Early administration of TLV, compared to increased FRM dosage, reduces the incidence of WRF in real-world elderly ADHF patients. In addition, it reduces the occurrence of 'worse' WRF-persistent and late-onset WRF-which are associated with increased rates of cardiac death or readmission for worsening heart failure in the 90 days after discharge.

Free-floating thrombi in the right atrium (RA) are extremely hazardous to patients with pulmonary thromboembolism, and optimal treatment methods remain unclear. We report a case of successful percutaneous intervention of a critical right atrial thrombus. The patient was a 50-year-old woman who had been under medication for acute myocarditis when she complained of sudden severe dyspnea. Echocardiography showed a mobile snake-like thrombus in the RA. The thrombus was pulled back to the distal inferior vena cava (IVC) using a catheter and an IVC filter was placed. Percutaneous treatment is useful for treating free-floating RA thrombi.

A case of peroneal nerve palsy caused by an intraneural ganglion is presented. The cystic mass was located posterolateral to the lateral femoral condyle and extended along the common peroneal nerve distal to the origin of the peroneus longus muscle. The nerve was compressed in the narrow fibro-osseous tunnel against the fibula neck and the tight origin of the peroneus longus muscle. The nerve was decompressed by complete tumor excision and transection of the origin of the peroneus longus muscle. Full recovery of nerve function was obtained in 6 months.

We examined the urinary disturbances in 56 consecutive patients with cervical compressive myelopathy using the latest International Continence Society classification. Of the 56 patients with cervical compressive myelopathy, 29 (52%) had some urinary subjective complaints, whereas the remaining 27 (48%) had none. Urologic examination indicated that 8 of these 29 (28%) patients with urinary complaints had urologic disorders other than neurogenic bladder. Of the remaining 21 patients, only 6 (25%) were judged to have neurogenic bladder on urodynamic study. Urodynamic study may be of limited value in diagnosing urinary disturbance in cervical myelopathy. Further, four cases (83%) showed underactive bladder activity in voiding phase, and only one case (17%) showed overactive bladder activity in filling phase. These results were contrary to those of previous studies indicating that cervical compressive myelopathy is associated with overactive bladder activity in filling phase. There were no significant differences in motor or sensory Japanese Orthopedic Association scores between the patients with and without urinary complaints. However, the patients with urinary complaints had significantly longer durations of myelopathy and delayed motor evoked potential latencies than those without urinary complaints. After surgery, 19 of the 21 (90%) patients with urinary complaints showed recovery from urinary disturbance. Operations in patients with cervical myelopathy were also effective against urinary disturbance. Urinary complaints may be an indication for surgical treatment despite the results of urodynamic study.

SUMMARY To assess left ventricular diastolic filling in patients with amyloid heart disease 12 patients with familial amyloid polyneuropathy and 15 normal subjects were studied by pulsed Doppler echocardiography. None of the patients had clinical evidence of overt heart disease or restrictive cardiomyopathy and only two of them showed ventricular wall thickening. The peak flow velocity of rapid diastolic filling and the acceleration rate of early diastolic inflow were significantly lower in patients with familial amyloid polyneuropathy than in controls. The pressure half time was significantly longer in patients than in controls. In addition, the peak flow velocity during atrial contraction and the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity were significantly greater in patients than in controls. Although there were no significant correlations between measurements ofdiastolic filling and clinical findings in patients with familial amyloid polyneuropathy, the ratio of atrial peak flow velocity to rapid diastolic peak flow velocity was significantly related to left ventricular posterior wall thickness.These findings suggest that in patients with cardiac amyloidosis without restrictive cardiomyopathy, abnormal left ventricular diastolic filling, manifested by a reduction in the rate and volume of rapid diastolic filling with enhanced atrial contraction, can be seen even in the early stage of the disease.Familial amyloid polyneuropathy causes progressive systemic amyloidosis with polyneuropathy that can affect the heart. Amyloid deposits have been reported in the myocardium when there is no clinically identifiable heart disease or ventricular wall thickening.' In earlier serial echocardiographic studies'2 we found that the development of extensive amyloid deposition caused not only progressive increases in ventricular wall thickness but also altered left ventricular systolic and diastolic function. Left ventricular diastolic filling in several cardiac diseases has been non-invasively assessed by pulsed Doppler echocardiography. But so far the profile of left Requests for reprints to Dr Minoru Hongo,

oonan syndrome is one of the most common nonchromosomal syndromes frequently accompanied by cardiovascular malformations. 1 The major cardiovascular defects are valvular pulmonary stenosis, commonly due to a dysplastic valve, 2,3 and hypertrophic cardiomyopathy (HCM), which predominantly affects the interventricular septum and left ventricle. [4][5][6][7][8][9] We report an adult case of Noonan syndrome with biventricular HCM accompanied by isolated right ventricular outflow tract (RVOT) obstruction without valvular abnormalities. To the best of our knowledge, these conditions are regarded as rather uncommon manifestations of cardiac defects in adults with Noonan syndrome. Case ReportA 42-year-old man with dyspnea and palpitation on exertion was referred from his local hospital for further cardiac examination in April 2000. Heart murmur and electrocardiographic abnormalities were first noticed when he was 10 years of age, and he had experienced mild dyspnea on exertion since that time. On admission, blood pressure was 118/68 mmHg and pulse was regular at 72 beats/min. Neither mental retardation nor sexual infantilism was observed. He was of short stature (152cm; < mean -3.0 SD), had a short neck, a shield-like chest with widely spaced nipples, cubitus valgus (Fig 1A), and the characteristic facial traits of ocular hypertelorism and low-set posteriorly rotated ears ( Fig 1B). A grade 3 systolic ejection murmur was heard at the mid-left sternal border and S4 was heard at the apex. An electrocardiogram showed left axis deviation, P waves with high peaks in the inferior limb leads, and deep S waves over the precordial leads. Chest X-ray showed cardiomegaly with normal pulmonary vascularity. Laboratory tests revealed prolongation of the activated partial thromboplastin time (46.2 s; normal value, 24-37 s) and a somewhat deficient clotting factor 11 (61.2%; normal value, 75-137%) but without any hepatic dysfunction. The lymphocyte karyotype showed a normal male pattern.Transthoracic echocardiography (Fig 2) revealed biventricular hypertrophy with asymmetric septal hypertrophy. The hypertrophied septum bulged out into the outflow portion of the right ventricle, thus reducing the size of the right ventricular cavity and resulting in outflow obstruction. Transesophageal echocardiography (Fig 3) demonstrated far more pronounced hypertrophy in the interventricular septum than in the free wall of each ventricle and marked narrowing of the RVOT. The pulmonary valve was normal. Magnetic resonance imaging clearly demonstrated marked biventricular hypertrophy including that of the left ventricular free wall (Fig 4). Cardiac catheterization showed a pulmonary capillary wedge pressure of 11 mmHg, pulmonary arterial pressure of 22/12 (16) mmHg, RVOT pressure of 22/6 mmHg, right ventricle apex pressure of 70/6 mmHg, right atrial pressure of 6 mmHg, systemic arterial pressure of 110/70 (90) mmHg, and cardiac index of 1.44 L·min -1 · m -2 . A systolic pressure gradient of 48 mmHg was seen across the right ventricular outflow tract (F...

The development of 31P-nuclear magnetic resonance (NMR) has enabled direct and non-invasive measurements of muscle metabolism. Serial measurements of the phosphocreatine/inorganic phosphate (PCr/Pi) ratio, which is closely related to the adenosine triphosphate/adenosine diphosphate (ATP/ADP) ratio and pH during and after forearm exercise were performed in 11 patients with chronic lung disease (CLD), nine patients with chronic heart failure (CHF) and eight control subjects. As compared with control subjects, the PCr/Pi ratio in the patients with CLD or CHF was lower during the recovery period and significantly lower at three and 4 min exercise. The pH values after exercise were lower in patients with CLD or CHF compared to control subjects. The PCr/Pi ratio at 4 min after exercise in the patients with CLD or CHF did not correlate with parameters of cardiac function or arterial and mixed venous oxygen tension. The arterial oxygen content and output in patients with CLD and CHF were significantly lower than that of control subjects. Nutritional parameters were not statistically different among the three groups. These observations suggest that metabolic abnormalities may be present in the skeletal muscles of patients with CLD and CHF that are not due to under-nutrition. These may result from reduced arterial oxygen output and, partially, from physical detraining.

No abstract