The effects of congenital right ventricular pressure and volume overload were studied in 3 patients with pulmonary stenosis. 7 with atrial septal defect and 6 with atrial septal defect plus pulmonary stenosis late after successful surgical correction. Gated equilibrium blood pool radionuclide ventriculography was used to measure right ventricular function at rest and during exercise and to compare it with eight normal subjects. Right ventricular ejection fractions at rest and during exercise were measured to be 61±9% and 66±13%. respectively, in the group with pulmonary stenosis. 49±7% and 54±8% in the group with atrial septal defect. and 65±13% and 69±13%, in the group with atrial septal defect plus pulmonary stenosis. The values in the groups with pulmonary stenosis and atrial septal defect plus pulmonary stenosis were significantly higher than the control subjects (45±5% and 51±5%, p<0.01) . The peak filling rate at rest and during exercise was also significantly higher in the groups with pulmonary stenosis and atrial septal defect plus pulmonary stenosis than in controls (at rest. 2.72±0.72, 2.53±0.94 vs. 1.64±0.24 p<0.05; during exercise. 4.38±1.23, 4.13±1.18 vs. 2.52±0.62, p<0.01). When patients with right ventricular systolic pressure equal to or greater than left ventricular systolic pressure and those with right ventricular systolic pressure less than left ventricular systolic pressure were compared, the right ventricular ejection fraction and peak filling rate were greater with the higher pressure at rest (71±10% and 3.12±0.81 vs. 55±3% and 2.30±0.27, p<0.05) and during exercise (75±11% and 4.86±1.01 vs. 59±3% and 2.61 ±0.35, p<0.05). Postoperative right ventricular hyperfunction may be due to preoperative pressure. but not volume. overload.

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Heart rate variation has been utilized as a parameter for validating autonomic nerve and sinus node function. However, few reports are available on the reproducibility of such data. In the present study, we studied the reproducibility of the diurnal variation of heart rate in 15 patients, and the effect of age differences on the variation in 30 normal men using a Holter ECG monitoring method. For investigating reproducibility. Holter ECG monitoring was per-formed twice, the two measurements being separated by a short interval. A moving average method applied on heart rate of every 3h exhibited essentially the same diurnal pattern of heart rate between two records in each patient. Excellent reproducibility of the pattern was also demonstrated by a lag correlation analysis. Variability of heart rate in normal men was independent of age. These results suggest that heart rate variation was essentially constant in each subject, at least within a short period.

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The long-term prognosis of athletes with long ventricular pauses has been unknown. In this study. thirty highly-trained cross-country skiers and 24 age-matched controls underwent 24 h Holter monitoring to detect the duration of the longest ventricular pause (LVP), and we followed the athletes for more than 3 years to evaluate prognostic significance of prolonged LVP. The LVPs of the athletes. averaged 2.2 ±0.6 sec (range 1.3-3.4), which were significantly longer than those. 1.6±0.3 sec, of the controls. In the athletes, 20 cases (66.7%) had LVPs more than 2 sec, and 5 (16.7%) showed LVPs longer than 3 sec. During 3 years follow-up, no athletes had symptoms of near syncope, syncope or death under continued heavy training. Our study suggested that athlete with pro-longed ventricular pause, even of 3 sec or more, did not have a different clinical risk than those without long pauses.

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Percutaneous transluminal coronary angloplasty has been reported to improve several clinical parameters. Functional papillary muscle dysfunction, which is also known to induce mitral valve regurgitation, is reversible after revascularization. We described a patient, with a 95% stenosis of proximal right coronary artery, whose mitral valve regurgitation disappeared after successful percutaneous transluminal coronary angioplasty.

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We report a case of a 48-year-old female who had atrioventricular nodal reentrant tachycardia (AVNRT) with 2:1 infra-His block and type 1 gap phenomenon.

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Human serum inhibited calcium ionophore-induced production of prostacyclin by cultured bovine aortic endothelial cells. The inhibitory fraction was purified from serum by anion-exchange and Blue-Sepharose affinity chromatography. The molecular weight of the purified substance was 67k dalton as determined by sodium dodecyl sufate-polyacrylamide gel electrophoresis. It was identified as human serum albumin by N-terminal amino acid sequence analysis. Human serum albumin was separated to two forms by high-performance liquid chromatography: mercaptalbumin (SH type) and nonmercaptalbumin (SS type). Both types of albumin inhibited the conversion of arachidonic acid to prostaglandin H₂ in a dose-dependent manner without affecting phospholipase A₂ or prostacyclin synthetase. This inhibition was more potent in mercaptalbumin than in nonmercaptalbumin. These results suggest that the conversion between mercaptalbumin and nonmercaptalbumin may play an important role in the modulation of prostacyclin synthesis by endothelial cells.

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A study of the natural history of 51 adult patients with atrial septal defect with pulmonary hypertension (ASD+PH) was performed. ASD+PH of less than 14 Um² of pulmonary artery resistance (PVR) was considered an indication for surgery. The prognosis of surgically treated patients was favorable. but that of medically treated patients was poor. For patients with ventricular septal defect with pulmonary hypertension (VSD+PH), surgery was considered for pulmonary-systemic vascular resistance ratio (Rp/Rs) less than 0.5. and for patients under than 10 years and, ideally, under 2 years of age.

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We have reviewed 116 cases of becterial endocarditis treated surgically and 26 cases treated medically since 1973. There were 123 patients with native valve endocarditis and 19 patients with prosthetic valve endocarditis. Overall, the left-sided valves were infected most frequently. There were 10 cases with right-sided valves involved. Multiple valves were infected in 6 patients. There were 6 perioperative deaths in the surgical group. The most common cause of death was multi-organ failure associated with uncontrollable sepsis. The overall operative mortality for active endocarditis was 7.7% (4/55), and for healed endocarditis. 3.3% (2/61). For active native valve endocarditis. the mortality was 4.2% (2/48), for healed native valve endocarditis. 3.6% (2/55), for active prosthetic valve endocarditis, 28.6% (2/7). and for healed prosthetic valve endocarditis, 0%. There was no difference in the operative mortality between active native valve endocarditis and healed native valve endocarditis. The mortality of active prosthetic valve endocarditis was significantly higher than that of active native valve endocarditis (p<0.01). Of the 26 patients treated medically. 7 died during the initial hospitalization. The major factor related to mortality in the medically treated patients was persistent sepsis (four patients), and congestive heart failure (three patients). The overall mortality of the medical group for active valve endocarditis was 15% (3/20), and for active prosthetic valve endocarditis. 67% (4/6). We conclude that patients with infective endocarditis with significant valve lesions who are unresponsive. to medical therapy should be considered for urgent surgery.

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Two hundred and five patients treated for infective endocarditis over the last 10 years were reviewed. There were 185 cases of native valve endocarditis (NVE) and 20 of prosthetic valve endocarditis (PVE). In the NVE group there were 175 clinically active patients and 10 non-active patients. The mortalities among 108 non-surgical and 57 surgical patients were 15.7% and 14.0%. respectively. Leading causes of deaths in the former were cardiac failure. embolism and cerebral hemorrhage. Patients with embolism showed significantly higher mortality. Culture negative endocarditis resulted in almost the same incidence of hospital death and urgent operation as staphylococcal endocarditis. and a higher incidence than streptococcal endocarditis. In 9 of 33 patients operated at our hospital, surgery was performed on an urgent basis and one NYHA class IV patient died. Indications for operation were intractable cardiac failure. uncontrollable infection and angina. In the PVE group, 3 of 4 patients operated in the active stage died of severe cardiac failure generated preoperatively. The only survivor was a patient operated early under stable hemodynamics. These results suggest that culture negative endocarditis should be observed as closely as staphylococcal endocarditis and early operation should be considered for patients with progressive cardiac failure, embolism and uncontrollable infection.

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From October 1981 to May 1990. 7000 elective percutaneous transluminal coronary angioplasties (PTCA) were performed at the Kokura Memorial Hospital, of which 5064 were analyzed using our computer system. The primary success rate of PTCA was 85%. in I vessel disease 88%, in 2 vessel disease 85%. and in 3 vessel disease 79%. Complications of PTCA were as follows: myocardial infarction. 2.1%; emergency CABG, 0.5%; death. 0.6%. We analyzed predictive factors for in-hospital death or emergency CABG. Five significant factors are significantly related: cerebral vascular accident, chronic renal failure, jeopardized collateral, abrupt closure, and dilatation of the left anterior descending artery.

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To evaluate the efficacies of percutaneous transluminal angioplasty (PTCA) and coronary artery bypass grafting (CABG) for angina pectoris, early and follow-up data were reviewed in 495 patients who had undergone these procedures from 1986 to 1988. In 173 patients with single vessel disease, there were no significant differences in initial success rate and early and late incidences of major complications or cardiac death between 152 patients with elective PTCA and 21 with urgent. When compared in 161 patients with multivessel disease, however, significant differences in success rate were found between 130 patients in the elective PTCA group and 31 in whom PTCA was urgent (81.6% vs. 64.5%, p<0.05). Significant differences were also found in early incidence. of major complications (3.1% vs. 12.9%, p<0.01), early mortality (1.5% vs. 9.7%, p<0.01). and the late incidence of cardiac events (6.2% vs. 25.0%, p<0.01). These results show that freedom from cardiac death and overall cardiac events in the elective PTCA group as significantly better than that in the urgent group at 42 months of follow-up. Comparing early and follow-up results, on the other hand, there was no statistically significant difference between the elective and urgent CABG groups. Thus, there appear to be limitations on the urgent use of PTCA for refractory unstable angina caused by multivessel disease, and urgent CABG was recommended to high-risk patients of urgent PTCA.

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To determine which therapeutic procedure is most appropriate for which type of aortic dissection, we investigated 146 cases of acute aortic dissection. In the group with dissection of the ascending aorta. 58.6% of patients given medical therapy and 48.8% of patients given surgical therapy died. In the group with dissection of the descnding aorta. 14.0% given medical therapy and 50.0% given surgical therapy died. High mortality in the medical group with type A dissection was caused by delayed operation. Better survival was achrered in treated than surgically treated patients with acute distal dissection. In patients with cardiac tamponade, aortic regurgitation, hemothorax/hemomediastinum. visceral ischemia and peripheral ischemia, mortalities following medical treatment were fairly high. Surgical treatment brought on improvement in mortality in these groups. However, in the cases complicated by renal dysfunction, the mortality in the surgical group was higher than that in the medical group. 42 patients (28.8%) had no evidence of any complication and only 6 (14.3%) died. In 20 cases (47.6%) of uncomplicated dissection, no blood flow was observed in the false lumen. In cases with open false lumen, the following abnormal findings were more conspicuous: thrombocytopenia, decreased level of fibrinogen, increased fibrin degradation product and soluble fibrin monomer complex. However, these changes seem to be minimal in cases with thrombosed false lumen. The measurement of coagulation factors may be one useful method to determine which therapeutic procedure is most suitable.

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Over the last ten years 96 patients with aortic dissection were encountered in our Institute. of whom 51 had type A dissection, and 45 had type B dissection. In the patients with type A dissection the long-term survival rate was poor if they were not operated upon without delay, and the cause of death was usually rupture of the aneurysms. In the patients with acute type B dissection the surgical indication was limited and, generally speaking the long-term survival rate of the medically trearted patients was more favorable.

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