Gated magnetic resonance imaging (MRI) was performed in 6 patients with familial hypertrophic cardiomyopathy associated with abnormal thallium perfusion, and 12 patients with ordinary hypertrophic cardiomyopathy. The patients with ordinary hypertrophic cardiomyopathy and abnormal thickening of the septal wall and normal left ventricular dimensions, while the patients with familial hypertrophic cardiomyopathy had focal wall thinning (usually involving the apical-septal wall) and dilated left ventricle in addition to hypertrophied heart. The quantitative measurement for cardiac dimensions using MRI was similar to that found on echocardiography in all cases. In addition, inhomogeneous signal intensities at left ventricular wall were observed in 3 cases of familial hypertrophic cardiomyopathy, which may suggest the existence of myocardial fibrosis. Gated MRI should be performed for early detection and follow-up of hypertrophic cardiomyopathy, since some patients will progress from hypertrophic cardiomyopathy to dilated cardiomyopathy.

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Right and left ventricular functions were assessed in children following surgical repair of tetralogy of Fallot. The results were analyzed with regard to the relative contribution of preoperative, perioperative and postoperative factors to postperative functional abnormalities. Pulmonary regurgination of our Grade 3 or more depressed right and left ventricular ejection fractions and enlarged right ventricular end-diastolic volume. Right and loft ventricular ejection fractions in patients with residual right ventricular outflow pressure gradients over 30 mmHg were significantly lower than those in patients with pressure gradients of 30 mmHg or less. The majority of those pressure gradients were at the pulmonary annulus or central pulmonary artery. Right and left ventricular ejection fractions were significantly lower in patients with a preoperative aortic oxygen saturation of less than 80% than in patients with one of 80% or more. The 3 variables of pulmonary regurgitation, residual pulmonary stenosis, preoperative aortic oxygen statistically independent. Left ventricular ejection fraction and end-diastolic volume correlated with the right ventricular ejection fraction and end-diastolic volume, respectively (r = 0.63, r = 0.68). These results show that severe pulmonary regurgitation, significant annular or central pulmonary stenosis and preoperative hypoxia are major contributing factors to right ventricular dysfunction after surgical repair of tetralogy of Fallot. The postoperative left ventricular dysfunction can be largely attributed to dysfunction of the right ventricle.

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A total of 20 patients were examined at rest and during stress with N-13-ammonia myocardial positron emission tomography (PET) before and after aortocoronary bypass surgery in an attempt to evaluate the effect of surgery on myocardial perfusion and to predict the graft status. The PET images were divided into anterior, septal, apical, lateral and posteroinferior segments for analysis and were evaluated as"normal"(no perfusion defects during stress and at rest), "ischemia"(stress-induced defects) and "fibrosis"(persistent defects both at rest and during stress). Approximately 90% of the segments which were ischemic before surgery became normal after surgery. Thus, ischemic changes are highly reversible, and the vessels perfusing these ischemic areas are most suitable for bypass surgery. However, most of the persistent defects failed to respond to revascularization surgery and, hence, represented irreversibly damaged myocardium. In predicting graft patency could be demonstrated by normal perfusion in postoperative images (p < 0.01) or by improved perfusion when pre- and postoperative images were compared (p < 0.01). However, graft occlusion could not be predicted reliablly. This study demonstrated that PET with N-13 ammonia was useful in the assessment of the effects of aortocoronary bypass surgery. However, this technique was not significantly superior to thallium-201 single-photon emission computed tomography for only qualitative analysis.

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To study relaxation characteristics of the infarcted myocardium, cyclic changes in the global left ventricular (LV) volume were measured in 20 patients with old myocardial infarction (OMI) and 17 normals (Normal) and those in the regional segment length were measured in 9 patients with anterior old myocardial infarction (anterior OMI) and 11 normals. The LV volume was calculated by using biplane LV cineangiograms. The regional segment length was calculated by measuring the spatial length between the 2 points of the ramifying branches on the left coronary arteries by using biplane coronary cineangiograms. The LV filling volume before atrial contraction (V_R) was significantly less in the OMI compared with that in the normals (Normal 38 ± 6 (mean ± SD) ml/m² vs 30 ± 7 ml/m² : p < 0.01), while filling volume by atrial contraction (V_a) did not significantly differ (Normal 15 ± 4 ml/m² vs OMI 17 ± 5 ml/m²). The lengthening of the segmental wall during diastole before atrial contraction (%L_R) in the infarcted portion was 5.0 2.9% which was also significantly less than that in the non-infarcted portion (9.6 4.2%). The extent of lengthening by atrial contraction (%L_a) did not differ between the 2 portions (non-infarcted portion 3.8 1.1% vs infarcted portion 3.5 1.2%). Reduction of %L_R was speculated to be caused by the incomplete relaxation in the myocardium adjacent to the infarcted portion and stiff myocardium in the infarcted portion. This study suggests that the infarcted myocardium may lead to a reduction of diastolic expansion before atrial contraction.

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End-systolic wall stress to end-systolic volume index (ESWS/ESVI) ratio is an index of myocardial contractility. In the presence of mitral regurgitation (MR), this ratio may be modified by the unloading effect of a leakage of flow into the low pressure left atrium. Therefore, to evaluate whether or not this ratio is an index of myocardial function in patients with MR, we compared the ratio with conventional measurements of myocardial performance in 11 patients with moderate to severe MR. The ESWS/ESVI ratio was 3.9±1.6 kdyn/cm⁵ per m² in MR and slightly lower than the control value of 4.6±0.6 kdyn/cm⁵ per m². The correlation between ESWS/ESVI ratio and ejection fraction was poor (r = 0.05, p : NS), while there was a close inverse correlation between the ratio and regurgitant fraction (r=0.76, p<0.01). These results strongly suggest that ESWS/ESVI ratio is a better indicator of myocardial function than ejection fraction in MR; however, this ratio could be affected by not only the inotropic state of the ventricle, but also by the extent of mitral regurgitation.

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Plasma renin activity in the renal veins (V) or infrarenal inferior vena cavae (IVC) of 20 patients with unilateral renovascular hypertension (RVH) was measured to determine how renal vein renin ratio (RVRR) compares with renin index (V-IVC/IVC) as a predictor of curability of RVH. Although there was no significant difference between them in predicting curability, 3 out of 4 patients with hypersecretion of renin (V-IVC/IVC &ges; 0.48) in the stenosed side with contralateral suppression (V-IVC/IVC &les; 0) on the normal side were cured. In addition, 7 out of 11 patients with contralateral suppression irrespective of values of renin index in the stenosed side were also cured. On the other hand, only one out of 6 patients who had neither hypersecretion nor contralateral suppression was cured. These results reconfirm that significant renin secretion with or without contralateral suppression, or only contralateral suppression of renin is highly suggestive of curable RVH.

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A 75-year-old man with quadricuspid aortic valve regurgitation affected by bacterial endocarditis is reported. The aortic valve consisted of 4 equalsized cusps (type a) and supernumerary cusp located between the right and noncoronary cusps. A right coronary ostium was close to the accessory commissure, but there was no displacement. A few small fenestrations were found at the 4 commissures and a large perforation resulting from endocarditis was observed in the noncoronary cusp. 2-D echocardiogram and angiogram suggested these findings, and they were confirmed at surgery. Successful aortic valve replacement was achieved.

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As an overview of cardiovascular disease in the aged, 3657 autopsy cases were analyzed for the frequency and age-wise incidence of cardiovascular disease. The three major categories, ischemic heart disease, valvular heart disease, and aortic aneurysm and dissection were described. 1. The incidence of overall cardiovascular disease increases sharply between the ages of 60 and 75. Prevention and treatment could be effectively directed at this age group. 2. The incidence of organic cardiovascular disease was: myocardial infarction 19.8 percent; valvular disease 10.0 percent; arteriosclerosis obliterans 3.5 percent; aortic aneurysm and dissection 3.3 percent; pericarditis 2.1 percent; cardiomyopathy 1.6 percent; cor pulmonale 1.4 percent; congenital heart disease 0.7 percent; and others 0.8 percent. 3. As coronary sclerosis progresses, death from ischemic heart disease increases; however, 7 out of 10 patients with 3 vessel disease still die of causes other than ischemic heart disease (pneumonia, malignancy etc.). The general management of infection and malignant neoplasms is important in addition to treatment of cardiovascular disease. 4. Except for mitral stenosis, valvular heart disease, the etiology of which is mostly non-rheumatic, increases with advancing age. 5. In aortic aneurysm, the rupture rate is relatively high in the thoracic aorta; however, this may be caused by the successful surgical repair of abdominal aneurysms. An aneurysm below 6 cm in diameter is not absolutely safe from rupture. 6. In aortic dissection, the interval from onset to the death of the patient is often too short to consider surgery.

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To examine the clinical efficacy of percutaneous transluminal coronary angioplasty in elderly patients, 350 consecutive procedures of coronary angioplasty were reviewed by dividing the patients into two groups: 142 cases of elderly patients whose ages were 65 years or older and 208 cases of younger patients. The primary success rate was satisfactory in both groups (8.6% in the elderly patients and 88.5% in the younger patients) and frequency of complication was acceptable (3.1% vs 2.9%) in both groups. Although restenosis tended to occur more frequently in the elderly patients (36.8% vs 27.1%), most of the lesions were re-dilated. These indicate that coronary angioplasty can be extended to elderly patients. The primary success rate started to decrease with circumflex arteries at age 70 years, and a similar trend was seen with right coronary arteries at age 65 years. Careful selection of the patients for coronary angioplasty as well as detailed analysis of the coronary anatomy and aorta are required to obtain clinical success and to prevent complications.

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Gardiovascular disease is the most common cause of death in the elderly. In fact, the cardiovascular disease is the number one cause of death in women and the number two cause in men of 65 years or over in Japan. We studied the clinical characteristics and significances of acute myocardial infarction as they relate to the aged.

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This study is a review of our experience with elderly patients, who have undergone coronary artery bypass grafting (CABG). Of 357 patients who underwent elective CABG from April 1982 to 1986, 50 patients (14.0%) were 65 years old or older. The incidence of preoperative cardiac conditions in the elderly was almost the same as that in patients less than 65 years of age. The incidence of noncardiac preoperative conditions in the older patients, such as diabetes mellitus, renal dysfunction, concomitant malignant disease, atherosclerotic lesion of the ascending aorta, was significantly higher than that in the younger age group. Early surgical mortality was 4.0% (2 cases) in the older group, and 1.3% (4 cases) in the younger group. There was no significant difference in statistics. The incidence of major postoperative complications was not significantly different between the two age groups, except that of cerebral infarction, which was significantly higher in the elderly group (6.0% vs 0.3%, p < 0.001). The rate of a long postoperative hospital stay was also significantly higher in the older group (43.8% vs 30.0%, p < 0.05). Longterm results, such as late mortality, symptom-free rate and graft patency, showed no significant differences between the two age groups. It is concluded that CABG can be performed in selected older patients with relatively low mortality and morbidity. Special attention should be paid to prevent perioperative cerebral infarction.

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One hundred and nine patients over the age of 65 years with valvular heart disease have been reviewed. Of these, 57 patients were treated medically (medical group) and the remaining 52 patients underwent valve surgery (surgical group). Of the 57 patients who were treated medically, 46 (81%) were in NYHA Functional Class I or II, 7 were in Class III, and 4 were in Class IV. Among these, there were 8 deaths. The 5 year survival rate of the medical group, calculated by the actuarial method, was 90 ± 5%. Eight patients had a nonfatal cerebrovascular accident. Of the 52 elderly patients who underwent valve surgery, 20 were in NYHA Functional Class II, 21 were in Class III, and 11 were in Class IV. Of these, there were 5 operative deaths (9.6%). Four patients died of postoperative low cardiac output syndrome and renal failure. One died of intraoperative aortic dissection. Of the 470 patients under the age of 65 years, there were 15 operative deaths (3.2%). Forty-one of the 47 hospital survivors have improved their cardiac functional classification, while 6 patients have remained in the same class as preoperatively. The average NYHA Class prior to operation was 2.7 improved to Class 1.3 after operation. The 3 year survival rate of the surgical group, calculated by the actuarial method, was 81 6%. Thus, the prognosis of asymptomatic elderly patients is good. Although operative mortality for the symptomatic elderly patients is relatively high, valve surgery can be performed with a satisfactory prognostic outlook.

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From January, 1979 to June, 1986, 70 consecutive elderly patients (30 males and 40 females) age 65 years or older underwent open heart surgery for valvular heart diseases at Mitsui Memorial Hospital in Tokyo. Seventeen patients (24.3%) were septuagenarians. Porcine bioprosthesis (Carpentier-Edwards) was inserted for the mitral and the tricuspid position, and mechanical valve (Bjork-Shiley or Duromedics) for the aortic position. Every patients received an antiocoagulant (warfarin) postoperatively all through the follow-up period. The mean duration of follow-up was 43 months and the cumulative follow-up was 195 patient-years. Fifteen patients died in hospital after operation, giving an operative mortality rate of 21.4%. Cardiac death occurred in only 5 and the other 10 patients died of other causes such as sepsis, cerebrovascular accident, and agranulocytosis, showing that these patients were already in an advanced stage of cardiac failure. Late death occurred in 5 patients, but there was no clear-cut cardiac death documented. The actuarial survival rated at 3 years old 5 years were 71.6% and 65.9% for all patients, and 90.5% and 83.3% for early survivors. The functional and symptomatic improvement of 49 late survivors was remarkable. Thirty-eight patients (77.6%) are now NYHA class I and II. The incidence of thromboembolic and hemorrhagic episodes was fairly low - 2% and 3% per patient year, respectively. Although the operative mortality is rather high in this study, it is clear that the surgical management of elderly patients with life-threatening valvular lesions results in substantial improvement and good prognosis in surviving patients. Advanced age alone should not be a contraindication to valvular surgery, and surgical treatment should be indicated in the earlier stages of cardiac failure.

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During the period from January 1983 to December, 1986, a total of 199 patients with thoracic aortic aneurysm underwent surgical treatment in our Cardiovascular Surgical Service. During this period, criteria for surgical indications were established and general surgical principles and techniques were standardized. As a consequence, surgical results appeared to stabilize during this period. It was clearly established that the surgical result for patients over 65 years was poor with high mortality compared to the younger age group (38.6% vs 7.2%). This tendency was in sharp contrast to that of abdominal aortic aneurysm surgery where low mortality (3%) was obtained regardless of age. Other factors influencing high mortality were as follows: 1) atherosclerosis as an etiological background, 2) aneurysm situated at the aortic arch, 3) Urgency for surgery, 4) pre- and postoperative status of respiratory and renal function. Late follow-up results showed that 25% of patients died, while 66% are in fair condition.

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Ninety-one patients with true and dissecting aortic aneurysm were reviewed. They ranged in age from 65 to 87 years (mean 71 years). Forty-eight patients were diagnosed with abdominal aortic aneurysm, 21 patients with thoracic aortic aneurysm and 22 patients with dissecting aortic aneurysm. They were divided into 2 categories, surgical group and non-surgical, and the prognoses of the 2 groups were compared. The average age of surgically treated cases was significantly younger than that of non-surgical cases. This study suggests that elective operation should be considered for abdominal aortic aneurysms because of the high risk of late rupture. In older patients with thoracic aortic aneurysm, the prognosis was better in surgically treated patients than in those not treated. However, the surgical mortality rate of elective operation was high. The surgical mortality rate of older patients with dissecting aortic aneurysm was not satisfactory, and medical treatment which decreases blood pressure should be considered first. All patients classified as Stanford type A should be operated on if possible.

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A total of 378 patients with aortic aneurysm, consisting of 128 with abdominal aortic aneurysm (AAA) and 250 with thoracic aortic aneurysm (TAA), underwent operation in our institution during the past 20 years. Of these patients, 58 with AAA and 63 with TAA were 65 years old or over. Preoperative complications tended to be observed more frequently in the aged patients than in the younger, `non-aged'patients. The early mortalities in the aged group were 5% for elective AAA operation, 40% for emergency TAA operation, 11% for elective TAA operation and 41% for emergency TAA operation. The 5-year survival rates in the aged group were 78.3 ± 5.8% for AAA and 63.4 ± 4.0% for TAA, which were not significantly different from those in the non-aged group, respectively. Postoperative complications tended to occur more frequently in the aged patients than in the non-aged patients both for AAA and TAA. The present data suggest that aggressive surgical treatment for aortic aneurysm in the aged is warranted unless other serious organ failure exists.

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