In order to clarify the reason the author stands against the movement for cardiac transplantation in Japan, certain crucial differences between death judged by the classical criteria and so-called brain death are briefly discussed, followed by the presentation of three major arguments. First, various problems associated with postoperative care of organ recipients are delineated, particularly side effects of immunosuppressive drugs and long term prognosis with reference to life expectancy as well as quality of life. Second, it is emphasized that transplantation involves prejudice and inequality, since the number of potential organ recipients far exceeds that of donors and only a small portion of transplant candidates can actually receive the organs while others have to wait in vain. Third, once organ transplantation from brain dead patients is allowed, numerous ethical and social problems would arise including an arbitrary expansion of the criteria for brain death, selection of donors and recipients by taking non-medial factors into consideration, development of organ commerce leading to the involvement of organized crime, and the birth of a trend in transplant candidates to wish for an early death of histocompatible donors. Finally, it is pointed out that we must give serious thought to the danger of "from neck down" transplantation creating a new person from two bodies (which is a brain transplant in actuality) in the future, since the difference between such a procedure and the multiorgan transplantation presently practiced in many developed countries is only quantitative and one cannot find a logical reason to ban the former while retaining the latter.

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The association of obesity and hypertension is well documented, and the combination is important as a coronary risk factor, but its nonpharmacological management is very difficult.
Japanese hypertensive obese subjects (HO, n=95) selected from 321 nonmedicated obese subjects with a body mass index>25kg/m² were characterized by the clinical features of significant diaphragmatic elevation, higher heart rate (HR), fasting blood glucose (FBS), total cholesterol (Tch), uric acid and γGTP values and lower vital capacity (VC) compared to those of normotensiveobese subjects (NO, n=226) (p<0.01). During a diet therapy program (about 1, 200kcal/day) for HO (n=55), 25 subjects were treated with a non-drug-dependent pulse-synchronized transpercutaneous electric abdominal muscle stimulator (PEM) (ca. 30, 000 muscle contractions/day) for 4 weeks. These subjects showed significant improvement with reduction in body weight (9.4%, 7.4kg), intra-abdominal visceral fat (VF) CT scan area (29%), abdominal subcutaneous area (10%) at the level of the umbilicus, blood pressure (BP), HR, FBS, γGTP, Tch, plasma norepinephrine, plasma renin activity and plasma insulin, an increase of VC and lowering of the diaphragm (p<0.05). The reductions in weight, BP, FBS and Tch in the diet group (n=30, 1, 200kcal/day for 4 weeks) were smaller than those in the PEM-diet group (p<0.05).The Japanese hypertensive obese patients had complications of many other coronary risk factors, and the reduction in weight and VF with PEM-diet therapy seems to be effective for improving these risk factors.

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Heart rates (HR) were measured before (control HR) and after (ischemic HR) balloon inflation during percutaneous transluminal coronary angioplasty in 96 patients with effort angina pectoris. The delta HR, defined as (ischemic HR-control HR), in the right coronary artery occlusion was significantly smaller than that in the left anterior descending artery or left circumflex artery occlusion. Among right coronary artery occlusions the delta HR in segment 1 occlusion was significantly smaller than that in segment 2 or segment 3 occlusion. It is suggested that the ischemia of the right ventricle plays an important role in producing a reflex bradycardic response in humans.

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Programmed cell death or apoptosis plays a major role in the modification of morphologic and functional maturity in various normal organ systems. However, it is also related to certain diseases. We conducted a pathological study of the apoptosis of cardiomyocytes in six cases with myocarditis (three of acute myocarditis and three of chronic or persistent myocarditis) using histochemical methods. In normal hearts obtained from autopsy cases, apoptosis was seen in endocardial cells. There was no apoptosis in myocardial cells, except for a few in myocytes with two nuclei. In myocarditis, although the myocytes of all cases with acute myocarditis did not show apoptosis, one of the three cases with chronic or persistent myocarditis showed many apoptotic myocytes. Apoptosis may be one of the mechanisms causing myocyte damage in myocarditis.

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Pericardiocentesis and drainage with a silicon rubber line were performed safely in 55 patients via the subxiphoid (80 times) or apical (1 time) approach at the bedside without echocardiographic guidance. The subxiphoid approach, which is close to the posterior of the sternum or the costal cartilage with a small acute-angle (15-30°) to the parietal pericardium in front of the right ventricle, can avoid injuring the heart, liver and lungs. A line with sideholes near the distal end, which provides convenient drainage and has better histocompatibility, can be kept in place for a long period of time (1-82 days). It was also convenient to inject air, drugs or fluid through the line. There were no procedure-related serious complications or deaths. Emergency drainage with the Seldinger technique, especially for small to moderate effusions, is safe and simple.

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The incidence of atherosclerotic and thromboembolic complications is quite high in hypertensive patients. Blood platelets and fibrinolytic activity may play an important role in the development of these complications. We investigated fibrinolytic activity and in vivo platelet release reaction in essential hypertension.
Plasma levels of beta thromboglobulin (BTG), platelet factor-4 (PF₄), tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1) and plasminogen were determined in 36 essential hypertensive and 20 age and sex-matched control subjects. Plasma BTG levels were significantly higher in the hypertensive subjects than in controls (p<0.05), whereas PF4 levels were similar for both groups suggesting an increase of in vivo platelet activity. PAM antigen levels were found to be significantly higher in the hypertensive patients as compared to the control subjects (p<0.01). On the other hand significant variations of t-PA antigen and plasminogen values were not observed in the two groups.
These results suggest that essential hypertension is associated with decreased fibrinolytic activity and enhanced platelet activity as evidenced by high plasma levels of PAI-1 and BTG.

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Published studies have indicated a circadian variation in the occurrence of several acute cardiovascular events, e.g., myocardial ischemia, myocardial infarction, sudden cardiac death and cardiac arrest. The aim of this study was to determine if there is a circadian variation in the occurrence of fatal pulmonary embolism, and to evaluate possible differences in the temporal pattern in relation to sex and age.
230 cases of fatal pulmonary embolism (74 out-of-hospital and 156 hospitalized) observed in a general hospital over a 9-year period were considered. The total sample was stratified both by sex and into four groups by age including, respectively, subjects aged less than 60 years (group A), between 60 and 69 (group B), between 70 and 79 (group C) and 80 years and over (group D). The data were analyzed by the single cosinor method.A significant morning pattern was found for the total population (p=0.011), females (p=0.033), and age subgroups C and D (p=0.015 and 0.008), with respective acrophases at 11.57, 11.23, 10.54 and 13.24.
A morning pattern in the onset of fatal pulmonary embolism is confirmed for the total population, although sex and age seem also to play an important role.

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The concept of external work reserve (EWR) related to the end-systolic pressure-volume relation in the left ventricle and introduced in previous publications is investigated. The potential clinical usefulness of indexes related to EWR as well as to different areas under the end-systolic pressure volume line (ESPVL) is indicated. The possibility of non-invasive clinical application of the results of this study is discussed.

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This study tested the efficacy of high resolution miniature transesophageal echocardiography (m-TEE;3.5mm-diameter probe, 7.5MHz, axial resolution of 0.25mm) in the evaluation of atherosclerotic lesions of the thoracic aorta rabbits exposed to a high cholesterol diet. The effects of the ACE inhibitor Alacepril (90mg/kg) on atherosclerosis were also assessed in normotensive, high cholesterol-diet rabbits by m-TEE, both in situ and in vitro. Oral treatment with Alacepril was begun on confirmation of atherosclerosis after a three month high cholesterol diet (group AL). Ultrasound examination reliably distinguished the lesions of atherosclerosis in situ. A three month course of Alacepril treatment decreased the systolic and diastolic blood pressures by approximately 20 and 5mmHg, produced a regression of atherosclerosis and significantly decreased the intimal plus medial thickness compared with hyperlipidemic-controls (group HC) (1.0+0.3 vs 1.6+0.4mm, p<0.02). The intimal surface involvement area in group AL was marginally smaller than in group HC (57+23 vs 76+23%, p=0.06). The high dose of Alacepril in this study did not affect the serum levels of t-cholesterol, HDL-C, LDL-C, triglycerides, or apoproteins A-I and B. These results suggest that Alacepril can produce regression of atherosclerosis, without changing circulating lipoprotein or apoprotein levels. Further miniature TEE offers high repeatability and is useful both in situ and in vitro for determining changes in arterial wall thickness and the severity of atherosclerosis.

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Selective coronary arteriography, performed in a 67-year-old man with post-infarction angina, demonstrated severe three vessel disease and coronary fistulous communications with the left ventricular chamber adjacent to a giant mural thrombus formed in the apical aneurysm. Most of the contrast media seemed to empty directly into the chamber without presenting hypervascular blushes of the thrombus itself. This was somewhat different from the observation previously reported in a case with coronary fistulae associated with a post infarction mural thrombus. It was stressed that one should not misinterpret this condition as a rare coronary artery-cardiac chamber shunt associating myocardial infarction.

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A 29-year-old woman with a stenosed prosthetic Hancock valve implanted in the tricuspid position underwent successful dilatation of the prosthesis by percutaneous transluminal balloon valvuloplasty using an Inoue balloon specifically modified for this valve.

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