The widespread use of the pulsed Doppler echocardiography has facilitated the noninvasive evaluation of abnormalities in the hemodynamic events between the left atrium and left ventricle (LV) by using transmitral and pulmonary venous flow velocity patterns. However, it has been shown that loading conditions, especially preload, influence the indices obtained from these velocity patterns. Recently, tissue Doppler imaging (TDI) has been developed and applied in clinical setting to clarify LV myocardial function. In particular, this procedure has the following characteristics 1) circumferential and longitudinal information of LV myocardium can be obtained; 2) early diastolic LV myocardial parameters are not influenced by preload; 3) LV myocardial contractility can be evaluated from the early systolic parameter; 4) LV systolic and diastolic asynchrony can be detected; 5) myocardial velocity gradient obtained from color-coded TDI is not influenced by entire heart motion; and 6) TDI parameters are useful for establishing the prognosis of LV heart failure. In the future, improvements in devices will facilitate tissue characterization in patients with myocardial disease or detection of endocardial and/or epicardial involvement of LV myocardium in patients with ischemic heart disease.

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Multiple system atrophy (MSA) is a severe neurological degeneration manifesting cerebellar ataxia, untreatable parkinsonism and dysautonomia. Because of so seriously intractable disease as amyotrophic lateral sclerosis, no small numbers of MSA patient are hospitalized in the neurological wards of the National Hospital. In this paper, the clinical and pathological feature of longterm followed-up cases of MSA are reviewed on the basis of studies performed in Suzuka National Hospital; progressive degeneration of the ponto-cerebllar and extrapyramidal systems in neuroimaging, bath-tub hypotension, neuro-leptic malignant syndrome, endocrinological disorder and progressive cerebral atrophy.
For the elucidation of the etiology and establishedment of treatment of MSA, scientific investigation in the National Hospitals are necessary.

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The goal of this study is to determine the surgical indication of small unruptured intracranial aneurysm and the merits or the demerits of brain dock. For this goal the prospective study (SUAVe Study, Japan) is in progress at 16 national hospitals. These hospitals must observe the natural history of small unruptured intracranial aneurysm (under 5mm) without surgical treatment. Until this point, 171 unruptured aneurysms (145 patients) were followed for 8.1 months on average. The annual rupture rate was 1.7% for two ruptured aneurysms of all and 4.2% in multiple aneurysms. The enlargement of aneurysm size was recognized in 9 aneurysms. Eight aneurysms of this were multiple aneurysms and one was single. These findings show that the growth rate and rupture rate is higher in multiple aneurysms rather than in single and that small unruptured intracranial aneurysm (under 5mm) may be safe for a certain period.

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Prader-Willi syndrome (PWS) is caused by dysfunction of the imprinted genes in the proximal portion of the long arm of chromosome 15. The dysfunction results, in turn, from deletion in the paternal 15q11-q13 region, maternal uniparental disomy (UPD), and infrequently from genetic microdeletions or mutations. We studied 34 pediatric patients in whom PWS was suspected, and demonstrated deletions in 14 of them by FISH analysis. Two in whom no deletions were revealed by FISH analysis were seen through DNA polymorphism analysis to have UPD. In addition, one case of complex translocation and one of partial trisomy were found by ordinary chromosome analysis. Two patients in whom a chromosomal examination of the amniotic fluid was performed had normal karyotypes, and FISH analysis detected no deletions. These results suggested that FISH analysis alone may not be able to detect PWS with UPD, and may fail to detect other clinically very similar chromosomal abnormalities. We emphasize the importance of conducting DNA polymorphism analysis and ordinary chromosome analysis in conjunction with FISH analysis.

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We investigated the frequency, time, circumstances, causes and consequences of falling in fourteen patients hospitalized with progressive supranuclear palsy (PSP) compared with eleven patients with Parkinson disease (PD) without dementia and Yahr stage overIII for two months. The rate of falling patients was 50% in PSP, against 45% in PD. The mean frequency of falling per month in PSP tended to be more frequent than in PD (3.2 times per month in PSP, 0.7 in PD). More than 20% of PSP patients sustained external injuries as a result of falling. The site of the injuries was mainly the face and head. Furthermore, falling was observed even in the bedridden state in PSP. Thus, falling is a serious long-term problem in caregiving for PSP. It was suggested that the cause of falling in PSP was not only postural instability but also frontal lobe dementia. In practice, PSP patients sometimes showed sudden unexpected behaviour despite the medical caregiver's carefulness, so prevention of falling is very difficult. It is necessary to take measures for preventing and decreasing external injuries.

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Though it is reported with the validity of the ultrasonic scalpel (US) to skeletonize the internal thoracic artery (ITA), we experienced graft stenosis in our early stage. In this report we angiograhically assessed the frequency of the graft stenosis. Aorto-coronary bypass grating cases were divided into early group (E-group, n=14) and late group, (L-group, n=14). In E-group the dissection of the ITA using US was begun at the fascia of transversus thoracis muscle, but in L-group at the proxi mal portion, where ITA was surrounded by fat tissue and the hard fascia was dissected by mosquito clamp and opened by low current electrocautery far from ITA, Angiography was performed 3 weeks after the operation, The frequency of graft stenosis was reduced markedly from 20% in E-group to 0% in L-group. One of the cause of graft stenosis was thermal degeneration, that was caused by frequent use of US in the proximity of ITA at the hard fascia.

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Patients with ascending or aortic arch disease combined with cardiac disease were sometimes encountered. We analyzed surgical outcome comparatively with patients undergoing concomitant cardiac operation or aortic grafting alone. Subjects were 90 patients, aged 63 years (range, 26-83 year), undergoing artificial graft replacement of ascending and aoric arch disease between August 1994 and December 2000. Concomitant surgery group (group C) consisted of 39 patients undergoing graft replacement concomitant with cardiac repairs. Concomitant cardiac procedures involved 23 aortic valve resuspension, 4 Bentall, 2 aortic valve replacement (AVR), 2 coronary artery bypass grafting (CABG), 2 CABG+resuspension, and 1 each AVR+CABG, Bentall+CABG, David, ventricular septal defect closure, pulmonary artery plasty. Graft replacement alone group (group A) consisted of 51 patients undergoing aortic graft interposition alone. Hospital mortality was 18% in Ggroup C and 9.8% in Group A (P=0.35). By multiple logistic regression analysis, age (P=0.013), concomitant cardiac operation (P=0.0079), and aortic rupture (P=0.0045) were found to be independent predictors of hospital deaths. No significant difference was observed in postoperative complications between two groups. There was no significant difference in actuarial survival between the graft replacement of ascending or aortic arch disease with-and without-cardiac repair (74±8% vs. 79±6% at 3 years, respectively). Concomitant procedure of ascending or aortic arch surgery and cardiac repair was conducted acceptably. Hospital morbidity and mid-term survival did not differ significantly between two groups.

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Recently critical pathway (CP) has been adopted in a large number of hospitals. An advantage of introduction of CP is accomplishment of medical care for each patient on schedule. Both medical doctor and medical co-worker can grasp the schedule of medical care for a patient, and cooper ate sufficiently as a team, including division of work, advancement of speciality and efficiency of medical care.
In this symposium 5 speakers and 2 special speakers presented their lectures, then discussed with audience about present problem and future course of CP. At the end of the symposium, Dr. Kaname Moriwaki, a director of Minami Wakayama National Hospital, presented his special lecture. We hope that this symposium will be useful for the further improvement of CP for each disease.

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Three patients had cholesterol embolism after cardiac catheterization. All patients were more than 60 years old and had severe arteriosclerosis of coronary artery with risk factors. Two patients occured after diagnostic cardiac catheterization and one patient after percutaneous transluminal coronary angioplasty. Right femoral artery was used in all patients. Case 1 had skin manupulation and ischemia of peripheral artery. Early administration of steroid hormone did not improve clinical features and his toes were amputated. But he is followed at out-patient clinic with good life prognosis. In case 2 with acute myocardial infarction early administration of steroid hormone prevented the renal function from worsening. But he died of reccurence of acute myocardial infarction. In case 3 using steroid hormone improved renal function markedly. The prognosis of cholesterol embolism is usually very poor without any effective treatment. But ealry diagnosis and treatment might improve prognosis. Furthermore the procedure of cardiac catheterization without using approach through severe arteriosclerosis of aorta is important for the prevention of cholesterol embolism.

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