Download Severe Right Ventricular Outflow Tract Obstruction

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AGE
(ysars)
3. Generalized
decrease
in the space
available
for
needle (percentage of safe space) with increasing age.
safe
FIGURE
the
intercostal
space”)
“safe
tance
as
artery.
A percentage
(the
percentage
was then obtained
using the rib-to-rib
the
denominator
artery distance
Percentages
and
the
of
dis-
were
used
inasmuch
intercostal
90
spaces.
90
of the
insertion
Right
00
thoracocentesis
Ventricular
Obstruction
Intracavitary
as the measurements
were
made
from
roentgenograms
which
had varying
degrees
of magnification,
and thus, “absolute”
distances
might
be open
to question.
Use of percentages
also
avoids
potential
confusion
resulting
from the absolute
“safe
space”
being
smaller
in small
persons
who
have
smaller
Severe
Tract
rib-to-intercostal
as the numerator.
70
Outflow
Caused
Cardiac
by an
Neurilemoma*
Successful Surgical Removal
and
Postoperative
Diagnosis
Benjamin
Betancourt,
M.D.;
Ef rain A. Defendini,
Charles
Johnson,
M.D.;
Manuel
De Jests,
M.D.;
Antonio
PavIa-Villamil,
M.D.; Aristides
DIaz Cruz,
and Julio C. Medina,
R.N., M.S.
M.D.;
M.D.;
RESULTS
Analysis
of the data demonstrated
toward
increasing
intercostal
artery
vancing
age
of safe
crease
(Fig
between
blood
strated
trend
with
the
tortuosity
artery
levels,
or
radiography.
aortic
ad-
“percentage
for thoracocentesis
tended
age (Fig 3). No correlation
intercostal
pressure
by chest
tortuosity
As a consequence,
available
advancing
space”
with
noted
2).
a definite
and
systemic
as
tortuosity
to dewas
demon-
The
results
60.
clearly
become
appears
the
for safe insertion
of a thoracocentesis
is decreased).
careful
performing
ticular,
border
space”
attention
be
paid
the
sternal
was found
amount
of space
needle
Thus,
to the
available
decreases
it is mandatory
proper
technique
(ie,
that
for
be inserted
than higher
just over the superior
in the rib interspace.
with
breath
a one-year
and chest
systolic
murmur
border.
1 Fraser RG, Pare JAP: Diagnosis
of Diseases
of the Chest.
Philadelphia, WB Saunders
Co, 1970
2 Baum
GL (ed):
Textbook
of Pulmonary
Diseases.
Boston,
Little
Brown
& Co, 1974
3 Dritsas
C, Flotte
CT: Severe
pulmonary
edema
and congestion
following
thoracentesis
in a patient
with
severe
aortic stenosis.
Md St Med J 18:74-78,
1967
522
base
ventricular
examination,
and
inability
was
of
the
enlarge-
ECG,
p
the
riinary
and
ventricle
chest
and
presenting
outflow
tumors
is very
necropsy.1
The
be
the
low
and
procedures
increasing
and
has
numbers
well-
is very
Post-
rare,
and
from
right
tumor
incidence
diagnosis
of
is often
demonstration
procardiac
made
and other radiographic
successful
removal
of different
cardiac
tumors.2
BETANCOURT El AL
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21027/ on 05/05/2017
at
has improved
led to the
#{176}Fromthe Department
of Cardiology
Hospital
PavIa,
Santurce,
Puerto
Supported
in part by El Programa
cional de Puerto
Rico.
Reprint
requests:
Dr. Betancourt,
Santurce,
Puerto
Rico 00910
this
the
intracavitary
The
their
the
and
neurilemoma.
arising
as an
antemortem
out-
of a large,
remarkably.
first
obstruction.
artery.
ventricular
accomplished,
neurilemoma
to
ducing
was
improved
appears
pulmonary
removal
as a benign
patient
cardiac
case
mass
the
in the right
surgical
interpreted
operatively,
enter
a mass
Successful
tumor
tract.
tumor
to
revealed
with the use of echocardiography
REFERENCES
at the
Right
by physical
history
of propain
was found
roentgenogram.
Cardiac
catheterization
showed
elevated right ventricular
pressure,
an intracavitary
pressure
encapsulated
intercostal
with
age. The
inthe ages of 40 and
in elderly patients, and in par-
thoracocentesis
that the needle
of the rib rather
that
tortuous
between
the
“safe
4/6
left
ment
flow
demonstrate
increases,
a grade
and
Angiography
increasingly
to be greatest
As tortuosity
to have
heart
gradient,
DIsctTssxoN
arteries
crease
A 32-year-old
woman
gressive
shortness
of
of
The
and Pathology,
General
Rico.
de Rehabilitaci#{243}n VocaGeneral
Hospital
Pavza,
CHEST, 75: 4, APR11, 1979
majority
of
however,
most
upon
the
Sudden
cardiac
of
are
hemodynamic
is one
death
are
tumors
them
histologically
effects
they
important
exert
the heart.
on
of cardiac
of blood
flow,
by thromboem-
phenomena.2B
right ventricular
Intracavitary
tion
been
has
tumors
and
myxomas
first case
tract
depending
consequence
tumors
and it can occur
by obstruction
production
of severe
arrhythmias,
and
bolic
benign;
fatal
potentially
caused
by
pseudotumors,
different
most
outflow
tract
types
common
of
and sarcomas.2’3
To our knowledge,
of obstruction
of the right
ventricular
caused
obstruc-
of
primary
which
this
are
is the
outflow
by a neurilemoma.
CASE
REPORT
A 32-year-old
woman
was asymptomatic
until
one year
prior to the first admission
on Jan 20, 1975, when she noted
exertional
dyspnea.
This progressed
rapidly
and was accompanied by chest pain and dyspnea even at rest. There was no
histoiy
of fainting
or palpitations.
She had four uneventful
pregnancies,
but she was told she had a heart murmur
during
her third pregnancy
eight years prior to this admission.
There
was no history
of rheumatic
fever, cyanosis,
anorexia,
weight
loss, or peripheral
edema.
She appeared
healthy.
The pulse
rate was 80 beats per minute;
blood
pressure,
170/110
mm
Hg, and there was moderate
distension
of neck veins at 45
degrees. The lungs were clear with a very active precordium
and easily palpable
right ventricle.
A systolic
thrill was felt
over the pulmonic
area and left sternal border.
The second
heart
sound
was
widely
split but with
normal
variation
during
respiration.
A grade 4/6 systolic
murmur
was heard
all over the precordium.
There
was no variation
in the
intensity
of the heart
sounds or in the murmur
in different
-I.
Ficunm
of right
1. Right atrial
angiogram
ventricular
outflow
tract
Microscopic
tissue, with
fiber
puscles
and
(Fig
sections
palisading
cellular
A variety
arrangement
of histologic
cardiac
and fasting blood sugar were normal.
Cardiac
catheterization
revealed
(all pressures
in millimeters of mercury)
a mean right
atrial
pressure
of 7, right
ventricular
inflow
120/0,
end diastolic
pressure
7; right ventricular
outflow
tract
50/0 with
a end diastolic
pressure
4;
pressure
curves of different
configurations
were recorded
in
the right ventricle;
pressure
gradient
at the right ventricular
outflow
tract
was
90.
The ascending
aortic
pressure
was
162/90,
mean 125; in the left ventricle
it was 162/0, with an
end diastolic
pressure
of 6.
Angiography
revealed
an enlarged
right atrium
and right
ventricle, narrowing
of flow at the level of the right ventricular outflow
tract due to a large radiolucent
mass in the right
ventricle
(Fig
1), and increased
thickness
at the left ventricular
wall. The aortogram
was normal.
On May 6, 1975, under cardiopulmonary
bypass,
a 8,75 x
6.25-cm
intracavitary
tumor
weighing
96 gm was removed
(Fig 2). It was attached to the parietal
band of the crista by
a broad
base which
extended
to the area of the tricuspid
valve. After excision of the mass, the base was deeply shaved
down to include portions
of the underlying
myocardium.
The
tumor
surface
was smooth,
and its cut surface
was
yellow.
FIGuRE
2. Gross
shiny capsule.
CHEST, 75: 4, APRIL, 1979
the typical
and fibers.
radiolucent
mass.
Antoni
type
AIn some areas, the
simulated
Meissner
cor-
DIscussIoN
murmurs
positions
or during
respiration.
There were no diastolic
or rumbles.
The ECG showed
a normal
sinus rhythm
with
normal
atrioventricular
conduction,
right axis deviation,
right ventricular
and right atrial enlargement,
right
bundle
branch
block, and ST-T wave abnormalities
considered
secondary
to
block or ventricular
enlargement
Chest x-ray films showed
marked
cardiomegaly
with
apparent
biventricular
components. Values for blood count, urinalysis,
blood urea nitrogen,
by a huge
obstruction
3).
right ventricular
been reported,
body
showed
of nuclei
severe
showing
the
most
specimen
types
tumors
frequent
(two
of primary
intracavitary
and pseudotuanors
has
of which
pieces
together)
have been in
showing
SEVERE RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION
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a
523
the
patient
tumor
improved
recurrence
remarkably,
has
been
and
noted
36
no
evidence
months
of
after
sur-
gery.
ACKNOWLEDGMENT:
We
are grateful
and contributions
of the following
persons:
J. Marques,
Dr. Waldo
Lopez,
Dr. Ramirez
Dr. Mike Fishbein,
and Mr. Rafael Alcocer.
for
Dr.
de
the help
Bernardo
Arellano,
REFEBENCES
1 Factor S, Tin F, et al: Primary
neurilemoma.
Cancer
37:883-890, 1976
2 Zager J, Orson Smith J, Goldstein
5, et al: Tricuspid
and
pulmonary
valves obstruction
relieved by removal of a
myxoma
of the right ventricle.
Am J Cardiol 32:101-104,
1973
3 Abbot OA, Warshausky
FE, Cobbs BW: Primary
tumors
and pseudo-tumors
of the heart. Ann Sung 155:855-872,
1962
4 Hallman
CL, Cooley DA, Webb
JA: Primary tumors of
the heart: Result of surgical treatment in 10 patients. J
Cardiovasc
Sung 7:447-457,
1966
5 Gleason
TH,
Dillard
DH,
Could
VE:
Cardiac
neurilemoma.
NY State J Med 72:2435-2436,
1972
6 Dammert
K, Elfung C, Helamen
P1: Neurogenic
sarcoma
in the heart. Am Heart J 49:694-800, 1955
7 Orshanskaia
RE: Neuroma
of the heart. Klin Med 39:142123, 1961
8 Jucker P: Diagnose der primaren bosartigen
Cesch wuiste
des Pericards.
Z Kiln Med 139:208-225, 1941
9 Hirsh
EF:
The innervation
of the human
heart.
Arch
Pathol 75:378-401, 1963
10 Evans RW:
Histologic Appearance
of Tumors,
2nd ed.
Baltimore, The William & Wilkins Co, 1960, p 360
order
of frequency:
myxoma,
sarcoma,
fibroma,
rabdomyoma
and hamartoma.24
Less frequently
encountered
include
tumors
endothelioma,
angioma.3’4
on
the
hematic
following
various
ventricular
inflow
right
ventricular
(e)
syncope;
(g) other
With
al,’
-primary
originating
in
we
primary
ventricular
the
outflow
sheaths
ventricular
The
but
value
tween
return
Unfortunately,
malities
were
from
of
After
nerve
her
blood
of
neuriwhich
the right
it originated
from
described
in the
fibers
muscles
by Hirsh.9
in this
patient
pressure
to
is not
almost
clear,
normal
suggests
a causal
relationship
hypertension.
Incidentally,
the
by
Factor
not
studies
for
performed.
et al,’
also
had
endocrine
However,
the
example
tumor,
neurofibromatosis
obstruction
of
papillary
of
bepa-
hypertension.
function
abnorpostoperatively,
Mucor
Mediastinitis*
Bradley
A. Connor,
M.D.;**
James W. Smith,
M.D.
A 69-year-old
man
with fever,
mediastinum,
refractory
his
tumors
review
reported
believe
the
questioned
neurogenic
first
of
by
of hypertension
postoperatively
the tumor
and
tient reported
524
and
et
of
has been
neurogenic
We
Factor
surface
is the
of myelinated
septum
cause
the
tract.
by
external
origin
evidence
clinically
and
tumors
intracavitary
without
itself
reported
structures.
this
fever;
cardiac
vs extension
believe
(f)
neurogenic
the
their
adjacent
benign
lemoma,
manifested
on
therefore,
right
(b)
(d)
(a)
manifestations.4
case
primary
cardiac
literature,
of the
lymphbased
obstruction;
effusion;
embolization;
described
and
hemato-
and
been
has
tract
pencardial
(c)
occurring
reported
been
heart,
teratoma,
observations:
outflow
pulmonary
exception
the
have
and
failure;
less frequently
the
all
cyst,
lipoma,
mesenchyrnoma,
Their
clinical
diagnosis
course.
mediastinal,
mucormycosis
tinum.’
Anderson,
lymphocytic
hypotension
cardium,
I.
M.D.4
leukemia
was
ediastinitis
involving
Perforation
and
acute
Invasion
of
coronary
paraplegia
the
and
present at post-mortem
usually
structures
of the
the
punctuated
myo-
arteries
with
examination.
occurs
secondary
passing
through
esophagus
of
fibrillation,
mediastinum,
spinal
and
presented
a pericardial
friction
rub,
widening
and left pleural
effusion.
Atrial
hospital
M
with
Ron
to infection
the medias-
or pharynx,
retro-
#{176}Fromthe Department
of Internal
Medicine,
University
of Texas Health
Science
Center
at Dallas,
and Medical
Service,
Veterans
Administration
Hospital,
Dallas.
*OBaylor Intern, supported in part by a stimulatory grant
from the Robert Patrick Thompson
Memorial
Fund.
Chief, Ambulatory
Care, Parkland
Memorial
Hospital;
Assistant Professor
of Internal
Medicine,
University
of Texas
Health Science Center at Dallas.
§Chief,
Infectious
Diseases,
Dallas VA Hospital;
Associate
Professor
of Internal
Medicine.
Reprint
requests:
Dr. Anderson,
UTHSC
at Dalla3,
5323
Harry
Hines
Bled, Dallas
75235
CONNOR, ANDERSON, SMITH
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CHEST, 75: 4, APRIL, 1979