Since 1984, we started to use DSA for diagnosis of cardiovascular diseases at Kurume University Hospital. Then, since 1986, we have used DSA for the same purpose at Kurume National Hospital too.
The results of conventional and research DSAs which we have done for the last 3 years were briefly discussed.
Conventional DSAs, such as, intravenous right and left ventriculography, aortography were satisfactorily performed.
In order to clarify an accuracy of densitometrically measured cardiac volume from the DSA image, experimental phantom study and clinical left ventriculography were performed. Good linear correlations were observed between volumes measured by videodensitometry of the DSA image and the real volumes of the phantoms in the experimental study and between left ventricular volumes determined by videodensitometry with DSA and mesured by an area length method in the clinical study, unless the obtained density was too high to get saturated or too low to be miss-counted. Therefore, adequate gain setting of the instrument and use of proper concentration of the contrast medium appeared to be essential in determining heart chamber volumes using DSA densitometry.
DSA is a subtraction image, in which a difference in X-ray absorption from a mask image is linearly amplified. Therefore, it seems possible to evaluate a small change in X-ray absorption of the cardiac silhouette during a cardiac cycle, even without using contrast medium. Utilizing this property of DSA image, we have developed a new approach to evaluate global and regional left ventricular function by DSA without contrast medium.
Videodensitometric analysis of digital subtraction coronary arteriography, a new approach for calculating contrast disappearance half-life (T1/2), was assessed in determining regional myocardial blood flow quantitatively. The T1/2 was calculated from a time-density curve generated in the 4 sectors of the myocardium perfused by the left anterior descending coronary artery. The mean T1/2 value of the 4 sectors correlated inversely with the great cardiac vein flow measured by the thermodilution metod (r=-0.89), and appeared to be a reliable index of myocardial blood flow. The relation of mean T1/2 with percent stenosis of the left anterior descending coronary artery was curvilinear (r=0.88) and an abnormally high T1/2 occurred in patients with coronary stenosis greater than 75%. In patients with comparable stenosis of the left anterior descending coronary artery, the apical T1/2 was significantly increased in those with impaired apical wall motion, while it was significantly decreased in those with coronary collateral vessels.
These findings suggest that regional myocardial blood flow begins to decrease in vessels with greater than 75% stenosis, and that myocardial contraction and collateral flow are additional factors that modify regional myocardial blood flow.

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Electropharmacologists and cardiologists have proposed a number of classifications for antiarrhythmic drugs during the past 3 decades and most of them have provoked considerable controversy. The 4-part classification presented by Vaughan Williams in 1969, based on microelectrode studies in isolated cardiac cells exposed to a series of chemical compounds, has been generally accepted and is most widely used. Following this classification, antiarrhythmic drugs now clinically available are reviewed. Confusion arose when studies showed that some drugs have more than 1 mechanism of electrophysiological action. Although the classification is useful to get a quick referencec to the drug, to call a drug by the name such as “class×drug” may sometimes lead to misunderstanding. One must bear in mind that the “class” only indicates the dominant action. The division of class I into subgroups IA, IB, IC based on the frequency-dependent nature of action was introduced. Data on amiodarone, whose antiarrhythmic mechanism is uncertain despite its definite clinical efficacy, are discussed to some detail together with our experiences. In closing, it was emphasized that various therapy of underlying diseases itself might be important to treat arrhythmias through normalizing the external milieu or by eliminating arrhythmogenic conditions.

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Recently the aortic pulse wave velocity measurement (PWV) is used as an index of generalized arterioscleosis because the arteriosclerosis of many organs is said to be preceded by the aortic arteriosclerosis.
But in some cases, patients with the calcified aorta in the X-ray films of the chest or of the abdomen and with high PWV happened to have no apparent arteriosclerotic organ disease. This fact implies that PWV has some limitations and other methods should be used together, although this method is expediently valuable.
We found a gross correlation between PWV and the thickness of the aortic valve measured during diastole with M-mode echocardiography (r=0.44, p<.0.01).
The relationship was not so clear between PWV and the ratio of the area of the aortic wall and valves and that of the aortic lumen (T/L ratio) measured using two-dimensional echocardiography (r=0.39, p0.05).
There was no correlation between the thickness of the aortic valves and the aortic wall measured with M-mode echocardiography (r=0.15).
No correlation was found between PWV and the aortic index (%) measured in the chest roentgenogram (r=0.10).
The aortic index (mm) was correlated with the aortic root dimension measured with M-mode echocardiography (r=0.49).
These findings suggest that the measurement of the aortic valve with M-mode echocardiography can be used to assess the degree of arteriosclerosis. Furthermore, concomitant use of PWV can estimate the degree of patient's arteriosclerosis more accurately with echocardiography.
On the occasion of the echocardiographic examination for other purposes, we can incidentally assess the degree of patient's arteriosclerosis.

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Echocardiographic examination was performed on 20 patients with Duchenne muscular dystrophy (DMD). The following results were obtained.
(1) The value of left ventricular end-diastolic dimension (LVDd) was slightly larger in DMD patients, but no correlation was observed between LVDd and left ventricular ejection fraction (LVEF) or age.
(2) The thickness of left ventricular posterior wall (LVPW) and ventricular septum (VS) were within normal range. And there was no tendency that the wall thickness became thinner with decreasing LVEF.
(3) Inverse correlation was observed between age and LVEF; LVEF decreased with age.
(4) The maximal amplitude of wall excursion and percent systolic thickening of LVPW and VS decreased in proportion with decrease in LVEF. Furthermore, LVEF was more closely related to the changes of LVPW than those of VS.

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Aspects of seasonal variation in blood pressure and influences of antihypertensive treatment on them were studied by use of design of experiments. Two year follow-up studies were carried out on 30 patients with essential hypertension under the treatment with Indenolol hydrochloride as β-blocker, Nicardipine hydrochloride as Ca-antagonist, Trichloromethiazide as diuretics, respectively. Systolic and diastolic arterial blood pressures were measured by sphygmomanometry. Left ventricular ejection fraction, stroke volume and heart rate were measured by echocardiogram and Doppler cardiogram. These numbers were set into the 2×3 square columns, and the mean square of unbiased estimation of population variance between columns as well as between rows were calculated and significance of interaction was tested. The seasonal variation of blood pressure was recognized to be deformed by the antihypertensive drugs. The way of being deformed was different among the three according to their pharmacological properties.

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To investigate the mechanism of exercise-induced ventricular arrhythmias, we examined the relationship between the RR interval (RR) and the corrected QT interval (QTc) from 24 hour ambulatory electrocardiographic recordings of 16 patients with ventricular premature contractions (VPCs). In 4 patients with exercise-induced VPCs and ventricular tachycardias, negative correlation between RR and QTc was observed. On the other hand, in only one out of 12 patients whose frequency of VPCs were decreased or unchanged during exercise, negative correlation was demonstrated between RR and QTc.
These results suggest that the tachycardia-induced delayed repolarization (the tachycardia-induced QTc prolongation) which leads the disarrangement of action potentials in the heart may play a role in the genesis of exercise-induced ventricular arrhythmias.

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The effects of various adrenergic agents, adrenaline (Ad), noradrenaline (Nad), phenylephrine (Phe), methoxamine (Methox), isoproterenol (Isop) on (14C) lidocaine (Lid) absorption, duration of anesthesia, heart rate and ECG were studied in guinea pigs. The absorption of Lid administered intradermally at the shaven back was increased with time and its peak was obtained 70min. Ad (0.1-1.0μg) administered with Lid inhibited Lid absorption about 50-61% and duration of Lid anesthesia was prolonged to 11-56min. Nad, Phe and Methox (moles equivalent to Ad 1.0μg) inhibited the absorption 37-45% and prolonged the duration of anesthesia for 15-21min. Three-fold dosages of Nad, Phe, Methox, however, prolonged the duration of anesthesia for about 43-58min. Ad-produced inhibition of Lid absorption was also observed even on intramuscular administration into the femoral region. The heart rate was increased by Ad 1.0μg at about 50min, but immediately by Isop, together with a slight increase in P-and T-waves, shortening of the P-P interval on ECG. The other compounds did not show any effect on the heart rate and ECG findings.

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We pointed out the problems of the antithrombotic drugs, and evaluated antithrombotic therapy after cardiovascular surgery in the Iwakuni National Hospital. The total number of the patients on antithrombotic therapy was 165 cases. The numbers of the patients with aorto-coronary bypass, valve replacement and arterial bypass by the vascular graft were 45, 50 and 70 cases, respectively. The mean age of the patients (124 males and 41 females) was 60.5±9.8 years, and the mean follow-up period was 40±16 months.
Major hemorrhagic complications were recognized in six patients, and three patients died of intracranial hemorrhage. Three patients were complicated with systemic thromboembolism, and were treated successfully by intensive care. In this study, the number of the patients with surgical management was 12 cases.
We conclude that the patients with mechanical valve replacement, arterial bypass by the vascular graft less than 6mm in diameter and a history of thromboembolism should be on both anticoagulants and antiplatelet agents.

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Plasma concentrations of human atrial natriuretic peptide (hANP) were measured in ten patients with progressive muscular dystrophy.
Eight patients were Duchenne type, one congenital type and one limb-girdle type.
Plasma hANP level in a 29-year-old man with limb-girdle type muscular dystrophy suffered from congestive heart failure was extremely high. And plasma hANP level in a 20-year-old man with Duchenne muscular dystrophy suffered from respiratory failure was also high.
But plasma hANP levels in the remaining eight were in normal range in spite of decreased vital capacity and abnormal Q waves on electrocardiograms.

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A successful treatment with long-term intra-aortic balloon pumping (IABP) in a patient with cardiogenic shock due to recurrent acute myocardial infarction was described.
A 69-year-old male developed an acute myocardial infarction (AMI) of the left ventricular inferior wall and of the right ventricle with a peak CPK level of 2155 IU/1. After 10 days of conventional treatment, AMI of inferior wall of the left ventricle recurred with a peak CPK level of 460 IU/1 and followed by a cardiogenic shock. A balloon catheter with a volume of 30ml was introduced percutaneously via femoral artery. But the improvement of the patient's hemodynamic state was gradual and minimal, so IABP was continued for several days. The patient gradually took a better course, so we tried to wean him from it but failed at the early stage of weaning because of a fall in systemic arterial pressure. Meanwhile, a partial weaning was begun on the 10th day after the initiation of balloon support and completed on the 14th day. The patient was discharged about 4 months after his admission.
A prompt initiation of IABP in the early stage of cardiogenic shock is recommended in combination with surgical intervention, if necessary.

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Kimura's disease is a chronic granuloma with numerous infiltration of eosinophils, which involves mainly the soft tissue of the neck and the head region. It recurrs remission and exacerbation despite of surgery or chemotherapy with a long clinical course. Leukocytosis, mainly eosinophilia (over 1500/mm³) and an increase in serum IgE level are found in the majority of the cases. The characteristic pathological features are the proliferation of lymphofolliculoid structures and infiltration of numerous eosinophils.
Although various terms such as eosinopholic granuloma, eosinopholic lymphoid granuloma have been used for this disease, they all are classified in so called “hypereosinophilic syndrome (HES)”. In HES multiple organ systems are involved including the heart, the skin and the nervous system. In half of cases the heart involvement was found and their prognosis becomes poor. Half of them have mitral regurgitation and/or tricuspid regurgitation. This paper describes a case of Kimura's disease with mitral stenosis and tricuspid regurgitation.
A 35-year-old man who had been treated by chemotherapy and surgical excision since 5 years of age, was admitted to our hospital with a chief complaint of dyspnea on effort. On admission, mild leukocytosis (10400/mm³) with a differential eosinophil count of 48% was observed. Echocardiogram shows mild enlargement of the left atrium and the increase in echo intensity of the anterior mitral leaflet and chordae tendinea and the diminished DDR of the anterior mitral leaflet. On cardiac catheterization, the pressure gradient between pulmonary wedge pressure and the left ventricular enddiastolic pressure was 9mmHg and mitral valve area was 0.85cm². Biopy specimen from the right ventricular myocardium did not reveal the characteristic infiltration of eosinophils and fibriosis of the endocardium.Since he had not a history of rheumatic fever, we considered that he had a complication with mitral stenosis due to infiltration of eosinophils to the mitral valve and subvalvular apparatus.

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Congenital pericardial defect is a comparatively unusual condition and to date only about 100 cases have been reported_ in Japan. Most cases are asymptomatic and found by chance at thoracotomy, or at autopsy.
Recently we experienced a case in which a congenital partial pericardial defect was suspected from the resuts of two-dimensional echocardiography and pericardioplasty was performed.
A 21-year-old man was admitted to our hospital for evaluation of chest pain. He had pericarditis at 9 years of age.
The chest x-ray film revealed a prominence in the 2nd arch of the left heart border, and also the prominent part was suggested to be left atrial appendage by two-dimensional echocardiography. We confirmed the presence of a left atrial appendage by pulmonary arteriography and recognized the abnormal prominence along segments 1 and 2 of the diastole on left ventriculogram.
From the above findings, a diagnosis of a congenital partial pericardial defect was made.
Formerly, a diagnosis of this condition was made by using the method of artificial pneumothorax, but this technique was an invasive and painful one.
From our study it appears that two-dimensional echocardiography and cardiovasculography may be the beneficial alternative techniques for the diagnosis of congenital pericardial defect.

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Four patients with pulmonary arteriovenous fistula (PAVF) were treated for the past ten years. Examinations of their families revealed Osler's disease (hereditary hemorrhagic telangiectasia) in all. In the four families, another three cases of PAVF were found. Of these seven patients with PAVF, only three underwent surgery. Of four unoperated patients, one died of brain abscess ten months after the diagnosis, one suffered from cerebrovascular accident one year after the diagnosis.

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Recent studies indicate that cardiogenic pulmonary edema occurs due to the increases in the pressure and the permeability of the pulmonary capillaries. We reported the 71-year-old man with repeated episodes of pulmonary edema because of the administration of both indomethacin and nif edipine.
Some investigators reported that these drugs influenced the metabolism of PGE₂ and changed the glomerular filtration pressure. Thus, we concluded that these drugs causeda decrease in urine volume because of the drug-induced renal insufficiency, and then evoked the pulmonary edema due to an increase in the body fluid volume.

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