-old woman with mixed connective tissue disease (MCTD), who developed perimyocarditis associated with massive pericardial effusion. The diagnosis of MCTD was based on clinical and serological findings. We confirmed myocarditis by right ventricular endomyocardial biopsy. The pericardial effusion gradually disappeared after the administration of prednisolone. Although there have been several reports of cardiac disease in adult MCTD, few cases of adult MCTD having perimyocarditis associated with massive pericardial effusion have been reported.

The correlation between the diameter of biopsied left and right ventricular myocardial cells and hemodynamic parameters in essential hypertension and mitral valve disease

For the purpose of studying the correlation between the diameter of myocardial cells and hemodynamic parameters in human beings, the left ventricular endomyocardial biopsy was performed in 29 cases. Eleven cases were normotensive patients. The remaining 18 subjects had a history of hypertension for more than 5 years. The mean diameter of the left ventricular myocardial cells was correlated with the systolic aortic pressure (r = 0.51, p less than 0.01) and the systemic vascular resistance index (r = 0.66, p less than 0.01). The same study was done on the right ventricle of 7 controls and 11 patients with mitral valve disease in which chronic right ventricular pressure overload was present. The mean diameter of myocardial cells biopsied from the right ventricle was correlated with the systolic pulmonary arterial pressure (r = 0.61, p less than 0.01) and the pulmonary vascular resistance index (r = 0.72, p less than 0.01). These findings indicate that the diameter of myocardial cells in both the left and right ventricles was closely related with its afterload.

Left ventricular endomyocardial biopsy findings in patients with essential hypertension and hypertrophic cardiomyopathy with special reference to the incidence of bizarre myocardial hypertrophy with disorganization and biopsy score

To investigate whether bizarre myocardial hypertrophy with disorganization (BMHD) is characteristic of hypertrophic cardiomyopathy (HCM), the histopathology of the biopsied left ventricular myocardium in 18 patients with essential hypertension (HT) and 14 patients with HCM was studied. A "biopsy score" was devised for a more quantitative evaluation of the BMHD and a comparative study on the biopsy score of the left ventricular biopsied specimen was also performed. The patients with HT were judged to be in stages I or II of the WHO criteria and had a history of hypertension of more than 5 years. The BMHD was defined as myocardial cells showing hypertrophy, disorganization, and bizarre nuclei. "Disorganization" of myocardial cells was distinguished both by the terminology and histopathological characteristics from "disarrangement" of myocardial cells. The biopsy score employed four factors and was determined according to the following formula: Biopsy score = hypertrophy of myocardial cells + (disorganization of myocardial cells) x 2 + bizarre nuclei + whorling of muscle bundles. Both the hypertrophy and the disorganization of myocardial cells were regarded as essential conditions indicating the presence of BMHD. The BMHD was found in 2 of 18 patients with HT (11%) and in 10 of 14 patients with HCM (71%) in the left ventricular biopsied specimens (P less than 0.005). However, "disarrangement" of myocardial cells was found in 13 of 18 HT patients (72%) and in 10 of 14 HCM patients (71%) in the left ventricular biopsied specimens, showing no difference between the two groups. The biopsy score in HCM patients was larger than that found in HT patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Biventriculographic and clinicopathologic evaluation of apical hypertrophy: with reference to asymmetrical septal hypertrophy with hypertension]

To clarify the pathogenesis of apical hypertrophy with asymmetrical septal hypertrophy (ASH), left ventriculography in the right anterior oblique projection (LVG), biventriculography (BVG), and endomyocardial biopsy of the right ventricle were performed for patients with ASH. The patients were categorized in four groups according to ECG, LVG and BVG. Patients with hypertrophic cardiomyopathy (HCM) were divided into two subsets; (A) Apical hypertrophy group (AH: nine patients), with ECG showing left ventricular hypertrophy (LVH) and giant negative T waves (GNT), and with LV configurations showing the S or SR form at end-diastole on LVG. (B) Non-apical hypertrophy group (non-AH: 12 patients), with ECG showing LVH without GNT and LV configuration showing R form at end-diastole on LVG (cf: Fig. 1). Patients with ASH and hypertension (ASH-HT) were also divided into two subsets; (A) AH: seven patients. (B) non-AH: nine patients. Analysis of LVG and BVG: In HCM, the septal configuration showed the TS X S form in both two subset groups. The septal configuration in ASH-HT was divided into the NH form, which was clearly distinguishable from the septal configuration in HCM, and the TS X S form as in cases with HCM. In both HCM and ASH-HT, the diastolic thickness of the anterior apical wall was significantly thicker in all patients with AH than that in non AH. In HCM, the diastolic thickness of the septum and the percent systolic thickening did not significantly differ between AH and non-AH groups. In ASH-HT, the NH form showed similar diastolic thickness of the septum and % systolic thickening in AH and non-AH groups. On the other hand, the TS X S form in non-AH group showed greater thickness and lower % systolic thickening similar to those of HCM. Histological analysis of endomyocardial biopsy; In HCM, the transverse diameters of the myocytes and the biopsy scores did not differ significantly between AH and non-AH groups. In ASH-HT, the TS X S form in non-AH group had longer diameters and higher biopsy scores similar to those of HCM compared to the NH form in AH group. In conclusion, both HCM and ASH-HT may have apical hypertrophy manifested by giant negative T waves in the EKG and spade like form of left ventriculogram. In addition, apical hypertrophy in ASH-HT with the NH form of septal configuration seemed to be caused by hypertension.

Quantitative approach to the histopathology of the biopsied right ventricular myocardium in patients with diabetes mellitus

For the purpose of studying the clinicopathology of the biopsied myocardium in patients with diabetes mellitus, the diameter of right ventricular myocardial cells and diffuse perimysial fibrosis of biopsied myocardium were measured quantitatively. Seven healthy controls and nine diabetic patients without hypertension or coronary arterial disease were subjected to this study. The degree of diabetic complications was mild to moderate. The diameter of myocardial cells was measured and the degree of diffuse perimysial fibrosis was assessed by the point-counting method using a square grid, in which the distance between the points was 10 micron. Over 2000 points which lay on the longitudinally cut myocardial cells and on the interstitial fibrosis stained by the Mallory-Azan method were measured. Percentage fibrosis was calculated according to the formula: percentage fibrosis = (points lying on the interstitial fibrosis)/[(points lying on the myocardial cell) + (points lying on the interstitial fibrosis)] X 100. The results were as follows. The mean diameter of right ventricular myocardial cells in patients with diabetes mellitus was significantly larger than that of controls (P less than 0.01). The percentage fibrosis of diabetic patients was significantly higher than that of controls (P less than 0.01). There was no significant correlation between the histopathological measurements and clinical features. It is concluded that hypertrophy of myocardial cells and interstitial fibrosis of the myocardium exist even in mild diabetes mellitus.

[Evaluation of septal hypertrophy and wall dynamics by biventricular cineangiography and endomyocardial biopsy]

To clarify clinically the pathogenesis of septal hypertrophy in terms of its morphology and wall dynamics, simultaneous biventricular cineangiography (BVG) and endomyocardial biopsy of the left ventricle were performed for patients with left ventricular hypertrophy. The patients were categorized in four groups according to their clinical and BVG findings; 1) 24 normal control subjects (C), 2) 39 patients with hypertension and symmetrical septal hypertrophy (SH-HT), 3) 17 patients with hypertension and asymmetrical septal hypertrophy characterized by the ratio (IVS/PW) greater than or equal to 1.3 by BVG, and 4) 25 patients with hypertrophic cardiomyopathy (HCM). The BVG's configuration of the septum in SH-HT showed a normal form of septal hypertrophy (NH form) essentially similar to that of the control subjects (N form), except for septal thickness increases of more than 10 mm. In HCM, a triangle or shell (TS) form or spindle (S) form of the septum was demonstrated by BVG. The TS form was characterized by straight or convex thickening of the septum from its center to its base toward the left ventricle. The S form was characterized by convex thickening localized to the central part and a relatively thin base. However, the configuration in ASH-HT was either the NH form (7 cases) or the TS or S form (10 cases). The configuration in ASH-HT with the NH form was not distinguishable from that of SH-HT, nor was the configuration in ASH-HT with the TS or S form distinguishable from that of HCM. Systolic thickening (%) of the septum and systolic shortening (%) of the septal length decreased significantly in this order: C, SH-HT, ASH-HT with the NH form, and ASH-HT with the TS or S form. Those of HCM were similar to those of ASH-HT with the TS or S form. In the cases of the N or NH form, there was a negative correlation between systolic thickening (%) and thickness of the septum in diastole. In cases with the TS or S form, systolic thickening (%) was not affected by the thickness of the septum in diastole, and a lower value was observed in all cases. Histological studies of endomyocardial biopsies revealed a positive correlation between the transverse diameters of the myocytes and the total systemic peripheral resistance (TSPR) in 25 patients with SH-HT. In 12 patients with HCM, there was no correlation, and severe hypertrophy of the myocytes was observed despite a lower TSPR.(ABSTRACT TRUNCATED AT 400 WORDS)

A case of juvenile hepatocellular carcinoma associated with liver cirrhosis in a family clustering of HBs antigen carriers and liver diseases

We describe a case of hepatocellular carcinoma in a 16-year-old boy whose mother, aunts, uncles, and cousins had liver dysfunction associated with HBs-Ag. Postmortem examination in this case revealed a hepatocellular carcinoma with a trabecular and partially pseudoglandular pattern involving the whole left and most of the right lobe, associated with liver cirrhosis of the postnecrotic type. Postmortem examination of the liver revealed numerous HBs-Ag positive hepatocytes demonstrated by Orcein staining in the nontumorous cirrhotic area, but not in the tumorous hepatocytes. Vertical transmission of HBV from his mother to the patient was suspected, and autopsy findings revealed continuous infection of HBV. Hepatocellular carcinoma in a young patient, especially when associated with HBs-Ag positive liver cirrhosis, as described here is rare in the English and Japanese literature.