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Tricuspid Valve Prosthesis and Thrombotic Obstruction
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Tricuspid Valve Prosthesis and Thrombotic Obstruction To the Editor: Dr. Bache's report, "Late thrombotic obstruction of Starr Edwards Prosthesis" (Chest 61:613, 1972) concludes "that prosthetic tricuspid valuthrombosis rarely if ever occurs de novo." At D.C. General Hospital we have had 3 heroin addicts with bacterial endocarditis who required tricuspid valve replacement. The patient operated on for persistent Pseudomonas infection, survived for one week. The second patient operated on for failure secondary to tricuspid and pulmonic regurgitation, continues to do well 33t years later, with irregular prothrombin control. The third patient with failure, recurrent infection and embolism took his warfarin irregularly and expired ten months later with marked thrombosis of the tricuspid orifice simulating tricuspid stenosis. There were no anatomic nor infectious contributors to the thrombosis. Tazewell Banks, M.D. Washington, D.C. Associate Professor of Medicine, Howard University School of Medicine.
pulmonary Hodgkin's disease could be recovered safely in this way, even in very seriously ill patients. Our own experience over the past two years, primarily in renal transplant recipients, confirms Dr. Fennessey's work. Our results referable to P. carinii pneumonitis are summarized in the August 17, 1972 issue of the New England Journal of Medicine. Although not reported as yet, we have also diagnosed tuberculosis, fungal and viral infections as well as lymphangitic spread of malignancy on the basis of material obtained via brush biopsy. Before resorting to either an open or closed transthoracic biopsy, I would strongly recommend a brush biopsy because the higher risk procedure might well be obviated. There will remain a small group of patients in whom one will have to use more invasive methods. Despite the comments of Dr. Faber, I believe that the results of the Mayo Clinic experience summarized in the August issue of Chest argue strongly for the safety and high diagnostic yield of transbronchial pulmonary parenchymal biopsy. Thus, in all but a very few cases, it should be possible to avoid any form of transthoracic biopsy and the attendant risk. Lawrence H. Repsher, M.D. Medical Director, Respiratory Care, Lutheran Hospital and Medical Center, Denver
The Diagnostic Potential of Endobronchial Brush Biopsy To the Editor: I would like to conunent upon the article entitled Lung Biopsy in the Acutely Ill-When and How? appearing in the October, 1972 issue of Chest. Drs. Hughes and Knospe have appropriately emphasized the necessity for biopsy material in the management of serious pulmonary disease in the immune-compromised host. Drs. Faber and Ramsey thoroughly reviewed the relative merits of the open vs the closed operative approach. However, I am concerned that endobronchial brush biopsy, the safest method of diagnosis in these patients, was never mentioned. This is an inexplicable oversight in view of the fact that the use of this technique was pioneered in the United States by Dr. John J. Fennessey of the University of Chicago. He demonstrated that Pneumocqstis carinii organisms, mycobacteria, several fungi, and tissue diagnostic of
650
To the Editor: Doctor Repsher's comments are appropriate and he is to be congratulated on his results in obtaining a diagnosis of Pneumocystis carinii pneumonia by the bronchial brushing technique. We have used this technique for several years, but have been unsuccessful in obtaining the organism in two patients subsequently proved to have this disease. At the time this patient was evaluated, we were unaware of Dr. Repsher's results, and he is correct that the relative safety of this procedure makes it useful as an early diagnostic tool. We have not had experience with the transbronchial parenchymal biopsy and would be reluctant to use it in this instance. Richard L. Hughes, M.D. Director of Pulmonary Medicine L. Penfield Faber, M.D. Director of Section of Thoracic Surgery Presbyterian-St. Luke's Hospital, Chicago
CHEST, VOL. 63, NO.4, APRil, 1973
Tricuspid Valve Prosthesis and Thrombotic Obstruction To the Editor: Dr. Bache's report, "Late thrombotic obstruction of Starr Edwards Prosthesis" (Chest 61:613, 1972) concludes "that prosthetic tricuspid valuthrombosis rarely if ever occurs de novo." At D.C. General Hospital we have had 3 heroin addicts with bacterial endocarditis who required tricuspid valve replacement. The patient operated on for persistent Pseudomonas infection, survived for one week. The second patient operated on for failure secondary to tricuspid and pulmonic regurgitation, continues to do well 33t years later, with irregular prothrombin control. The third patient with failure, recurrent infection and embolism took his warfarin irregularly and expired ten months later with marked thrombosis of the tricuspid orifice simulating tricuspid stenosis. There were no anatomic nor infectious contributors to the thrombosis. Tazewell Banks, M.D. Washington, D.C. Associate Professor of Medicine, Howard University School of Medicine.
pulmonary Hodgkin's disease could be recovered safely in this way, even in very seriously ill patients. Our own experience over the past two years, primarily in renal transplant recipients, confirms Dr. Fennessey's work. Our results referable to P. carinii pneumonitis are summarized in the August 17, 1972 issue of the New England Journal of Medicine. Although not reported as yet, we have also diagnosed tuberculosis, fungal and viral infections as well as lymphangitic spread of malignancy on the basis of material obtained via brush biopsy. Before resorting to either an open or closed transthoracic biopsy, I would strongly recommend a brush biopsy because the higher risk procedure might well be obviated. There will remain a small group of patients in whom one will have to use more invasive methods. Despite the comments of Dr. Faber, I believe that the results of the Mayo Clinic experience summarized in the August issue of Chest argue strongly for the safety and high diagnostic yield of transbronchial pulmonary parenchymal biopsy. Thus, in all but a very few cases, it should be possible to avoid any form of transthoracic biopsy and the attendant risk. Lawrence H. Repsher, M.D. Medical Director, Respiratory Care, Lutheran Hospital and Medical Center, Denver
The Diagnostic Potential of Endobronchial Brush Biopsy To the Editor: I would like to conunent upon the article entitled Lung Biopsy in the Acutely Ill-When and How? appearing in the October, 1972 issue of Chest. Drs. Hughes and Knospe have appropriately emphasized the necessity for biopsy material in the management of serious pulmonary disease in the immune-compromised host. Drs. Faber and Ramsey thoroughly reviewed the relative merits of the open vs the closed operative approach. However, I am concerned that endobronchial brush biopsy, the safest method of diagnosis in these patients, was never mentioned. This is an inexplicable oversight in view of the fact that the use of this technique was pioneered in the United States by Dr. John J. Fennessey of the University of Chicago. He demonstrated that Pneumocqstis carinii organisms, mycobacteria, several fungi, and tissue diagnostic of
650
To the Editor: Doctor Repsher's comments are appropriate and he is to be congratulated on his results in obtaining a diagnosis of Pneumocystis carinii pneumonia by the bronchial brushing technique. We have used this technique for several years, but have been unsuccessful in obtaining the organism in two patients subsequently proved to have this disease. At the time this patient was evaluated, we were unaware of Dr. Repsher's results, and he is correct that the relative safety of this procedure makes it useful as an early diagnostic tool. We have not had experience with the transbronchial parenchymal biopsy and would be reluctant to use it in this instance. Richard L. Hughes, M.D. Director of Pulmonary Medicine L. Penfield Faber, M.D. Director of Section of Thoracic Surgery Presbyterian-St. Luke's Hospital, Chicago
CHEST, VOL. 63, NO.4, APRil, 1973