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We herein report the case of a 63-year-old man who presented with a 3-month history of a cutaneous nodular lesion of his jaw, low grade fever, lethargy and progressive cognitive impairment. He had a 30-year history of multiple sclerosis and had been treated with fingolimod for the previous 2 years. Laboratory data revealed CD4 lymphocytopenia and a tissue culture of the skin nodule was positive for Cryptococcus neoformans. Cerebrospinal fluid and serum cryptococcal antigen tests were also positive and we diagnosed him to have disseminated cryptococcosis. This dissemination might be associated with fingolimod-induced CD4 lymphocytopenia. The risk of an opportunistic infection should therefore be considered when encountering fingolimod-treated patients.

One hundred and seventy-two patients (110 were greater than or equal to 65 years and 62 were less than 65 years) with congestive heart failure (CHF) were prospectively evaluated to determine various pathophysiologic mechanisms of CHF. The incidence of CHF with normal left ventricular (LV) systolic function was higher in elderly (30% vs 12%, p less than 0.05). Of the 110 elderly patients, LV systolic function was impaired in 77. Fifty-five patients had LV dilatation without increased wall thickness, and the clinical diagnosis was "dilated cardiomyopathy in the elderly". Twenty-two patients had hypertrophied LV and a high incidence of hypertension, and they were diagnosed as "hypertensive heart failure" due to contractile dysfunction. On the contrary, the remaining 33 patients did not have impaired LV contractile function. Thirteen patients lacking LV hypertrophy had enlarged atria. CHF was induced by reduced chamber compliance called "the stiff heart syndrome". Twenty patients had hypertrophied LV and a high incidence of hypertension. They were diagnosed as having "hypertensive hypertrophic cardiomyopathy of the elderly" and abnormalities of diastolic function accounted for the CHF. Since echocardiography can easily and accurately diagnose the pathophysiologic mechanism of CHF, an increased awareness of its occurrence in the elderly and use of echocardiography would reduce diagnostic and therapeutic errors.

Between 1980 and July 1983 three infants and children with cardiac fibromas underwent surgical resection at Kobe Children's Hospital. Two of them survived and have an excellent clinical result 6 years and 7 years postoperatively. The results of late follow-up with the use of 24-hour dynamic electrocardiography, two-dimensional echocardiography, thallium-201 myocardial scintillation scan, and technetium 99m sodium pertechnetate-gated blood pool imaging have proved that the patients are free of arrhythmic episodes, free of recurrence of tumor, have no significant myocardial perfusion defect, and have normal left ventricular function.

To identify the evidence of presymptomatic manifestations of dilated cardiomyopathy (DCM), we studied 30 patients with latent DCM (mean 37 +/- 14 years) who satisfied the following criteria: 1) left ventricular (LV) systolic function was slightly reduced; 2) LV end-diastolic dimension (< 54 mm) and coronary arteries were normal. The incidence of ECG abnormalities was relatively high; nonspecific ST-T changes were the most common (90%). The incidence of grade 3 or 4 ventricular premature contractions according to Lown's classification on 24 hour ambulatory ECGs was 50%. Perfusion defects were observed in 83% on the thallium-201 images. Right ventricular biopsy showed that the interstitial fibrosis was milder (9 +/- 9%) in the study subjects than in 32 patients with DCM (17 +/- 8%) who were treated in our hospital, but there were no significant differences in the diameters of the myofibers (15 +/- 4 vs 17 +/- 4 microns) between the 2 groups. During the follow-up study, deterioration of LV dysfunction was observed in 3 patients. One patient died suddenly. These findings proved the importance of the early detection and characterization of latent state of DCM.

To evaluate the utility of rest-injected 201Tl initial and delayed images for assessing the viability of severe asynergic regions, we studied 17 patients with apparently prior infarcted myocardium in combination with 99mTc ventriculography before and after revascularization. In 51 regions with severe asynergy, the percent 201Tl uptake was calculated as the ratio of counts on the segment with asynergy to the maximum counts on the normal segment. Eleven of 14 regions with resting 201Tl redistribution (Group 1) had improved wall motion after revascularization. However, 14 of 37 regions without redistribution also improved (Group 2). Twenty-three regions without redistribution or improved wall motion after revascularization (Group 3) had lower regional 201Tl uptake on their delayed images than those in Groups 1 and 2. Moreover, the initial regional uptake of Group 2 was higher than that of Group 3. These results suggest that redistribution on rest-injected 201Tl scans indicates reversibility of severely asynergic myocardium and that high 201Tl uptake in regions without redistribution may predict improvement in wall motion after revascularization. We conclude that 201Tl uptake may be useful as a marker of viability of severe asynergic regions before revascularization.

We report 5 patients, who had no cardiac abnormalities at their initial evaluation but progressed to dilated cardiomyopathy (DCM) during a mean follow-up period of 8.2 years. Their echocardiograms revealed increases in left ventricular (LV) end-diastolic dimensions, deterioration of LV contractions, and reduction in the LV wall thickness. Electrocardiographic changes were developed of rhythm disturbances, intensified ST-segment and T-wave changes, and the prolonged QRS durations. These findings, especially those of electrocardiography, seemed to be important for an early detection and characterization of DCM.

To determine the incidence and clinical significance of pericardial effusion after acute myocardial infarction, two-dimensional echocardiography was serially performed in 137 consecutive patients. Pericardial effusion was observed in 45 patients (33%), of whom 22 were followed until they recovered and were discharged. Pericardial effusion was more frequent in patients with anterior acute infarction than those with inferior acute infarction, and so it was in non-recanalized patients than in recanalized ones. Patients with pericardial effusion had higher peak levels of creatine kinase, higher wall motion score indices, and higher defect scores of thallium imagings. The improvement of regional wall motion at an infarct zone in patients with pericardial effusion was less regardless of the successful early recanalization. These results show that pericardial effusion is a common event in patients with acute myocardial infarction and observation of transition of pericardial effusion is important for predicting prognosis.

In order to evaluate the usefulness of a stress T1-201 myocardial scintigraphy in semiquantifying the myocardial perfusion, 10 normal subjects and 71 patients with coronary artery diseases were studied with sequential imaging over 3 hours. Myocardial to background ration (M/B) in the exercise phase was significantly higher in the normal subject group than in the coronary artery disease groups. Three hours after exercise (redistribution phase), M/B decreased significantly in the normal subject group but remained unchanged in the coronary artery disease groups. Percent change of M/B with exercise was lower in the effort angina pectoris group (97 +/- 11.2%), and the old myocardial infarction group (101 +/- 14.5%) than in the normal subject group (127 +/- 12%). Sensitivity and specificity of this method were 93% and 47%, respectively. Out of 11 patients with variant angina pectoris, 9 patients showed positive scintigram. Of the 9, however, 6 cases were without organic coronary stenosis in the coronary angiography. There was a significant correlation between M/B on redistribution images (RD.M/B) and ejection fraction determined by left ventriculograms (r = 0.61, p less than 0.001), indicating a close relation between the amount of the residual viable myocardium and the left ventricular function. M/B and its percent change with stress T1-201 myocardial scintigraphy reflect the myocardial perfusion and myocardial perfusion reserve and their semiquantitative analysis provides a useful means for detection of ischemic heart disease.

A 40-year-old man was admitted to our hospital in May 1982 for evaluation of a heart murmur. A standard 12-lead electrocardiogram (ECG) showed an abnormal Q wave in lead III. Echocardiography revealed prolapse of the anterior mitral valve leaflet (MVP), but neither dilatation nor wall motion abnormalities of the left ventricle (LV) were observed. Thallium-201 scintigraphy revealed an abnormal thallium uptake at the apex and inferior wall. He had no episode of acute myocardial infarction or myocarditis, but complete right bundle branch block suddenly appeared, and he was hospitalized in October 1984. He had no coronary artery lesions, and only mild mitral regurgitation on left ventriculography. The motion of the interventricular septum and apex was reduced on echocardiography and a persistent perfusion defect was observed at the inferior wall and the interventricular septum on T1-201 scintigraphy. In December 1985, he experienced an Adams-Stokes attack due to complete atrioventricular block. Echocardiographically, the left ventricle became enlarged and the wall motion abnormality and a perfusion defect on T1-201 scintigrams were of relatively severe degree. Thus, left ventricular dilatation and wall motion abnormality may progress in some cases of MVP as it did in this one. We consider this case a very interesting one in speculating on the relationship between MVP and DCM.

In order to investigate the usefulness of percutaneous transluminal coronary angioplasty (PTCA) on subsequent left ventricular (LV) function in patients with acute myocardial infarction (AMI), regional ejection fraction (REF) was calculated from the left ventriculogram and compared in the acute and chronic phases (4 weeks after infarction) in 19 successful cases of PTCA (group A). In addition, 15 successful cases of intracoronary thrombolysis (PTCR) (group R) and 14 unsuccessful cases (group U) were also analyzed in this study. From the results, the following points were elucidated. (1) REF of group A in the chronic phase showed a significant increase compared to that in the acute phase (10 +/- 18% vs 20 +/- 19%, p less than 0.01), and this was similar to that observed in group R (9 +/- 19% vs 21 +/- 16%, p less than 0.01). (2) All cases in group A showed a significant increase in REF (p less than 0.02), if recanalization occurred within 3 hours after the onset of AMI. Some cases in the 3-6 hour recanalization group showed a decrease in REF. (3) In group A, only patients with subtotal occlusion on the initial coronary angiogram showed a significant increase in REF 4 weeks later (p less than 0.01), whereas patients with total occlusion on the initial coronary angiogram showed no significant increase in REF. (4) In group A, only patients recanalized between 3 and 6 hours showed a severe degree of prolonged contrast staining immediately after successful recanalization following PTCA. Thus, chronic phase regional wall motion was markedly improved by PTCA in those cases with residual flow. In contrast, abrupt recanalization after PTCA might causally decrease regional wall motion due to hemorrhagic infarction, if it is performed in cases with total occlusion.

Forty-seven patients with coronary artery disease characterized by angina pectoris and/or old myocardial infarction underwent two maximal exercise tests, the supine ergometer test and the upright treadmill test, to study the relationship between exercise capacity and exercise hemodynamics. Subjects were divided into 3 groups: Group I (n = 19) achieved 25 or 50 watts, Group II (n = 15) achieved 75 watts and Group III (n = 13) achieved 100 or 125 watts. During ergometer exercise, the mean pulmonary capillary pressure elevated by 25.3 +/- 8.3 mmHg in Group I, 20.8 +/- 8.8 mmHg in Group II and 12.0 +/- 8.4 mmHg in Group III; the Group III value was significantly smaller than the other groups. The stroke volume index decreased by 3.6 +/- 8.8 ml/m2 in Group I, and increased by 10.9 +/- 8.7 ml/m2 in Group II and 10.7 +/- 14.7 ml/m2 in Group III. Thus, the impaired exercise capacity correlated with the abnormal exercise hemodynamics and its severity. In addition, the exercise capacity in the treadmill test was comparable to that in the ergometer test. It was concluded that the impaired exercise capacity in the both supine and upright exercise tests was well related to the development of abnormal exercise hemodynamics in patients with coronary artery disease.

To elucidate the role of right ventricular asynergy and tricuspid regurgitation (TR) in hemodynamic alterations occurring during right ventricular infarction, left and right ventriculography with pressure measurements were performed in 22 patients with acute inferior myocardial infarction. Twelve patients with a proximal right coronary artery (RCA) occlusion (Group I) had elevated right atrial pressure (16 +/- 4 vs 8 +/- 5 mmHg, p less than 0.01), low cardiac output (2.5 +/- 0.7 vs 3.5 +/- 0.6 l/min/m2, p less than 0.05) and a greater degree of TR, compared with 10 patients with a distal RCA occlusion (Group II). Inferoposterior wall asynergy of the right and left ventricles was similar in Groups I and II. In Group I, there was an additional asynergy of the anterolateral free wall of the right ventricle. Cardiac output in those patients was not related to the left ventricular ejection fraction (EF) but to the right ventricular EF. A greater degree of TR was found in association with a lower right ventricular EF. The decrease in cardiac output was closely related to the extent of TR. These results indicate that right ventricular asynergy and TR due to proximal RCA occlusion may play important roles as causes of hemodynamic alterations seen during the acute phase of inferior myocardial infarction.

A patient with acute inferior infarct is described who showed increased 201Tl uptake in the anterior chest wall following cardioversion which mimicked increased lung uptake of the tracer. The site of accumulation of 201Tl corresponded to that of 99mTc-pyrophosphate (PYP) and the right sided catheterization revealed almost normal hemodynamic data.

A patient with malignant fibrous histiocytoma of the heart is described who was initially presented with a left atrial tumor. Subsequent 201Tl and 67Ga scintigraphy showed massive uptake of the tracers by the tumor and the pattern of uptake was thought to reflect underlying necrosis and hemorrhage within the tumor.

To evaluate the effects of early recanalization on left and right ventricular wall motion in acute myocardial infarction (AMI), we serially observed their degrees in 66 patients with AMI. The patients were categorized as Group 1:17 with spontaneous recanalization within 6 hours of onset of the chest pain; Group 2:34 with effective recanalization within 6 hours (10 by PTCR, 10 by PTCR+ PTCA, and 14 by direct PTCA), and Group 3:21 without effective recanalization. The Group 2 patients were classified in 3 subgroups according to the time intervals from onset of symptoms to recanalization; 11 patients with recanalization within 2 hours (Group 2a), 10 between 2 and 4 hours (Group 2b), and 13 between 4 and 6 hours (Group 2c). The left and right ventricular wall motion abnormality indexes (WMAI) were defined as the means of point scores for the degrees of regional wall motion abnormality at 11 segments of the left ventricle and seven segments of the right ventricle on serial two-dimensional echocardiograms. Results were as follows: 1. The LV-WMAI of Group 1 was smaller on day 1, and improved on day 28 as compared to those of the other groups (0.63 +/- 0.35 to 0.18 +/- 0.18, p less than 0.001). 2. The improvements of the LV-WMAI from days 1 to 28 in Group 2a (WMAI: 1.01 +/- 0.57 to 0.26 +/- 0.26, delta WMAI: 82 +/- 14%) and Group 2b (1.03 +/- 0.38 to 0.52 +/- 0.48, 54 +/- 36%) were greater than that in Group 2c (1.01 +/- 0.46 to 0.64 +/- 0.52, 38 +/- 47%).(ABSTRACT TRUNCATED AT 250 WORDS)

In order to differentiate transient myocardial ischemia from infarction, the delayed thallium-201 myocardial imaging (redistribution image) is widely utilized, however, the precise mechanism of redistribution remains unsolved. In the present study, we proposed a new method to elucidate myocardial ischemia on images. In normal subjects, patients with old myocardial infarction (OMI) without angina pectoris (AP) and patients with AP, 1.4 mCi of thallium-201 (Tl-201) was intravenously injected at the peak exercise, and immediately myocardial images were obtained in the three projections. Then, 0.3 mg of nitroglycerin (NTG) was sublingually given, and 0.6 mCi of Tl-201 was readministered. NTG myocardial images were analyzed in the left anterior oblique projection and evaluated visually and quantitatively. There was no significant difference in the relative activity on exercise to NTG images in normal subjects and patients with OMI, while patients with AP showed increased activity on exercise to NTG images. Furthermore, the increase in relative activity done by the exercise-nitroglycerin study was greater than that by the conventional exercise-redistribution study in patients with AP. It was concluded that a new method in the present study is able to image myocardial ischemia distinctly and could be useful in clinical studies.

This study clarified thallium-201 (Tl) kinetics in the early stage after exercise in patients with ischemic heart disease (IHD). Tl was administered for 39 patients with IHD and eight normal subjects during maximal exercise. Immediately after exercise, dynamic data were obtained using a double slant-hole collimator at one frame/2 min for a 20 min period. The data of 10 frames (20 min) were spatially smoothed, and semiquantitative segmental analyses of the uptake and kinetics of Tl were performed by computer. In eight normal subjects, Tl uptake was uniform throughout the continuous 20 min, and Tl activity was unchanged throughout the 20 min period after exercise. Among 39 patients with IHD, 39 had Tl defects in the first frame (initial defect). Among 39 initial defects, 15 (38%) showed complete or partial early redistribution as early as 20 min and Tl activity in the defect increased (10.5 +/- 1.5%) over the 20 min period. Early redistribution occurred in 10 (43%) of 23 patients with effort angina and in five (83%) of six patients with variant forms of angina, but in no patients with myocardial infarction. Patients with early redistribution showed a greater frequency either of good collateral vessels or of mild stenosis of the coronary artery, compared with those who had no early redistribution. In conclusion, analysis of Tl kinetics in the early stages after exercise can provide important information about the coronary perfusion state during recovery from transient ischemia, and early redistribution may be a sign of preserved hyperemic flow in the ischemic region.

The purpose of this study was to investigate the relationship between exercise capacity and resting left ventricular function assessed by several non-invasive methods in patients with old myocardial infarction. Subjects were 25 male patients whose endpoint was either dyspnea or general fatigue at the symptom-limited maximal graded treadmill exercise test according to Bruce protocol. The indices obtained by non-invasive cardiac examinations included left ventricular fractional shortening (% FS), scintigraphic infarct size (% SIS) by 201Tl myocardial scintigraphy and PEP/ET (so-called Weissler's index). A significant correlation of exercise duration with % FS (r = 0.67, p less than 0.001) or with % SIS (r = -0.55, p less than 0.02) indicated that the more was impaired resting left ventricular function, the more was decreased exercise capacity. Also, a significant correlation of systolic blood pressure at the end-point in exercise test with % FS (r = 0.58, p less than 0.005) or with % SIS (r = 0.69, p less than 0.001) indicated that inadequate blood pressure response might be partially attributed to impaired left ventricular function during exercise. The response of heart rate at the Bruce protocol stage I correlated with % FS (r = -0.67, p less than 0.001) and with % SIS (r = 0.53, p less than 0.02), respectively. These findings may be interpreted as chronotropic compensatory mechanism for limited stroke volume during exercise in patients with imparied left ventricular function. Thus, it was concluded that resting left ventricular function assessed by non-invasive cardiac examinations may predict exercise capacity prior to the test to some extent. These informations can be utilized for the decision of the planning at cardiac rehabilitation and also for the guidance in daily activities. Additionally, low level exercise test with treadmill is considered to be valuable for screening cases with impaired left ventricular function in old myocardial infarction.

To determine the clinical significance of an increased thallium-201 (Tl-201) activity in the lung and of its clearance from the lung after exercise, computer-quantitated Tl-201 lung activity was measured and compared with hemodynamic parameters at rest and during exercise in 35 patients with coronary artery disease (CAD). All patients underwent a supine bicycle ergometer exercise test and mean pulmonary artery wedge pressure (PAWP) was measured by a Swan-Ganz catheter. Coronary angiography was also performed. On computer-generated initial and 2 and a half hours delayed anterior images, regions of interest were selected over the myocardium (M) and lung (L), and the initial L/M ratio and the (initial L)/(delayed L) ratio were calculated as indices of an increased Tl-201 lung uptake and lung clearance, respectively. The initial L/M ratio and the (initial L)/(delayed L) ratio had no significant correlation with mean PAWP at rest and had a weak negative correlation with the resting ejection fraction (r = -0.57 and r = -0.58, respectively). However, both ratios showed good correlations with mean PAWP during peak exercise (r = 0.85 and r = 0.80, respectively), suggesting that they provide useful indices for assessing the severity of exercise-induced left ventricular dysfunction.

A method for quantitatively and visually assessing myocardial perfusion using a new transmission computed tomography scanner and contrast media injection was devised. Myocardial perfusion was assessed before and after percutaneous transluminal coronary angioplasty (PTCA). Six patients with left anterior descending coronary artery stenosis undergoing PTCA were successfully studied. Dynamic scans, each with a scan time of one sec, were performed at the mid left ventricular level using bolus injections of contrast medium from the inferior vena cava. Regions of interest (ROIs) were located in the left ventricular cavity and in the myocardium perfused by the left anterior descending coronary artery, and gamma-variate fitted time density curves were recorded within the first pass phase, excluding recirculation. Cardiac outputs calculated from the ventricular curves of the ROIs in the left ventricular cavity correlated well with the thermodilution measurements using Swan-Ganz catheters (r = 0.90, p less than 0.01). The ratios of myocardial blood flow (F) to the tissue element volume (V) were calculated (F/V) from the myocardial curves of the ROIs in the myocardium as parameters of myocardial perfusion, according to the Zierler's principle. The F/Vs in the myocardium perfused by the left anterior descending coronary artery before PTCA were significantly less than those of the control subjects (4.4 x 10(-2) +/- 1.2 x 10(-2) vs 8.1 x 10(-2) +/- 2.9 x 10(-2): p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

To clarify the significance of regional myocardial perfusion, 31 patients of old myocardial infarction including 11 cases undergoing PTCA with a left anterior descending artery lesion were studied using dynamic transmission computed tomography with excellent time resolution. Serial one-second dynamic scans with an electrocardiographic triggering system were performed at the middle level of the left ventricle using a bolus injection of contrast medium via the inferior vena cava. The F/V (F = flow, V = volume) ratio, a parameter of perfusion per unit of myocardium, was calculated from gamma-variate fitted time density curves obtained in the myocardium and in the left ventricular cavity. The F/V ratio was significantly lower in patients not only with severe but also mild and no coronary artery stenosis (post PTCA: 185 +/- 54, 50-75% stenosis: 193 +/- 47, 90% stenosis: 181 +/- 51, 99% stenosis: 140 +/- 34, 100% stenosis: 142 +/- 27 ml/min/100 g, control value: 243 +/- 51 ml/min/100 g, post PTCA, 50-75% stenosis, 90% stenosis vs control p less than 0.05, 99%, 100% stenosis vs control p less than 0.005). The functional images depicting myocardial perfusion frequently revealed abnormal perfusion findings in patients not only with severe but also mild and no coronary stenosis. In the patients with mild or insignificant coronary stenosis, the F/V ratio was dependent on the severity of left ventricular wall motion abnormalities (hypokinesis: 192 +/- 51, akinesis or dyskinesis: 141 +/- 32 ml/min/100 g; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The prognostic significance of the doughnut pattern of technetium-99m pyrophosphate myocardial uptake was evaluated in 140 patients with acute anterior infarction. There were significantly higher early complications, greater mortality and more severe hemodynamic abnormalities in the doughnut pattern group than in the non-doughnut pattern group. The former had a more depressed left ventricular ejection fraction and larger thallium-201 defect size (27.6 +/- 10.4 versus 40.0 +/- 13.5%, p less than 0.001 and 9.9 +/- 3.6 versus 5.6 +/- 3.3, p less than 0.001, respectively). There was, however, considerable overlap of the ranges of these variables for both groups. The patency rate of the infarct vessel during the acute phase of infarct in each group was similar (54.8 versus 45.2%). It is concluded that the prognostic value of the doughnut pattern may be limited to some extent by this overlapping and the presence of this pattern does not appear to correlate with the lack of residual blood flow to the infarcted area.