Pulmonary Circulatory Disturbance Research Articles

Pulmonary circulatory disturbance following endoscopic injection sclerotherapy

We compared arterial blood gas analysis and 99mTc-MAA lung perfusion scintigraphy before and after endoscopic injection sclerotherapy (EIS) in 17 cases of esophageal varices complicating liver cirrhosis. EIS was performed by the intra-variceal injection method with 5% ethanolamine oleate (EO) as the sclerosant agent. In blood gas analysis, the mean values of partial arterial oxygen tension (PaO2) and oxygen saturation (SaO2) were decreased, and the mean value of alveolar-arterial O2 difference (AaDO2) was increased, compared with before EIS while breathing room air. On lung perfusion scintigram, the pulmonary blood flow was markedly decreased, demonstrating hypoperfusion and/or perfusion defect, compared with before EIS in most the cases. It was suggested that pulmonary embolism and/or pulmonary circulatory disturbance occurred after EIS. It is important to note that pulmonary circulatory disturbances potentially may occur after EIS without any accompanying symptoms such as dyspnea, cough, or hemoptysis.

Pulmonary circulatory disturbance on magnified peripheral pulmonary wedge angiography in chronic pulmonary emphysema

Magnified peripheral pulmonary wedge angiography was performed in chronic pulmonary diseases. We classified the wedge angiography into five types based on the changes of capillary background (CBG) findings. Type I (normal), Type II (CBG is scattered and pulmonary arterial branches are tortuous), Type IIIa (CBG is decreased and pulmonary arterial branches are normal), Type IIIb (CBG and pulmonary arterial branches are also decreased or disappeared), Type IV (totally convergent). Using this classification, wedge angiography was performed in 42 patients out of 66 patients with chronic pulmonary emphysema diagnosed by selective alveolo-bronchography (SAB). Each type was compared in terms of hemodynamic data, blood gases and pulmonary function. Pulmonary emphysema was classified into types II, IIIa, and IIIb. There was no relation between SAB findings and wedge angiography classification. Severe hemodynamic data cases were found in types II and IIIb. The PaO2 of type II and IIIb were significantly lower than that of type IIIa. In pulmonary function tests, the mixed impairment type of ventilation was more frequently seen in type IIIb than IIIa. There was no relationship between SAB findings (66 cases) and hemodynamic data. These results suggest that classifying wedge angiography into five types (I, II, IIIa, IIIb, IV) may be useful for evaluating severity and determining prognosis and therapeutic measures in chronic pulmonary emphysema.

Undiagnosed late-onset chylothorax accompanied by fatal acute pulmonary thromboembolism after surgical treatment of lung cancer: An autopsy case and review of the literature

Late-onset chylothorax is a relatively rare and essentially benign postoperative complication. We describe an autopsy case of undiagnosed hemi-chylothorax accompanied by fatal acute pulmonary thromboembolism after pulmonary resection and lymph node dissection for lung cancer, reviewing the literature. The patient was a 60-year-old woman. She complained of dyspnea on the 20th postoperative day, which gradually increased. The patient suddenly died 2 days later. Autopsy demonstrated right chylothorax (1000 ml), and fatal acute pulmonary thromboembolism, mainly on the left side, originating from the lower extremities. Postoperative chylothorax, causing respiratory and pulmonary circulatory disturbance, may provide an important predisposition to ward fatality due to pulmonary thromboembolism even among those showing a milder type; thus careful management is necessary.

Scanning electron microscopy of vascular corrosion casts and histologic examination of pulmonary microvasculature in dogs with dirofilariosis.

To characterize structural changes in pulmonary vessels of dogs with dirofilariosis. 8 dogs with dirofilariosis and 2 unaffected control dogs. Pulmonary artery pressure was measured in affected dogs, and dogs then were euthanatized. Scanning electron microscopy was used to examine vascular corrosion casts of pulmonary vasculature. Tissue sections of pulmonary vasculature were evaluated by use of histologic examination. Pulmonary artery pressure was higher in dogs with severely affected pulmonary vessels. In tissue sections, dilatation, as well as lesions in the tunica intima and proliferative lesions resulting in constriction or obstruction, were frequently observed in branches of the pulmonary artery. Numerous dilated bronchial arteries were observed around affected pulmonary arteries. Hyperplastic venous sphincters were observed in small pulmonary veins and venules. In corrosion casts, affected pulmonary lobar arteries had dilatation, pruning, abnormal tapering, constriction, and obstruction. In small arteries and arterioles, surface structures representing aneurisms and edema were seen. Bronchial arteries were well developed and extremely dilated, and they formed numerous anastomoses with pulmonary arteries at all levels, from the pulmonary trunk to peripheral vessels. Capillaries in the lungs were dilated with little structural change. Small pulmonary veins and venules had irregular annular constrictions that were caused by hyperplastic smooth muscle cells of venous sphincters. Scanning electron microscopy of microvascular casts delineated links between the bronchial and pulmonary circulations in dogs with dirofilariosis. Results of scanning electron microscopy provided a structural explanation for the development of pulmonary circulatory disturbances and pulmonary hypertension in dogs affected by dirofilariosis.

Ventricular septal defect and multiple aneurysms

A 41-year-old man with a small perimembranous ventricular septal defect (VSD) developed aneurysms and aortic elongation, tortuosity and dissecting aneurysm. The asymptomatic VSD, without pulmonary circulatory disturbance, was considered hemodynamically benign and too small to warrant surgical closure. However, prolonged strenuous sporting activities could have potentiated premature development of aortic sclerosis and the unusual vascular lesions secondary to the VSD, and an injury may have precipitated mural dissection in the vulnerable aortic wall. Clinicopathological analysis of the unusual complications associated with the VSD suggests that closure of the defect at an early age should be considered to possibly obviate premature degenerative, valvular and vascular changes in adulthood and also secondary endocardial infection.

Management of pulmonary circulatory disturbance associated with chronic respitatory failure

Management of pulmonary circulatory disturbance associated with chronic respitatory failure

The usefulness of thallium-201 myocardial perfusion scintigraphy in the diagnosis of chronic cor pulmonale.

To open up the possibility of exact clinical diagnoses of chronic cor pulmonale, we performed thallium-201 myocardial perfusion scintigraphy on patients with chronic pulmonary disease. From the thallium activity in the left ventricle (plus ventricular septum) and right ventricle counted scintigraphically, we determined the thallium activity ratio of left to right ventricle (TAR). The intra- and inter-observer variations of this ratio were negligible. We compared TAR with pulmonary hemodynamic findings and with left to right ventricular mass ratio measured at autopsy, and obtained the following results. 1) Left to right ventricular mass ratio determined in 11 autopsied patients by the method of Fulton et al. was closely correlated with TAR values (r = 0.90, p less than 0.001). 2) In patients with chronic pulmonary disease, there were highly significant exponential inverse correlations between TAR and pulmonary arterial mean pressure, total pulmonary vascular resistance and right ventricular systolic pressure the the coefficients of -0.75, 0.72 or -0.77, respectively (p less than 0.001). These results suggested the possibility that the severity of pulmonary circulatory disturbance may be ascertained non-invasively by TAR measurement. Thus, thallium-201 myocardial perfusion scintigraphy is able to reveal non-invasively right ventricular hypertrophy in patients with chronic pulmonary disease, and it might be a useful means of clinically diagnosing chronic cor pulmonale. If TAR obtained from scintigrams is smaller than 2, the patient concerned may possibly have right ventricular hypertrophy and he or she may be diagnosed as having chronic cor pulmonale.

Scintigraphic evaluation of regional pulmonary circulation and ventilation abnormalities in mitral valvular disease and congestive heart failure.

Regional pulmonary mean transit time, MTT (RV-Lung) was measured by radionuclide angiography using 99mTc-pertechnetate or 99mTc-HSA. In 8 normal subjects, MTT (RV-Lung) in upper (U) and lower (L) lung fields averaged 2.48 and 2.81 sec, respectively. In MS and CHF groups, MTT (RV-Lung) in L was markedly prolonged (5.04 and 5.10 sec, respectively) and after appropriate medical or surgical treatment, MTT in L markedly reduced. Pulmonary ventilation perfusion scintigraphy with 133Xe was performed in 18 patients with MS. Both Vu/L and Ou/L increased in accordance with the severity of disease, however, Vu/L had never exceeded unity. The estimation of regional MTT in the lung field is to be useful way in evaluating the severity of pulmonary circulatory disturbance in MS or in congestive heart failure.

Pulmonary circulatory disturbances in pulmonary hypertension with special reference to pathophysiological significances of pulmonary vascular resistance index.

Pulmonary circulatory disturbances in pulmonary hypertension with special reference to pathophysiological significances of pulmonary vascular resistance index.

Prognostic evaluation of pulmonary circulatory disturbances in patients with chronic obstructive ventilatory disorders

山口大学三瀬内科で扱かつた慢性閉塞性換気障害をもち,諸検査成績のえられた65症例について最長10力年におよび臨床経過並びに予後を観察した結果,予後判断に必要な条件としての換気,肺機能異常の程度を評価するために行なつた機能的障害度区分の有用性を把握し,かつ肺動脈圧中間圧(PAm)を主とする肺循環動態を分析し,その障害の程度を前述の機能障害度区分と比較することは疾患の予後を判断する上に一層の信頼性を加うることを知つた.とくに肺高血圧の有無,その程度を肺動脈圧中間圧(PAm)でもつて4段階にわけて観察した結果, 1)慢性肺気腫,肺気腫を主病変とした肺結核,珪肺などの病群と気管支拡張症あるいは気管支喘息を主病変とし,ある程度の肺気腫を合併した症例,さらに肺気腫をともなわない気管支拡張症,気管支喘息,肺結核などの病変とでは病状の進展,重症度,予後にはかなりの相違があり,前者では機能的障害度と肺循環障害度はよく平行し,この両者からきわめて有意な評価が可能であつたが,後者では多彩な経過を示し,これらの推定方法では評価が難かしかつた. 2)前者において正常肺血圧,肺高血圧群とにわかちおのおのの検討を行ない, PAmのもつ意義が大であるとともに,とくにPAmと楔入圧(WP),肺血管抵抗(PVRI),右室拡張期終圧(RVd)との相互関係から,かなり正確に予後評価が可能であつた.

Pathophysiological Significances of Serotonin in Pulmonary Circulation

The estimation of whole blood serotonin and the related substances and analysis of the haemodynamic effects in serotonin administration were made in man and dog. In cardiac patients with pulmonary hypertension, notwithstanding their elevated reactivity of pulmonary circulation to serotonin, whole blood serotonin levels were markedly lowered. Prominent decrease of whole blood serotonin and blood platelet, increase of urinary excretion of 5-hydroxyindole acetic acid and the rise of the pulmonary arterial pressure were noted in the experimental pulmonary embolism with auto-clot in dogs. Active serotonin seemed to be released from the circulating blood platelet to play some roles in the pulmonary circulatory disturbances.

Relation of "Pulmonary P" to Pulmonary Circulatory Disturbances, Especially to Pulmonary Hypertension, in Patients with Chronic Pulmonary Disease

So-called pulmonary P has been described, and discussed by many investigators, but as to criteria of pulmonary P, there are still some different opinions. The purpose of this study was to investigate the relationship between the magnitude of the P waves and the disturbances of the pulmonary hemodynamics, especially pulmonary hypertension, in patients with chronic pulmonary diseases. Material and Method : Ninety patients with chronic pulmonary disease (62 cases with pulmonary emphysema, 12 with bronchial asthma, 3 with silicosis, 3 with bronchiectasis, 2 with pulmonary tuberculosis, 2 with lung tumor, 2 with pulmonary fibrosis, one with primary pulmonary hypertension, one with pyothorax, one with chronic bronchitis, and one with pulmonary sarcoidosis) were studied. Electrocardiograms of routine 12 leads were recorded just before the right heart catheterization. Results : The incidence of P waves with heights of above 0.2 mV in all of leads II, 111, and aVF increased with elevating pulmonary artery mean pressure (PAm). However, such P waves were observed in 12.5 per cent of cases without pulmonary hypertension. When P waves were 0.25 mV or more in lead II and above 0.2 mV in leads III and aVF, such a'. combination of P waves was more closely correlated with PAm than the other type of P waves, and was defined as "pulmonary P" in this study. It was found that 60 per cent of cases with PAm over 30 mmHg, 25 per cent of cases with PAm of from 20 to 29 mmHg, 10 per cent of cases with PAm of from 17 to 19 mmHg, and none of cases with PAm below 16 mmHg showed this pulmonary P. Among the cases who had the pulmonary P, PAm was measured in 1 5 cases, right ventricular systolic pressure (RVs) in 10, right ventricular end-diastolic pressure (RVd) in 6, right atrial mean pressure (RA) in 7, pulmo-nary vascular resistance index (PVRI) in 1 1, total pulmonary resistance index (TPRI) in 9, and the average values of these were 30.2 mmHg, 41.8 mmHg, 6.0 mmHg, 3.4 mmHg. 488.1 dynes, sec, cm<-5>/M2, and 743.0 dynes, sec, cm<-5>/M2 respectively. On the other hand, among the cases who did not have the pulmonary P, PAm was measured in 75 cases, RVs in 43, RVd in 48, RA in 33, PVRI in 46, and TPRI in 46, and the average values of these were 19.1 mmHg, 27.1 mmHg, 3.9mmHg, 2.5mmHg, 285.3 dynes, sec, cm5<ookikutsur -5M2, and 440.6 dynes, sec, cm-5/M2 respectively.

Clinical course and prognosis of chronic pulmonary emphysema with special reference to pulmonary circulatory disturbance.

Clinical course and prognosis were studied in 103 patients with chronic pulmonary emphysema with special reference to clinical features and pulmonary hemodynamics, and in 78 patients of whom right heart catheterization was performed. The periods of the follow-up were between 1.5 and 10 years (4.4 years on an average).Thirty cases died during these periods and 73 cases were still alive. Details of 73 living patients in the clinical situation were "improved" in 25 cases (24.2%), "unchanged" in 32 cases (31.3%) and "worsen" in 16 cases (15.5%).Among 30 cases of "dead", 8 patients died from right heart failure, 5 died from probable right heart failure and the other 17 cases died from other causes such as infection, malignancy and et cetera.The results suggest that pulmonary hemodynamics, especially pulmonary artery mean pressure (PAm), is an important factor in predicting the prognosis of chronic pulmonary emphysema. Thus, any one of the following items can be taken as a valuable index for judgement of poor prognosis:(1) PAm of over 30 mm.Hg(2) Ecg of RVH following the ordinary criteria plus PAm of over 22mm.Hg(3) PaCO2 of over 50mm.Hg plus PAm of over 22mm.Hg(4) WP of over 8mm.Hg (especially of over 13mm.Hg) plus PAm of over 22mm.Hg(5) PVRI of over 600 dynes•sec.cm.-5/M.2 plus PAm of over 22mm.Hg(6) MBC of less than 35% plus PAm of over 22mm.Hg Either of the following items could be employed as a useful index for poor prognosis.(1') SaO2 of less than 88% plus marked ventilatory disturbance(2') RVd of over 8mm.Hg

PATHOHISTOLOGICAL AND ELECTRON MICROSCOPIC STUDIES OF THE LUNG IN MITRAL STENOSIS WITH SPECIAL REFERENCE TO THE CORRELATION BETWEEN MORPHOLOGICAL CHANGES AND CARDIOPULMONARY DYNAMICS

There have been many studies on the correlation between histological changes of the lung an, d clinical findings or cardiopulmonary dynamics in mitral stenosis. However, there are still different opinions as to this correlation. In this presentation the relation between pulmo-nary circulatory disturbances and histological or electron-microscopical findings in patient with mitral stenosis was investigated. Material The investigation was made of 12 patients with mitral stenosis. All patients were submitted to surgical treatment (commissurotomy). Cardio-pulmonary function tests were performed prior to the operation except one. The lung from a patient with mild tuberculosis was investigated for comparison. Methods Small piece of the lung was excised form the lingual region of the left lung at commissurotomy. The specimen was immediately divided into two parts, and a part of them was fixed by infusion using I per cent osmic acid for electron microscopic examination, the other part was fixed with 10 per cent formaldehyde for histological examination. Histological preparations were made in usual fashion, and hematoxylin-eosin, PAS, van Gieson's and Verhoeff's procedures were employed for tissue staining. The fixed specimen for electron-microscopic examination was embedded into methacrylate after preliminary washing with water and following dehydration. And then submitted to ultra-microtome. The slices thus obtained were mounted on a formvar coated mesh for electronmicroscopic observations and photogram. Results (1) It was found histologically that the changes in lung tissue progressed in the order of dilatation of capillaries, thickening of capillary wall and then thickening of alveolar wall. Thickening of alveolar wall was seen in 7 of 12 cases. Moderate to advanced thickening of alveolar wall was accompanied with fibrosis, and the more thickening advanced, the more fibrotic changes became remarkable. Decrease in number of capillaries was predominant and cuboidalization of the alveolar wall was noted in such cases.

Pathogenesis of the acute pulmonary edema occurring after brain operation and brain trauma.

(1) By investigating many autopsy cases, it was found that the incidence of combination of the pulmonary edema was high in the cases with central nervous system diseases, particularly in the cases having localized foci in the vicinity of the internal capsule, the lentiform nucleus and the third ventricle. (2) From the histological viewpoint, an attempt was made to classify the clinical cases of postoperative acute pulmonary edema into 3 groups: (1) that occurring after a brain operation or brain trauma, (2) that occurring after a cardiopulmonary operation of cases with pulmonary circulatory disturbances, (3) that occurring after an abdominal operation of cases with metabolic disorders. It is worthy of note that the incidence of the postoperative pulmonary edema was significantly high after brain surgery. (3) In the examination of the pulmonary vascular innervation, the reflex pathway has been clarified and the 2 centers were assumed to be in the reflex arc of the innervation of the pulmonary vessels. The higher center of the reflex arc ascending through the vagus nerve was in the nuclei of the preoptic areas, while the lower center of the reflex arc ascending through the sympathetic or sinus nerve was in the medulla. The authors have also confirmed that the site of cerebral damage in the clinical cases of pulmonary edema, occurring after a brain operation or a brain trauma, had a close relation to either the higher or the lower center of the pulmonary vascular innervation or the both. (4) The authors have succeeded in the experimental production of the characteristic pulmonary edema of cerebral origin by a complete destruction of the bilateral preoptic areas. Pathophysiology concerning the experimentally produced pulmonary edema has been studied in detail. (5) Based on the results of both clinical and experimental studies, the pathogenesis of the clinical pulmonary edema occurring after a brain operation or a brain trauma was assumed to be as follows. The operation or trauma was directly responsible for the development of pulmonary hypertension, the prolongation of pulmonary circulation time, and the increase in the permeability of the pulmonary capillaries. At the same time, the operation or the trauma directly caused the changes in renal or hepatic circulation and endocrine regulation, inducing anuria, disturbance of water and electrolytes balances. The combination of these factors accelerated a selective pulmonary edema of an acute type.