CASE REPoRT
A patient under our care underwent percutaneous transthoracic needle aspiration biopsy of a right upper lobe cavitating lesion of the lung. His clinical state and data on studies of pulmonary function precluded thoracotomy. Flexible fiberoptic bronchoscopic examination had not yielded a diagnosis. The diagnosis before and after the procedure was that of a cavitating epidermoid.carcinoma. Immediately after the biopsy, the patient developed a tension pneumothorax. A chest tube was inserted, and the lung was reinflated. The patient did well for approximately six hours, when suddenly he developed massive subcutaneous emphysema, starting with the right side of the chest and progressing to symmebic subcutaneous emphysema of the abdomen, thorax, neck, and head. The patient at this time also developed mediastinal emphysema and a Hammond's crunch. He became hypotensive and hypoxic and required endotracheal intubation. He was placed on a volume ventilator and ventilated with 100 percent oxygen. Within four hours the mediastinal emphysema had completely resolved, as had 95 percent of the subcutaneous emphysema. DISCUSSION
Although we are aware of reports recommending ventilation with increased oxygen tension for pneumatosis cystoides intestinalis,l-a we were unable to find a case similar to ours in the literature. Using an increased inspired oxygen concentration is certainly known to be helpful for resorption of air in the chest in the typical case of pneumothorax. A response of this magnitude was, for this patient, lifesaving. Although this is our first occasion to observe such an occurrence, we will certainly employ the same technique again when the occasion arises. We would be interested to know if any other physicians have observed a similar chain of events. Interestingly, since this first case, we had another patient in whom life-threatening mediastinal emphysema developed and in whom this technique worked equally well and as rapidly. T.].O'NeiU, M.D.; Michael C.]ohman, M.D.; David A. Edwards, M.D.; and Patrick Dietz, M.D. Reno, Nev
REFERENCES 1 Forgacs P, Wright PH, Wyatt AP: Treatment of intestinal gas cysts by oxygen breathing. Lancet 1:579-582, 1973 2 Simon NM, Nyman KE, Divertie MB, et at: Pneumatosis cystoides intestinalis: Treatment with oxygen via closefitting mask. JAMA 231:1354-1356, 1975 3 Gruenberg JC, Batra SK, Priest RJ: Treatment of pneumatosis cystoides intestinalis with oxygen. Arch Surg 112: 6264,1977
Echocardiographic Determinations of Systolic Time Intervals in Mitral Valvular Prolapse To the Editor:
We have determined systolic time intervals by echocardiographic studies in 25 patients with clinical evidence of mitral valvular prolapse without significant mitral regurgitation, and we found no alteration of ventricular function when measured by these determinations. The clinical entity of mitral valvular prolapse comprises a wide range of clinical manifestations, such as premature venbicular contractions," ocular disturbances,s sudden death,a pain in the chest, and association with myocardial Infarction,« Because of reports of abnormal left ventricular
CHEST, 76: 4, OCTOBER, 1979
function associated with this syndrome, G we calculated systolic time intervals in 25 patients with mitral valvular prolapse by echocardiographic studies' (Fig 1). Kleid et all published a study of 30 patients with this syndrome and obtained similar results when measuring systolic time intervals by pulse-phonocardiographic studies. When our data were compared with data from normal subjects, there was no statistical difference. Systolic time intervals in patients with mitral valvular prolapse are difficult to evaluate, since the influence of severe mitral insufticiency cannot be distinguished from the abnormalities found in diminished intrinsic contractile performance of the left ventricle as seen in primary myocardial disease. Our study corroborates the investigation of IOeid et aI,I who demonstrated. that left ventricular performance remains well preserved in patients with mitral valvular prolapse. The abnormalities observed by others on angiographic studies in which abnormal patterns of motion were seen may in many instances reflect the effect of the anatomic deformity itself in relation to the pattern of contraction of the papillary muscle and may not result from primary myocardial disease. None of our patients were significantly symptomatic, and our results correlate well with the concept that abnormalities in the ratio of the preejection period over the left ventricular ejection time parallel the ejection fraction as determined by angiograms," It has been demonstrated that the preejection period is found to be increased with shortening of the left ventricular ejection time in patients with mitral insufBciency, even in the presence of normal intraventricular pressures and a normal contractile pattem.s Obtaining normal values in our patients supports the analysis that the mechanical consequences of abnormal motion of the mitral valvular apparatus might be responsible for the associated regional contractile abnormalities and might not be a sequel of primary disease of the myocardium. We conclude from this study that left ventricular function remains normal in patients with mitral valvular prolapse in whom minimal or no mitral i.nstlfflciency eoextsts, These patients can be studied serially by echocardiograms in order to detect early manifestations of left ·ventricular dysfunction which may develop in mitral insufficiency due to mitral valvular prolapse.. lairo Ramif'ez, M.D. and Nancy C. Flowe", M.D., F.e.C.p. Dioision of Cardiology, Depattment of Medicine Unioef'rity of Louisoille Reprint requests: Dr. Ramirez, Divlrion of CardioloBfl, Department of Medicine, Unioersity of LouiBoille Health Sciences Center, 323 E Chestnut St, LouisoiUe 40202
REFERENCES 1 Sloman G, Wong M, Walker J: Arrhythmias on exercise in patients with abnormalities of the posterior leaflet of the mitral valve. Am Heart J 83:312-317, 1972 2 Wilson LA, Keeling PWN, Malcolm AD, et al: Visual complications of mitral IeaHet prolapse. Br Med J 2:86-88, 1977 3 Marshall CE, Shappell SD: Sudden death and the ballooning posterior leaflet syndrome. Arch Pathol 98:134-138, 1974 4 Cheslet E, Matisonn BE, Lakier JB, et at: Acute myocardial infarction with normal coronary arteries. Circulation 54:203-209, 1976 5 Scampardonis G, Yang SS, Marahao V, et al: Left ventricular abnormalities in prolapsed mitral leaflet syndrome. Circulation 48:287-297, 1973
COMMUNICATIONS TO THE EDITOR 483
FIGURE 1. Measurement of systolic time intervals on aortic echocardiogram. RVO, Right ventricular outflow; Ao, aorta; LA, left atrium; LAW, left atrial wall; arrow 1, preejection period; and arrow .2, left ventricular ejection time (1 2 = electromechanical systole). 6 Kleid J], Arvan SB, Martin C : Systolic time intervals in the REFERENCES syndrome of midsystolic click and late systolic murmur. 1 Wagner RB, Paidipaty BB: Another advantage of the Chest 71:65-69,1977 flexible fiberoptic bronchoscope: An easy tracheal cannula7 Lewis RP, Rittgers SE, Forrester WF, et al: A critical tion in preparation for bronchography (letter to editor) . review of the systolic time intervals . Circulation 56:146Chest 75 :108, 1979 157,1977 8 Wanderman KL, Goldberg M], Stack RS, et al: Left 2 Lutch IS, Ryan KG: Bronchography combined with bronventricular performance in mitral regurgitation assessed choscopy : A new method (letter to editor). Chest 75 :108, with systolic time intervals and echocardiography. Am ] 1979 Cardiol 38 :831-836, 1976 3 Schoenbaum SW, Pinsker KL, Rakoff S], et al: Fiberoptic bronchoscopy: Complete evaluation of the tracheobronchial tree in the radiology department. Radiology 109:571Bronchography with Bronchoscopy 575,1973 To the Editor: 4 Webster's New Collegiate Dictionary, Springfield, Mass., G and C Merriam Co, 1977, p 1058 l The two communications , 2 dealing with the use of the fiberoptic bronchoscope to help perform bronchographic studies deserve some comment. The "new method" described by Lutch and Ryan 2 was described in 1973. 8 The use of the To the Editor: word, "serendipitous" ("obtained or characterized by serendipity;" "the gift of finding valuable or agreeable things not My coauthor and I apologize for overlooking the previous sought for"'), by Wagner and Paidipaty- is incorrect. If report by Schoenbaum et all in our search of the literature. these authors- had encountered an unexpected situation We are pleased to agree entirely with the suggestions in that during the fiberoptic bronchoscopic procedure and subsepublication, and we wish to encourage the use of the comquently had utilized the instrument in a novel fashion (in this bined bronchoscopic-bronchographic procedure. instance, to facilitate bronchographic studies), their usage would be proper. John S. Latch, M.D ., F.C.C .P. The employment of the fiberoptic bronchoscope to help Woodland Clinic, Woodland, Calif perform bronchographic studies is neither new nor serendipitous but should be considered an alternative to the traditional "blind" methods of passing a bronchographic catheter. 1 Schoenbaum SW, Pinsker KL, Rakoff S], et al: Fiberoptic Kenneth L. Pinsker, M.D., F.C .C.P. bronchoscopy: Complete evaluation of the tracheobronDivision of Pulmonary Medicine chial tree in the radiology department. Radiology 109:571Montefiore Hospital and Medical Center, Bronx, NY 575, 1973
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494 COMMUNICATIONS TO THE EDITOR
CHEST, 76: 4, OCTOBER, 1979
A patient under our care underwent percutaneous transthoracic needle aspiration biopsy of a right upper lobe cavitating lesion of the lung. His clinical state and data on studies of pulmonary function precluded thoracotomy. Flexible fiberoptic bronchoscopic examination had not yielded a diagnosis. The diagnosis before and after the procedure was that of a cavitating epidermoid.carcinoma. Immediately after the biopsy, the patient developed a tension pneumothorax. A chest tube was inserted, and the lung was reinflated. The patient did well for approximately six hours, when suddenly he developed massive subcutaneous emphysema, starting with the right side of the chest and progressing to symmebic subcutaneous emphysema of the abdomen, thorax, neck, and head. The patient at this time also developed mediastinal emphysema and a Hammond's crunch. He became hypotensive and hypoxic and required endotracheal intubation. He was placed on a volume ventilator and ventilated with 100 percent oxygen. Within four hours the mediastinal emphysema had completely resolved, as had 95 percent of the subcutaneous emphysema. DISCUSSION
Although we are aware of reports recommending ventilation with increased oxygen tension for pneumatosis cystoides intestinalis,l-a we were unable to find a case similar to ours in the literature. Using an increased inspired oxygen concentration is certainly known to be helpful for resorption of air in the chest in the typical case of pneumothorax. A response of this magnitude was, for this patient, lifesaving. Although this is our first occasion to observe such an occurrence, we will certainly employ the same technique again when the occasion arises. We would be interested to know if any other physicians have observed a similar chain of events. Interestingly, since this first case, we had another patient in whom life-threatening mediastinal emphysema developed and in whom this technique worked equally well and as rapidly. T.].O'NeiU, M.D.; Michael C.]ohman, M.D.; David A. Edwards, M.D.; and Patrick Dietz, M.D. Reno, Nev
REFERENCES 1 Forgacs P, Wright PH, Wyatt AP: Treatment of intestinal gas cysts by oxygen breathing. Lancet 1:579-582, 1973 2 Simon NM, Nyman KE, Divertie MB, et at: Pneumatosis cystoides intestinalis: Treatment with oxygen via closefitting mask. JAMA 231:1354-1356, 1975 3 Gruenberg JC, Batra SK, Priest RJ: Treatment of pneumatosis cystoides intestinalis with oxygen. Arch Surg 112: 6264,1977
Echocardiographic Determinations of Systolic Time Intervals in Mitral Valvular Prolapse To the Editor:
We have determined systolic time intervals by echocardiographic studies in 25 patients with clinical evidence of mitral valvular prolapse without significant mitral regurgitation, and we found no alteration of ventricular function when measured by these determinations. The clinical entity of mitral valvular prolapse comprises a wide range of clinical manifestations, such as premature venbicular contractions," ocular disturbances,s sudden death,a pain in the chest, and association with myocardial Infarction,« Because of reports of abnormal left ventricular
CHEST, 76: 4, OCTOBER, 1979
function associated with this syndrome, G we calculated systolic time intervals in 25 patients with mitral valvular prolapse by echocardiographic studies' (Fig 1). Kleid et all published a study of 30 patients with this syndrome and obtained similar results when measuring systolic time intervals by pulse-phonocardiographic studies. When our data were compared with data from normal subjects, there was no statistical difference. Systolic time intervals in patients with mitral valvular prolapse are difficult to evaluate, since the influence of severe mitral insufticiency cannot be distinguished from the abnormalities found in diminished intrinsic contractile performance of the left ventricle as seen in primary myocardial disease. Our study corroborates the investigation of IOeid et aI,I who demonstrated. that left ventricular performance remains well preserved in patients with mitral valvular prolapse. The abnormalities observed by others on angiographic studies in which abnormal patterns of motion were seen may in many instances reflect the effect of the anatomic deformity itself in relation to the pattern of contraction of the papillary muscle and may not result from primary myocardial disease. None of our patients were significantly symptomatic, and our results correlate well with the concept that abnormalities in the ratio of the preejection period over the left ventricular ejection time parallel the ejection fraction as determined by angiograms," It has been demonstrated that the preejection period is found to be increased with shortening of the left ventricular ejection time in patients with mitral insufBciency, even in the presence of normal intraventricular pressures and a normal contractile pattem.s Obtaining normal values in our patients supports the analysis that the mechanical consequences of abnormal motion of the mitral valvular apparatus might be responsible for the associated regional contractile abnormalities and might not be a sequel of primary disease of the myocardium. We conclude from this study that left ventricular function remains normal in patients with mitral valvular prolapse in whom minimal or no mitral i.nstlfflciency eoextsts, These patients can be studied serially by echocardiograms in order to detect early manifestations of left ·ventricular dysfunction which may develop in mitral insufficiency due to mitral valvular prolapse.. lairo Ramif'ez, M.D. and Nancy C. Flowe", M.D., F.e.C.p. Dioision of Cardiology, Depattment of Medicine Unioef'rity of Louisoille Reprint requests: Dr. Ramirez, Divlrion of CardioloBfl, Department of Medicine, Unioersity of LouiBoille Health Sciences Center, 323 E Chestnut St, LouisoiUe 40202
REFERENCES 1 Sloman G, Wong M, Walker J: Arrhythmias on exercise in patients with abnormalities of the posterior leaflet of the mitral valve. Am Heart J 83:312-317, 1972 2 Wilson LA, Keeling PWN, Malcolm AD, et al: Visual complications of mitral IeaHet prolapse. Br Med J 2:86-88, 1977 3 Marshall CE, Shappell SD: Sudden death and the ballooning posterior leaflet syndrome. Arch Pathol 98:134-138, 1974 4 Cheslet E, Matisonn BE, Lakier JB, et at: Acute myocardial infarction with normal coronary arteries. Circulation 54:203-209, 1976 5 Scampardonis G, Yang SS, Marahao V, et al: Left ventricular abnormalities in prolapsed mitral leaflet syndrome. Circulation 48:287-297, 1973
COMMUNICATIONS TO THE EDITOR 483
FIGURE 1. Measurement of systolic time intervals on aortic echocardiogram. RVO, Right ventricular outflow; Ao, aorta; LA, left atrium; LAW, left atrial wall; arrow 1, preejection period; and arrow .2, left ventricular ejection time (1 2 = electromechanical systole). 6 Kleid J], Arvan SB, Martin C : Systolic time intervals in the REFERENCES syndrome of midsystolic click and late systolic murmur. 1 Wagner RB, Paidipaty BB: Another advantage of the Chest 71:65-69,1977 flexible fiberoptic bronchoscope: An easy tracheal cannula7 Lewis RP, Rittgers SE, Forrester WF, et al: A critical tion in preparation for bronchography (letter to editor) . review of the systolic time intervals . Circulation 56:146Chest 75 :108, 1979 157,1977 8 Wanderman KL, Goldberg M], Stack RS, et al: Left 2 Lutch IS, Ryan KG: Bronchography combined with bronventricular performance in mitral regurgitation assessed choscopy : A new method (letter to editor). Chest 75 :108, with systolic time intervals and echocardiography. Am ] 1979 Cardiol 38 :831-836, 1976 3 Schoenbaum SW, Pinsker KL, Rakoff S], et al: Fiberoptic bronchoscopy: Complete evaluation of the tracheobronchial tree in the radiology department. Radiology 109:571Bronchography with Bronchoscopy 575,1973 To the Editor: 4 Webster's New Collegiate Dictionary, Springfield, Mass., G and C Merriam Co, 1977, p 1058 l The two communications , 2 dealing with the use of the fiberoptic bronchoscope to help perform bronchographic studies deserve some comment. The "new method" described by Lutch and Ryan 2 was described in 1973. 8 The use of the To the Editor: word, "serendipitous" ("obtained or characterized by serendipity;" "the gift of finding valuable or agreeable things not My coauthor and I apologize for overlooking the previous sought for"'), by Wagner and Paidipaty- is incorrect. If report by Schoenbaum et all in our search of the literature. these authors- had encountered an unexpected situation We are pleased to agree entirely with the suggestions in that during the fiberoptic bronchoscopic procedure and subsepublication, and we wish to encourage the use of the comquently had utilized the instrument in a novel fashion (in this bined bronchoscopic-bronchographic procedure. instance, to facilitate bronchographic studies), their usage would be proper. John S. Latch, M.D ., F.C.C .P. The employment of the fiberoptic bronchoscope to help Woodland Clinic, Woodland, Calif perform bronchographic studies is neither new nor serendipitous but should be considered an alternative to the traditional "blind" methods of passing a bronchographic catheter. 1 Schoenbaum SW, Pinsker KL, Rakoff S], et al: Fiberoptic Kenneth L. Pinsker, M.D., F.C .C.P. bronchoscopy: Complete evaluation of the tracheobronDivision of Pulmonary Medicine chial tree in the radiology department. Radiology 109:571Montefiore Hospital and Medical Center, Bronx, NY 575, 1973
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494 COMMUNICATIONS TO THE EDITOR
CHEST, 76: 4, OCTOBER, 1979
