Echocardiographic Midsystolic Notching of Pulmonic Valve and Hypertension

2 Weyman AE, Dillon IC, Feigenbaum M, et al: Echocardiographic patterns of pulmonic valve motion with pulmonary hypertension. Circulation 50:905-910,1974 3 KaJcu R, Neumann A, Bommer LV, et al: Sensitivity and specificity of the pulmonic valve echogram in the detection of pulmonary hypertension (abstract). Am I Cardio141: 436, 1978 4 Nanda NC, Gramiak R, Robinson TI, et al: Echocardiographic evaluation of pulmonary hypertension. Circulation 50:575-581, 1974 5 Wilson CS, Krueger SK, Caudill CC, et al: Simultaneous echocardiographic recording of both semilunar valves: Report of a case without transposed great vessels. Chest 68:743-745,1975 To the Editor: I read with interest Wilson's letter. In my previously reported case,! there were no thoracic or spinal deformities. Recently, we 2 described the echogram of the pulmonic valve in 45 children with a variety of cardiac defects. Four had normal pulmonary arterial pressure and midsystolic closure or notching of the posterior pulmonic cusp. None of them had a supracristal ventricular septal defect or infundibular pulmonary stenosis. Moreover, in a current study in our insti.tution, three of a group of 30 normal newborns had midsystolic closure also. None of these patients had skeletal anomalies by clinical examination. In our laboratory, it has been possible to record adequate echograms of the pulmonic valve (opening and closure) in about 90 percent of infants and 70 percent of older children. Similar figures have been reported by others. S These percentages are even higher in the presence of pulmonary hypertension. The recording of the echogram of the pulmonic valve in children is probably enhanced by the relative size ratio of the great arteries and likely by the depth and spatial orientation of the pulmonic valve; however, why midsystolic closure occurs in patients with normal pulmonary arterial pressure in the absence of a supracristal ventricular septal defect or obstruction of the right ventricular outflow tract is not known.

Jose Marln-Garcia, M.D. Section of Pediatric Cardiology Department of Pediatrics Unioenity of Tennessee Medical Center, Memphis

1 Marin-Garcia I: Echocardiographic pulmonic valvular motion in idiopathic hypertrophic subaortic stenosis (letter to editor). Chest 74: 483-484, 1978 2 Marin-Garcia I, Anthony CL, Arnon R: The pulmonic valve echogram in the assessment of pulmonary hypertension in children. Read before the Section of Cardiology of the American Academy of Pediatrics, Chicago, Oct 22, 1978 3 Hirschfeld S, Meyer R, Schwartz D, et al: Measurement of right and left ventricular systolic time intervals by echocardiography. Circulation 51:304-309,1975

F'ICtII\E

1. Target sign for emphysema.

CASE

REPoRT

An 84-year-old white man came to the emergency room with a history of increasing shortness of breath for the past two weeks and production of one cup of yellowish tenacious sputum per day. He had not seen a physician for over 20 years and had a history of smoking two pacIcs of cigarettes per day for over 50 years. Physical examination showed a thin aged man who was moderately short of breath. Examination of the lungs revealed markedly decreased breath sounds and course upperairway rhonchi over all pulmonary fields. Bilateral, ll~-cm, slightly raised, scarlet circular lesions were noted just proximal to the patellae on the anterior aspects of the thighs. Findings from the remainder of the cutaneous examination were normal. On questioning, the patient related spending many hours each day with his elbows resting on his knees "to help my breathing." The chest x-ray film showed depressed hemidiaphragms and clear hyperlucent pulmonary fields. Arterial blood gas levels with the patient breathing room air were as follows: arterial oxygen pressure, 56 mm Hg; arterial carbon dioxide tension, 35 mm Hg; and pH, 7.44. Despite therapy, the patient died one week later. Autopsy revealed severe panlobular emphysema, with evidence of pulmonary hypertension and right ventricular hypertrophy. Pulmonary cultures grew Hemophilus influenZll6. Specimens from the lesions on the thighs were not taken. DISCUSSION

I have named this finding the target sign for emphysema. One other instance has been observed in a patient admitted for his third hospitalization who required therapy with mechanical ventilation due to acute respiratory failure, secondary to COPD. The clinician should be aware of this sign, which seems to be related to severe COPD. I would like to inquire if this sign has been observed by others. Jeffrey R. Whiteside, M.D. Intern, Department of Medicine Indiana UnWersity Medical Center, Inc&nopolis

Target Sign for Emphysema

Intrapleural Iniection of Iodized Oil in Pancreatic Pleural Effusions

To , the Editor:

To the Editor:

I would like to report a physical finding of chronic obstructive pulmonary disease ( COPD) which has not yet been described.

De Koster! suggested injecting iodized oil into the pleural

530 COMMUNICATIONS TO THE EDITOR

To demonstrate pancreaticopleural fistulae, TombroJf and

cavity very early in the course of hemorrhagic pleural effu-

CHEST, 75: 4, APRIL, 1979