SummaryBuckground: The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling.Hypothesis: The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation.Methods: We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation ( 10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm.Results: Mean pulmonary capillary wedge pressure, Vwave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomycpathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and Vwave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopath y.Conclusion: Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.

Monoclonal antibodies specific for the adhesion molecules participating in lymphocyte homing, lymphocyte function associated antigen‐1 (LFA‐1) and very late antigen 4 (VLA4), and their respective ligands, intercellular adhesion molecule 1 (ICAM‐1) and vascular cell adhesion molecule 1 (VCAM‐1), were used to characterize their expression pattern in human lymph nodes by immunohistochemical and immunoelectron microscopic techniques. The location of LFA‐1‐positive lymphocytes and selective expression of ICAM‐1 on the luminal plasma membrane of high endothelial venule endothelium suggested that the LFA‐1/ICAM‐1 adhesion pathway participates only in the initial step of the lymphocyte migration process. Lymphocytes passing through endothelium appear not to be influenced by this pathway. VCAM‐1 was detected occasionally on the endothelium of high endothelial venules in the hyperplastic lymph nodes in the mesentery, but not in peripheral lymph nodes. VLA4‐positive lymphocytes tended to be more frequently observed within high endothelial venules in mesenteric lymph nodes than in peripheral ones. Strong expression of both ligands, ICAM‐1 and VCAM‐1, was noted on the plasma membrane of follicular dendritic cells, and was especially prominent on their labyrinthine folding, and on the interdigitating cells in the paracortex. Furthermore, both LFA‐1‐and VLA4‐positive lymphocytes localized around these cells. This suggests that LFA‐1/ICAM‐1 and VLA4/VCAM‐1 adhesion pathways play an important role in the lymphocyte recognition of antigen‐presenting cells.

SummaryBuckground: It has become evident that mitral regurgitation (MR) is not uncommon in healthy subjects, and Doppler color flow mapping is a technique that imparts important information relevant to its detection.Hypothesis: Using transthoracic echocardiography, this study evaluated the mechanism of physiologic MR in young normal subjects using transthoracic echocardiography.Methods: The study population consisted of 48 young normal subjects (mean 21 5 5 years) with M R (physiologic MR group), 40 age-matched young normal subjects (mean 20 k 5 years) without MR (control group), 45 patients (mean 41 k 15 years) with mitral valve prolapse with MR (MVP group), and 27 patients (mean 59 k 13 years) with ruptured chordae tendineae (rupture group).Results: Men were predominant in the rupture group, whereas there were no significant gender differences in the other three groups. Left ventricular end-diastolic dimension and left atrial systolic dimension were slightly smaller in the physiologic MR group than in the control group, but were significantly smaller than those in the MVP and rupture groups. The ratio of the maximum anteroposterior diameter to the maximum transverse diameter on chest radiography and the ratio of the short-to long-axis diameter of the left ventricular cavity at end diastole, determined from two-dimensional short-axis echocardiogram, were significantly lower in the physiologic MR group than in the other three groups. Mitral regurgitation occurred more frequently at the posteromedial commissural site in the physiologic MR and MVP groups. whereas there was no preference for location in the rupture group. Early systolic MR was often observed in the physiologic MR group, whereas pansystolic MR was common in the MVP and rupture groups.Conclusion: As a causal mechanism for physiologic MR detected in young normal subjects, "flattening" of the thorax during growth may cause morphologic abnormalities of the left atrial and ventricular cavities, resulting in spatial imbalance of the mitral complex and resulting in malcoaptation of the valve.

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Aims This study aimed to evaluate the clinical parameters including late gadolinium enhancement (LGE) of cardiovascular magnetic resonance to predict re-worsening of left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy (DCM). Methods and results We included 138 patients with recent-onset DCM who had an LVEF <45% and underwent LGE of cardiovascular magnetic resonance imaging at diagnosis and echocardiography at the yearly follow-up [median 6 (4-8.3) years]. Initial LVEF recovery was defined as LVEF increase >10% from baseline, resulting in LVEF ≧45% after treatment. The patients were divided into three groups: (i) improved (n = 83, 60%), defined as those with sustained LVEF ≧45%; (ii) re-worsening (n = 39, 28%), those with >5% decrease and LVEF <45% after the initial LVEF recovery; and (iii) not-improved (n = 16, 12%), those without initial LVEF recovery. The primary endpoint was a composite of hospitalization for heart failure or sudden cardiac death. In baseline, LGE was observed in 70 patients. The LGE area was significantly larger in the re-worsening and not-improved groups than that in the improved group (P < 0.001). Loess curves of long-term LVEF trajectories showed that LVEF in the re-worsening group increased in the first 2 years and slowly declined thereafter. Multivariate logistic regression analysis demonstrated that LGE area [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03-1.16, P = 0.004], B-type natriuretic peptide (OR 1.49, 95% CI 1.05-2.21, P = 0.030) level at the initial recovery, and LVEF (OR 0.91, 95% CI 0.86-0.97, P = 0.004) at the initial LVEF recovery were independent predictors of re-worsening of LVEF. During a median follow-up of 2273 (interquartile range: 1634-3191) days, the primary endpoint was observed in 31 (22%) patients. Univariate Cox proportional hazards analysis demonstrated that the risk of experiencing the primary event in the re-worsening group was significantly higher (hazard ratio: 4.30, 95% CI 1.63-11.31, P = 0.003) than that in the improved group and was lower than that in the not-improved group (hazard ratio: 0.33, 95% CI 0.15-0.72, P = 0.006). Conclusions Re-worsening of LVEF was observed in 28% of patients with recent-onset DCM who showed an initial improvement in LVEF. High LGE burden, higher B-type natriuretic peptide level, and lower LVEF at the initial LVEF recovery were independent predictors of re-worsening of LVEF in patients with DCM. Careful observation is recommended for patients with a high risk for re-worsening of LVEF, even in those with an initial LVEF recovery.