The clinical applicability and usefulness of diagnostic procedures in nuclear cardiology have been briefly reviewed, and personal experiences in this field were presented.

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One hundred and four patients with congenital heart disease and over the age of 40 years have been visited the Second Department of Internal Medicine, Gunma University Hospital during the last 11 years. The most frequent lesion was the atrial septal defect of secundum type (72 cases) which was followed by ventricular septal defect (12 cases) and patent ductus arteriosus (7 cases). Forty eight of the above cases were first pointed out the cardiac abnormalities at the age of 40 years or later, while a correct diagnosis of congenital heart disease had been made only in 14 cases before.
The numbers of the disabled patients increased with the advancing age. Three fourths of the elderly patients over the age of 60 years were classified as being NYHA function class III or IV. Significant positive correlations were demonstrated between the age and the cardio-thoracic ratio and between the age and the right ventricular systolic pressure in atrial septal defect.
The clinical course of 68 cases followed for 2 years or longer were rather favorable under proper medical care. Only 3 died, while 9 cases without any medical supervisions were deteorirated. The course of 17 operated cases were good. Although an appropriate medical care is effective to relieve the symptoms, we thought that the surgical interventions should not be hesitated in middle-aged and even in elderly patients with congenital heart disease if indicated.

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The long-term results of surgical treatment in 97 cases of acquired valvular disease were compared with observations in 102 medically treated patients.
In the medical group, the 10 year survival was 48% in isolated mitral stenosis and 59% in mitral regurgitation with or without stenosis. The eight-year survival in aortic valve disease with or without mitral involvement was 70%. The leading cause of death was congestive heart failure, followed by cerebral embolism and sudden death.
The survival was significantly better in the surgical than in the medical group in the presence of obvious signs or histories of congestive heart failure. The prognosis was also more favorable in surgical group of mitral valve disease of NYHA functional classes II-IV. The occurrences of congestive heart failure and thromboembolism were less frequent in the surgical group.
Based on the above findings, we conclude that surgical intervention is indicated in valvular disease when signs or histories of congestive heart failure are obvious. Surgery is also the treatment of choice in mitral valve disease of NYHA functional classes II-IV.

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A follow-up study of 196 patients with atrioventricular block and long-term cardiac pacing revealed that the presence of congestive heart failure, cardiomegaly, significant coronary sclerosis and the advanced age were the important factors in a worsening prognosis. On the other hand, no prognostic factors were identified in sick sinus syndrome.
Forty of 275 patients with long-term cardiac pacing died during the last 12 years. Thirty-one died within three years after the implantation of the cardiac pacemaker. The leading cause of death was congestive heart failure (13 cases), followed by cerebro-vascular accidents (12 cases), sudden unexpected death (five cases), malignancies (five cases) and acute myocardial infarction (two cases).

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One hundred thirty-six patients diagnosed as idiopathic cardiomyopathy between April 1974 and July 1983. at the Second Department of Internal Medicine, Gunma University Hospital, were followed for an average of 36.6 months. During this period, 21 patients died, while 25 were lost to follow-up. The five-year survival rate was 94.0% in hypertrophic nonobstructive cardiomyopathy (HCM), 74.3% in hypertrophic obstructive cardiomyopathy (HOCM) and 70.7% in dilated cardiomyopathy (DCM), respectively. Eleven of 21 deaths were sudden and unexpected, while seven cases of DCM and one of HOCM died of congestive heart failure. An increased cardiothoracic ratio on x-ray film suggested a poor prognosis in DCM, but echocardiographic measurements of left atrial and left ventricular dimensions as well as the left ventricular ejection fraction were not useful for prognostic predictions. Thromboembolism was complicated in four cases of HCM and three of DCM. All seven were associated with atrial fibrillation. Routine use of anticoagulants was thought to be of value in idiopathic cardiomyopathy, both hypertrophic and dilated, when associated with atrial fibrillation.

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Right ventricular endomyocardial biopsies were performed in 34 patients with hypertrophic cardiomyopathy (HCM) and in 26 with dilated cardiomyopathy (DCM). The degree of myocardial interstitial fibrosis and that of myocardial fiber disarray were assessed from light-microscopic samples. Cell diameters were measured from the light-microscopic samples. For electron-microscopic investigation, a semiquantitative score system derived from Sekiguchi was used. The following results were obtained.
1) Interstitial fibrosis was more prominent in DCM, while myocardial fiber disarray was more so in HCM.
2) There was no correlation between myocardial cell diameter and ultrastructural alterations in HCM and DCM.
3) In HCM, myocardial fiber disarray was correlated with ultrastructural alterations.
4) In DCM, the left ventricular ejection fraction was negatively correlated with ultrastructural alterations.
5) In HCM, there was no correration between interventricular septal thickness and myocardial cell diameter.

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Fifty-one cases of acute myocardial infarction, 25 anterior and 26 inferior, were admitted to the Second Department of Internal Medicine, Gunma University Hospital, between August, 1980 and May, 1983. Right ventricular infarction was complicated in eight cases of inferior infarction. Although the male to female ratio was 2 : 1 in the group as a whole, only two of 19 patients under the age of 60 were women. There were nine hospital deaths (18%). The mortality rate was high in the eighth decade as compared with the seventh decade (10%) and younger age group (11%). Six patients died of pump failure, three of cardiac rupture.
The systolic blood pressure, heart rate, and pressure rate product were lower in inferior infarction than in anterior infarction. Ventricular tachycardia and/or fibrillation were complicated in four cases, while second to third degree A-V block appeared in 13. The latter was usually present in inferior infarction, especially in those with right ventricular involvement. Atrial tachyarrhythmias were also frequent in the presence of right ventricular infarction.
Five of eight cases with right ventricular infarction were classified as Forrester subset 3. In the cases with right ventricular infarction, the mortality was relatively low, although the hemodynamic disorders persisted longer than other cases. External pacemaker was usually needed for treatment of bradyarrhythmias associated with right ventricular infarction.

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Coronary angiograms of 17 patients with myocardial infarction and under the age of 40 were reviewed. As compared with older patients, multivessel disease was infrequent. None had three vessel disease and only four had two vessel disease., while no significant coronary stenosis was demonstrated in four. Stenosis of the left circumflex branch and right coronary artery was also infrequent. Corresponding to the low incidence of significant right coronary artery stenosis, inferior infarction was noted in only four of the patients. Multiple regression analysis to determine the relationship of the risk factors to the severity of coronary stenosis revealed that the multiple correlation coefficient was far greater in young than in older patients. The standard regression coefficient was great for total serum cholesterol and serum uric acid in young patients.

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The relationship of serum lipids, apoproteins and other hitherto known risk factors to the severity of angiographically defined coronary atherosclerosis was examined in 143 male patients between the age of 40 and 59. The severity of the coronary atherosclerosis was significantly correlated with plasma LDL-cholesterol, total cholesterol, the apo B/apo A-I ratio and the apo B/ Apo A-II ratio. On the other hand, no significant correlation was demonstrated between the severity of the coronary atherosclerosis and serum HDL-cholesterol, apo A-I, apo A-II and apo B. The coronary atherosclerosis was less severe in light drinkers than in nondrinkers.

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Clinical records of 23 cases of infective endocarditis admitted to our department during the last 11 years were reviewed. All had underlying heart disease : six had congenital heart disease and 17 had acquired valvular disease. The duration of the disease before the correct diagnosis was three months or longer in eight cases. Causative organisms were recovered in 16 patients (69.6%), while the blood culture was positive in 12 of 15 cases (80%) not receiving intravenous administration of antibiotics for at least seven days before admission. The most frequently recovered organism was streptococcus. viridans. Echocardiographic studies could reveal suggestive signs of the disease in 12 of 20 subjects. Congestive heart failure was a complication in 12 cases. Six patients died in the hospital, while three died after discharge. Of these, eight had acquired valvular disease. The mortality was high in the cases with negative blood culture. Marked anemia, low serum iron and low serum cholesterol also suggested a poor prognosis.

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In 145 outpatients with essential hypertension, the cardiac index correlated positively and the total peripheral resistance negatively with the age. The plasma volume was significantly increased in hypertensives over the age of 60 as compared with the normal volunteers. Although the plasma norepinephrine level increased with advancing age in normal volunteers, no significant correlation was observed between the these values in hypertensives. The plasma norepinephrine levels tended to be higher in the hypertensives than in normotensives among the subjects aged under 40. There was a negative semilogarithmic correlation between the basal plasma renin activity and the salt intake in hypertensives. The plasma norepinephrine levels were not different in subgroups of hypertensive patients with high, normal and low renin activity. The degree of plasma renin activity increased after furosemide injection and was negatively correlated with the salt intake as well as the age.

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The diagnostic validities of abdominal computed tomography, adrenal isotopic scanning and adrenal venous sampling for localization of adrenal lesions were compared in 18 cases of primary aldosteronism including 15 cases with adrenal adenoma and 3 cases with adenomatous hyperplasia. Of the above 3 diagnostic procedures, It was concluded that computed tomography was the most accurate and useful. The localization of the adrenal lesion was precisely diagnosed by this procedure in 94%, while accurate diagnosis was made in 71% by adrenal venous sampling and in 56% by adrenal isotopic scanning, respectively.Abdominal computed tomography failed to demonstrate the adrenal lesion in only 1 case with the smallest adenoma of 0.9 × 0.8 × 0.7cm in size. The incidence of false positive diagnosis was 12% for adrenal venous sampling, but nil with computed tomography or adrenal isotopic scanning.

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Quadriceps femoris muscle biopsy was performed in 29 cases of motor nueron disease, consisting of 17 cases of amyotrophic latemal sclertosis (ALS) and 12 cases of spinal progressive muscular atrophy (SPMA). The average age was 61 years for ALS and 51 years for SPMA. Small angulated fibers were demonstrated in all of the patients, including those with only little clinical evidence of muscle weakness. Group atrophy, significant muscle fiber atrophy and the appearance of targetoid fibers, characteristic of the degenerative process, were more prominent in ALS and/or those with rapid progression of the disease, while signs indicating regeneration, such as type grouping and the appearance of hypertrophic fibers, were more prominent in SPMA and/or those with slow progression. Type II grouping was more frequently seen than type I grouping in all subgroups. A possibility was considered that the prognosis of motor neuron disease might largely depend on the degree of type II regeneration.

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During the last 11 years, 259 diabetics who visited our outpatient diabetic clinic were treated for at least for six months. Of these, 111 are still regularly visiting our outpatient clinic and 58 are cared for at other medical insitutions, while 40 died and 21 are without any medical supervdsion at present. Twenty-nine cases were lost to follow-up. All the living patients initially treated by insulin are under proper medical care now.
The mortality rate was significantly higher in insulin-treated patients than in those given diet therapy alone or those treated by oral hypoglycemic agents. The mortality rate was also high in patients over the age of 60 years and in relatively young patients under the age of 40 years. The leading causes of death were cerebrovascular accidents (11 cases) and heart failure (11cases).

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One hundred seventy patients underwent fiberoptic bronchoscopy (FOB). Transbronchial biopsy (TBB) in 22 patients with intrabronchial lesion visible achieved an overall 68% diagnostic success rate of 68% for final dibgnosis. Transbronchial lung biopsy (TBLB) in 82 patients with diffuse and localized diseases achieved the same success rate. Using these two methods and transbronchial brush biopsy together yielded a higher rate of diagnostic success (78%).
FOB was performed for various thoracic diseases. Primary lung cancer was the most frequently encountered disease (24%), obstructive lung diseases were the second (11%), and lung tuberculosis was the third (10%).
A positive cytology on biopsy material was obtained at the rate of 84% in patients with primary lung cancer. TBLB revealed granuloma compatible with sarcoidosis in four of six patients with stage I sarcoidosis. FOB was also of great value for the diagnosis of infectious pulmonary diseases, especially tuberculosis, and was very useful to diagnose diffuse pulmonary diseases.
Complications with TBB, TBLB and brush biopsy were unilateral pneumothorax in one case and a small amount of bleeding in several patients.No severe complication was observed.

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We have often noted that the values for some blood components, such as serum protein and hemoglobin, in patients during hospitalization are lower than those taken at an outpatient clinic, and the differneces seem to increase by age. One hundred and two not severely ill patients were divided into 3 groups by age : 1) less than 39, 2) 40-69, and 3) more than 70 years old. Blood components, i.e., serum protein, red blood cells, hemoglobin, hematocrit, serum sodium, serum potassium and serum urea nitrogen, were determined at the outpatient clinic during hospitalization early in the morning with the subjects in the supine position and again after discharge at the outpatient clinic. Serum protein, red blood cells and hemoglobin significantly decreased on admission, but serum sodium, potassium and urea nitrogen did not change as compared to the outpatient status. The alteration in serum protein was greater by age, though not significantly so. As the difference between in-and outpatients might be caused by the shift of body fluid distribution by posture, plasma volume and extracelluar fluid volume were measured in the supine and standing positions in 6 healthy subjects. In the standing position, a significant decrease in plasma volume but not in extracelluar fluid volume, was observed, indicating that body fluid shift occured from the intravascular to extravascular space. Thus, serum protein, red blood cells and hemoglobin, which are not permeable from intra-to extravascular space were diluted when they were withdrawn early in the morning in the recumbent position during hospitalization. On the other hand, no significant changes were observed in serum sodium, potassium and urea nitrogen, which move freely between the intra-and extravascular space.

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