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Tricuspid Valve Subacute Bacterial Endocarditis Complicating Tetralogy of Fallot
TRICUSPID VALVE SUBACUTE BACTERIAL ENDOCARDITIS
227
et al, 4 Alvarez and Colbert5 and Bigger and Vinson.6 Kiviranta 3 stated that the incidence of carcinoma of esophagus in patients with lye stricture of 24 years' duration or more is a thousand times higher than in the normal population.
Tricuspid Valve Subacute Bacterial Endocarditis Complicating Tetralogy of Fallot*
The interval between lye ingestion and development of carcinoma in our patient was 12 years. The minimum latency period in previously reported cases was 22 years. Our present knowledge regarding the carcinogenic effect of lye is no more than that of other irritants elsewhere in the body. Carcinogenic effect of esophageal insults has been discussed in detail by Rose.7
Lamberto C. Maramba, M.D.; Frank ]. Hildner, M.D., F.C.C.P.; Philip Samet, M.D., F.C.C.P., and Jack ]. Greenberg, M.D., F.C.C.P.
Patients with carcinoma of the esophagus engrafted on lye stricture are considerably younger than patients with other forms of carcinoma of the esophagus. The average age of patients in the series reported by Kiviranta3 was 43 years. Diagnosis of carcinoma in these patients is often delayed until the lesion is far advanced since the symptoms are blamed on lye stricture. One may speculate on the etiology of carcinoma following lye stricture. It may weii be that this chemical "burn" is analogous to skin bums, and the carcinoma is, thus, of the same origin as the weii known "bum-cancer." In addition, there seems to be a much higher incidence of carcinoma of the esophagus in those societies which utilize very hot liquids by mouth. The incidence of malignant transformation of lye stricture does not warrant esophageal resection. However, should a patient need surgical intervention to relieve the stricture, resection of the esophagus with intrathoracic esophageal reconstruction seems to be a wiser choice than a bypass procedure.
This report records for tbe first time tbe occurrence of isolated subacute bacterial endocarditis involving the tricuspid valve in a patient whose condition evolved into classic tetralogy of FaUot, and who required prosthetic replacement of the valve in addition to surgical therapy for the congenital lesions. Postoperative complete heart block was corrected with implantation of a P-wave synchronous pacemaker. The exceUent clinical improvement observed in our patient, in addition to previous similar reports, further indicate that prosthetic valves can be seated in areas of infection and heal properly.
T
here have been no reports of associated isolated subacute bacterial endocarditis ( SBE) involving the tricuspid valve in tetralogy of Fallot despite many studies on this condition. This paper reports such a case which required total surgical correction in addition to tricuspid valve replacement. Complete heart block complicated surgical correction and was treated by implantation of a P-wave synchronous pacemaker. °From the Division of Cardiology, Department of Medicine and the Division of Thoracic Surgery, Department of Surgery, Mount Sinai Hospital, Miami Beach, Florida and the University of Miami School of Medicine, Coral Gables, Florida.
REFERENCES
1 Cattell HW: Cancer of the esophagus following a stricture, due to the taking of lye with recent metastasis to the liver. Trans Path Soc Philadelphia 17:18, 1896 2 Benedict EB: Carcinoma of the esophagus developing in benign structure, New Eng J Med 224:408, 1941 3 Kiviranta UK: Corrosion carcinoma of the esophagus, 381 Cases of Corrosion and Nine Cases of Corrosion Carcinoma. ACTA Otolaryng (Stockholm) 42:89, 1952 4 Arrants JE, Albueme H, Jurkiewicz MJ: Carcinoma of the esophagus with a history of lye ingestion, Amer Surg 31:107, 1965 5 Alvarez AF, Colbert JG: Lye stricture of the esophagus complicated by carcinoma. Canadian J Surg 6:470, 1963 6 Bigger JA, Vinson PP: Carcinoma secondary to burn of esophagus from ingestion of lye; report of a case. Surgery 28:887, 1950 7 Rose EF: Carcinogenesis and oesophageal insults. South African Med J 42:334, 1968 Reprint requests: Dr. Pate, 951 Court Avenue, Memphis 38103
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
FIGURE 1A. Preoperative electrocardiogram showing normal sinus rhythm with first degree AV block and probable right atrial and right ventricular hypertrophy.
228
MARAMBA ET AL 10: SO AM
4/U/fl
CASE REPORT
The patient is a 37-year-old man who had a known heart murmur since childhood. On his initial admission in 1967, he complained of palpitations, anorexia and weight loss. He
r
! ~ .· L.J._! - ..
L ~ 1
-+j_j.±t:tti!t:Jtttli:l.::!::l!.
I·-'·-' .. ! ·.L.!-.I-4---I__j
A precordial electrocardiogram obtained 23 after surgery demonstrates a normally functioning P-wave synchronous pacemaker with a P-wave pacemaker impulse interval of 0.18 second.
denied syncopal episodes, squatting, or cyanosis at birth. Six months prior to admission he began to complain of weakness and 15 to 20 pound weight loss, but denied signs and symptoms of congestive heart failure. Subsequently, he was admitted to another hospital with a diagnosis of possible SBE. Although this diagnosis was not confirmed by positive blood cultures, he was intensively treated with antibiotics. His past medical history included chronically draining right ear, and intermittent "bronchial asthma" since age five years. In 1957, he was admitted to a Rhode Island hospital complaining of generalized weakness, dyspnea, palpitations and dizziness. Cardiac catheterization at that time revealed 90.0 percent aortic 02 saturation, normal aortic, left ventricular and pulmonary artery (PA) pressures (Table 1). During right heart catheterization, the catheter was passed from the right ventricle ( RV) into the left ventricle ( LV) and aorta. There was a 15 mm Hg systolic gradient across the pulmonic valve. The impression at that time was a mild degree of infundibular pulmonic stenosis, ventricular septal defect ( VSD) with a large left-to-right shunt, and a right-sided aortic arch. Physical examination disclosed no stigmata of SBE or signs of congestive heart failure. The blood pressure was 126/80, ventricular rate 100 per minute and regular, respiratory rate 15 per minute and normal temperature. On cardiac examination, the point of maximal impulse was palpated in the 5th interspace, outside the midclavicular line. There was a right ventricular heave, but no pulmonary artery pulsation. There was a systolic thrill in the left 4th intercostal space. S1 was split. S2 showed a wide fixed split. The aortic component of S2 was greater than the pulmonic component. There was grade IV on a scale of VI apical holosystolic murmur transmitted to the axilla. A grade III on a scale of VI systolic ejection murmur was best heard at the pulmonary area. There was no diastolic murmur, rub, or gallop. Abdominal examination showed no hepatosplenomegaly. The femoral pulses were felt ahead of the radials. The electrocardiogram showed normal sinus rhythm; the P-R interval was 0.24 second, and the QRS duration was 0.12 second. The pattern was suggestive of probable right atrial and right ventricular enlargement (Fig 1A). Fluoroscopy and chest roentgenograms with barium revealed a right-sided aortic arch and right heart hypertrophy and dilatation, with diminished main P A shadow ( Fig 2). Cardiac catheterization demonstrated a probe patent foramen ovale, right ventricular infundibular and pulmonic valvular stenosis. There was a 71 mm Hg RV-PA gradient. Angiocardiography revealed left-to-right shunt at the ventricular level and tricuspid regurgitation. The hematocrit ( Hct) was 35.5 percent and the hemoglobin ( Hgb) was 11.5 grams percent. The leukocyte count was 10,600 with normal differential. Urinalysis was normal. Blood cultures showed no bacterial growth. Surgery was done on March 14, 1967. Findings included: 1) a right infundibular chamber; 2) a stenotic pulmonary valve; 3) hypertrophied crista-supraventricularis over-hanging a 2.5 em ventricular septal defect; 4) considerable overriding of the aorta; 5) huge right atrium; 6) right-sided aortic arch; and 7) a tricuspid valve massively involved with friable vegetations on the valve leaflets and at least four ruptured chordae tendineae. The patient underwent closure of the VSD, resection of the infundibular stenosis, pulmonary valvulotomy and tricuspid valve replacement with a No. 9 Kay-Shiley disc valve. At the termination of cardiopulmonary bypass, the patient had a heart rate between 60-70 beats per minute with alternating complete and 2:1 AV block. An insulated wire
CHEST, VOL 59, NO. 2, FEBRUARY 1971
229
TRICUSPID VALVE SUBACUTE BACTERIAL ENDOCARDITIS Table
l~ardiac
CatheterU!ation Data
Before Surgery* (2/8/57) Ten Years Right Atrium Right Ventricle Pulmonary Artery Pulmonary Wedge Aorta Left Ventricle Left Atrium Aortic 0 2 Saturation
12/4 mm 44/6 mm 30/15 mm 8mm 130/80 mm 130/10 mm
Hg Hg Hg Hg Hg Hg
90.0%
Mter Surgery* (3/10/67) 4 Days (mean) 10 mm Hg 98/5 mm Hg 27/3 (mean) mm Hg
(2/5/69) 2 Years (mean) 6 mm Hg 38/6 mm Hg 28/9 (mean 20) mm Hg*
140/90 mm Hg 143/6 mm Hg (mean) 10 mm Hg 98%
130/70 mm Hg 105/10 mm Hg (mean) 3 mm Hg 93.8%
*Pulmonary artery pressure was obtained indirectly by wedging a No. 7 Gensini catheter into the left superior pulmonary vein. Surgery was performed on March 14, 1967. had been placed on the right ventricle so that external pacing could be performed if the heart rate fell further. On the ninth postoperative day, he suddenly developed a temperature of 103•F. Complete blood count showed Hct 35 percent; the Hgb 10.4 grams percent, and the white cells 19,000 with 70 percent polys, 29 percent bands, and 1 percent lymphocytes. Because of the vegatations on the tricuspid valve, and growth of coagulase negative Straphylococcus albus from the resected valve, it was assumed that bacterial endocarditis had recurred. Blood cultures were again negative. He was however, treated with aqueous penicillin 25 million units every 12 hours with cephalothin ( Keflin) 2 grams every six hours intravenously. During this period, cardiac pacing was not required. A spontaneous idioventricular rate of 60 with complete heart block was the predominant rhythm. The temporary pacing wires were removed on the 19th postoperative day. Cardiac arrest occurred the next day. Resuscitation procedures were started immediately and subsequent ventricular tachycardia (Fig lB) was terminated by a 400 watt-
second DC shock. Under fluoroscopic guidance, a No. 3.5 F bipolar pacing catheter was passed via an antecubital vein through the tricuspid prosthesis into the RV where good capture was obtained. Four days later, a P-wave synchronous pacemaker was implanted by thoracotomy. The patient, thereafter, made excellent recovery. The patient was re-examined two years postoperatively. Cardiac examination on February 4, 1969, revealed a thrill felt most prominently in the 3rd and 4th intercostal spaces at the left sternal border. The point of maximal impulse remained unchanged. A grade V on a scale of VI, holosystolic murmur was heard best over the 3rd left intercostal space. Tricuspid prosthetic valve sounds were heard all over the precordium. S2 was physiologically split, and the aortic component was greater than the pulmonic component. The electrocardiogram revealed normal P-waves followed at regular intervals by pacemaker induced ventricular complexes and the P-R interval remained fixed at 0.18 sec (Fig 1C). On February 5, 1969, a follow-up cardiac catheterization revealed normal left heart pressures and 98 percent aortic ~ saturation (Table 1 ). A No. 7 Gensini catheter, advanced from the right atrium through probe-patent foramen ov'ale, was wedged into the left superior pulmonary vein to record the PA pressure indirectly. There was a 10 mm Hg recidual gradient across the pulmonic valve. The RV pressure was obtained two ways: via the tricuspid prosthetic valve with a No. 50 polyethylene tubing and with a Gensini catheter passed from the. left ventricular outflow tract through a residual VSD. Left ventriculography demonstrated the residual VSD and right atrial contrast injection showed a large atrium and a relatively large RV outflow tract. DISCUSSION
FIGURE 2. A posteroanterior view of the chest shows a rightsided aortic arch, marked right atrial and ventricular hypertrophy and diminished main pulmonary artery shadows.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
Most congenital cardiovascular maHormations increase the risk of bacterial endocarditis. 1 • 2 A tabulation of congenital cardiac defects listed according to frequency of associated SBE would include: VSD, congenital pulmonic stenosis, patent ductus arteriosus, tetralogy of Fallot, congenital bicuspid aortic valve, atrial septal defect, coarctation of the aorta, truncus arteriosus, and fibroelastosis. 1 • 2 To our knowledge, however, the association of isolated SBE involving the tricuspid valve with Fallot's tetralogy has not been reported before. "High pressure or jet areas" such as the outflow tract of the right ventricle, the pulmonary and aortic valves, edges of the VSD, and more recently sites of Blalock
230
LULENSKI, PIFARRE AND NEVILLE
anastomoses are commonly reported as sites of vegetations of SBE in tetralogy of Fallot.:l Right-sided SBE is rare and is said to comprise 4-5 percent of the general incidence of endocarditis. 4 It is frequently encountered among heroin addicts. There have been only 68 previously reported cases of tricuspid insufficiency due to SBE. 5 Isolated SBE of the tricuspid valve in tetralogy of Fallot is, however, distinctly unusual. The proper use of antibiotics have clearly improved the prognosis of SBE. 4 However, resulting complications like "refractory" congestive heart failure require more definitive life-saving measures.~ Recently, Kennedy et al 5 reported a 28-year-old woman with SBE and in congestive heart failure in whom prosthetic replacement of the tricuspid valve was perforined with good results. Subsequently, emergency and/or elective valvular replacement was shown to be a safe and effective procedure during and/or shortly after antibiotic treatment for SBE.U- 7 Thus, our patient who had evolved into a classic tetralogy of Fallot, 11 complicated by SBE of the tricuspid valve, underwent surgery with prosthetic replacement of the valve. The excellent clinical recovery observed further indicates that prosthetic valves can be seated in areas of infection and heal properly. Thus far, there is no recurrence of sepsis.
REFERENCES
Vogler WR, Dorney ER: Bacterial endocarditis in congenital heart disease. Amer Heart J 64:198-206, 1962 2 t>.loss AJ, Adams FH: Heart Disease in Infants, Children and Adolescents. Baltimore, William and Wilkins, 1968, pp 840-49
Rapid Growth of a Pleural Mesothelioma* Ga~ C. Lulenski, M.D., Roque Pifarre, M.D., F.C.C.P., and WiUiam E. Neville, M.D., F.C.C.P.
A patient with diffuse pleural mesotheUoma presenting as a large mass in the left hemithorax is described. Despite a normal chest roentgenogram three months earUer and symptoms of only three days' duration, the patient expired within three weeks of admission. This confirms the potential rapid growth of this malignancy. the description of pleural mesothelioma as a F ollowing distinct entity, Klemperer and Rabin separated the 1
tumor into two varieties on a histologic basis. Godwin 2 emphasized the differences between these two types of mesothelioma. The first was a slow growing, well encapsulated, and often resectable form which he called "localized fibrous mesothelioma." The second was more malignant in nature, both clinically and pathologically, with widespread metastases commonly found within the pleural space. These lesions were rarely surgically removable, and were referred to as "diffuse." Both types of mesothelioma seem clearly related to exposure to asbestos, whether the fiber be crocidolite, amosite, or crysolite.a-6 While the incidence of this tumor is very low ( 0.07 percent) 7 there have been several cases in which the interval between the onset of symptoms and death has been less than three months. 2 •5 · 7 · 8 This somewhat enforces the malignant nature of the diffuse type of °From the Cardiopulmonary Surgical Section, Veterans Administration Hospital, Hines, I!linois and the De~a~tment of Surgery, Loyola University Stntch School of Medicme, Maywood, Illinois.
3 Kerr A Jr: Subacute Bacterial Endocarditis, Springfield, Illinois, Charles C Thomas, 1955 4 Lerner PI, Weinstein L: Infective endocarditis in the antibiotic era. New Eng J Med 274:199-206, 259-266, 323331, 1966
.5 Kennedy JH, Sabga GA, Fisk AA, et a!: Isolated tricuspid valvular insufficiency due to subacute bacterial endocarditis: Report of a case with recovery following prosthetic replacement of the tricuspid valve. J Thorac Cardiovas Surg 51:498-506, 1966 6 Windsor HM, Shanahan MS: Emergency valve replacement in bacterial endocarditis. Thorax 22:25-33, 1967
7 Stason WB, DeSanctis RW, Weinberg AN, et a!: Cardiac surgery in bacterial endocarditis. Circulation 38:514-523, 1968 8 Gasul BM, Dillon RF, Urla V, et a!: Ventricular septal defect~: Their natural transformation into those with infundibular stenosis or into the cyanotic or noncyanotic type of tetralogy of Fallot. JAMA 164:847-858, 1957 Reprint requests: Dr. Hildner, 4300 Alton Road, Miami Beach 33138
FIGURE 1. Radiograph of the chest four weeks after right upper lobectomy for emphysematous bleb ( 12 weeks prior to last admission). No evidence of mass in left chest.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
227
et al, 4 Alvarez and Colbert5 and Bigger and Vinson.6 Kiviranta 3 stated that the incidence of carcinoma of esophagus in patients with lye stricture of 24 years' duration or more is a thousand times higher than in the normal population.
Tricuspid Valve Subacute Bacterial Endocarditis Complicating Tetralogy of Fallot*
The interval between lye ingestion and development of carcinoma in our patient was 12 years. The minimum latency period in previously reported cases was 22 years. Our present knowledge regarding the carcinogenic effect of lye is no more than that of other irritants elsewhere in the body. Carcinogenic effect of esophageal insults has been discussed in detail by Rose.7
Lamberto C. Maramba, M.D.; Frank ]. Hildner, M.D., F.C.C.P.; Philip Samet, M.D., F.C.C.P., and Jack ]. Greenberg, M.D., F.C.C.P.
Patients with carcinoma of the esophagus engrafted on lye stricture are considerably younger than patients with other forms of carcinoma of the esophagus. The average age of patients in the series reported by Kiviranta3 was 43 years. Diagnosis of carcinoma in these patients is often delayed until the lesion is far advanced since the symptoms are blamed on lye stricture. One may speculate on the etiology of carcinoma following lye stricture. It may weii be that this chemical "burn" is analogous to skin bums, and the carcinoma is, thus, of the same origin as the weii known "bum-cancer." In addition, there seems to be a much higher incidence of carcinoma of the esophagus in those societies which utilize very hot liquids by mouth. The incidence of malignant transformation of lye stricture does not warrant esophageal resection. However, should a patient need surgical intervention to relieve the stricture, resection of the esophagus with intrathoracic esophageal reconstruction seems to be a wiser choice than a bypass procedure.
This report records for tbe first time tbe occurrence of isolated subacute bacterial endocarditis involving the tricuspid valve in a patient whose condition evolved into classic tetralogy of FaUot, and who required prosthetic replacement of the valve in addition to surgical therapy for the congenital lesions. Postoperative complete heart block was corrected with implantation of a P-wave synchronous pacemaker. The exceUent clinical improvement observed in our patient, in addition to previous similar reports, further indicate that prosthetic valves can be seated in areas of infection and heal properly.
T
here have been no reports of associated isolated subacute bacterial endocarditis ( SBE) involving the tricuspid valve in tetralogy of Fallot despite many studies on this condition. This paper reports such a case which required total surgical correction in addition to tricuspid valve replacement. Complete heart block complicated surgical correction and was treated by implantation of a P-wave synchronous pacemaker. °From the Division of Cardiology, Department of Medicine and the Division of Thoracic Surgery, Department of Surgery, Mount Sinai Hospital, Miami Beach, Florida and the University of Miami School of Medicine, Coral Gables, Florida.
REFERENCES
1 Cattell HW: Cancer of the esophagus following a stricture, due to the taking of lye with recent metastasis to the liver. Trans Path Soc Philadelphia 17:18, 1896 2 Benedict EB: Carcinoma of the esophagus developing in benign structure, New Eng J Med 224:408, 1941 3 Kiviranta UK: Corrosion carcinoma of the esophagus, 381 Cases of Corrosion and Nine Cases of Corrosion Carcinoma. ACTA Otolaryng (Stockholm) 42:89, 1952 4 Arrants JE, Albueme H, Jurkiewicz MJ: Carcinoma of the esophagus with a history of lye ingestion, Amer Surg 31:107, 1965 5 Alvarez AF, Colbert JG: Lye stricture of the esophagus complicated by carcinoma. Canadian J Surg 6:470, 1963 6 Bigger JA, Vinson PP: Carcinoma secondary to burn of esophagus from ingestion of lye; report of a case. Surgery 28:887, 1950 7 Rose EF: Carcinogenesis and oesophageal insults. South African Med J 42:334, 1968 Reprint requests: Dr. Pate, 951 Court Avenue, Memphis 38103
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
FIGURE 1A. Preoperative electrocardiogram showing normal sinus rhythm with first degree AV block and probable right atrial and right ventricular hypertrophy.
228
MARAMBA ET AL 10: SO AM
4/U/fl
CASE REPORT
The patient is a 37-year-old man who had a known heart murmur since childhood. On his initial admission in 1967, he complained of palpitations, anorexia and weight loss. He
r
! ~ .· L.J._! - ..
L ~ 1
-+j_j.±t:tti!t:Jtttli:l.::!::l!.
I·-'·-' .. ! ·.L.!-.I-4---I__j
A precordial electrocardiogram obtained 23 after surgery demonstrates a normally functioning P-wave synchronous pacemaker with a P-wave pacemaker impulse interval of 0.18 second.
denied syncopal episodes, squatting, or cyanosis at birth. Six months prior to admission he began to complain of weakness and 15 to 20 pound weight loss, but denied signs and symptoms of congestive heart failure. Subsequently, he was admitted to another hospital with a diagnosis of possible SBE. Although this diagnosis was not confirmed by positive blood cultures, he was intensively treated with antibiotics. His past medical history included chronically draining right ear, and intermittent "bronchial asthma" since age five years. In 1957, he was admitted to a Rhode Island hospital complaining of generalized weakness, dyspnea, palpitations and dizziness. Cardiac catheterization at that time revealed 90.0 percent aortic 02 saturation, normal aortic, left ventricular and pulmonary artery (PA) pressures (Table 1). During right heart catheterization, the catheter was passed from the right ventricle ( RV) into the left ventricle ( LV) and aorta. There was a 15 mm Hg systolic gradient across the pulmonic valve. The impression at that time was a mild degree of infundibular pulmonic stenosis, ventricular septal defect ( VSD) with a large left-to-right shunt, and a right-sided aortic arch. Physical examination disclosed no stigmata of SBE or signs of congestive heart failure. The blood pressure was 126/80, ventricular rate 100 per minute and regular, respiratory rate 15 per minute and normal temperature. On cardiac examination, the point of maximal impulse was palpated in the 5th interspace, outside the midclavicular line. There was a right ventricular heave, but no pulmonary artery pulsation. There was a systolic thrill in the left 4th intercostal space. S1 was split. S2 showed a wide fixed split. The aortic component of S2 was greater than the pulmonic component. There was grade IV on a scale of VI apical holosystolic murmur transmitted to the axilla. A grade III on a scale of VI systolic ejection murmur was best heard at the pulmonary area. There was no diastolic murmur, rub, or gallop. Abdominal examination showed no hepatosplenomegaly. The femoral pulses were felt ahead of the radials. The electrocardiogram showed normal sinus rhythm; the P-R interval was 0.24 second, and the QRS duration was 0.12 second. The pattern was suggestive of probable right atrial and right ventricular enlargement (Fig 1A). Fluoroscopy and chest roentgenograms with barium revealed a right-sided aortic arch and right heart hypertrophy and dilatation, with diminished main P A shadow ( Fig 2). Cardiac catheterization demonstrated a probe patent foramen ovale, right ventricular infundibular and pulmonic valvular stenosis. There was a 71 mm Hg RV-PA gradient. Angiocardiography revealed left-to-right shunt at the ventricular level and tricuspid regurgitation. The hematocrit ( Hct) was 35.5 percent and the hemoglobin ( Hgb) was 11.5 grams percent. The leukocyte count was 10,600 with normal differential. Urinalysis was normal. Blood cultures showed no bacterial growth. Surgery was done on March 14, 1967. Findings included: 1) a right infundibular chamber; 2) a stenotic pulmonary valve; 3) hypertrophied crista-supraventricularis over-hanging a 2.5 em ventricular septal defect; 4) considerable overriding of the aorta; 5) huge right atrium; 6) right-sided aortic arch; and 7) a tricuspid valve massively involved with friable vegetations on the valve leaflets and at least four ruptured chordae tendineae. The patient underwent closure of the VSD, resection of the infundibular stenosis, pulmonary valvulotomy and tricuspid valve replacement with a No. 9 Kay-Shiley disc valve. At the termination of cardiopulmonary bypass, the patient had a heart rate between 60-70 beats per minute with alternating complete and 2:1 AV block. An insulated wire
CHEST, VOL 59, NO. 2, FEBRUARY 1971
229
TRICUSPID VALVE SUBACUTE BACTERIAL ENDOCARDITIS Table
l~ardiac
CatheterU!ation Data
Before Surgery* (2/8/57) Ten Years Right Atrium Right Ventricle Pulmonary Artery Pulmonary Wedge Aorta Left Ventricle Left Atrium Aortic 0 2 Saturation
12/4 mm 44/6 mm 30/15 mm 8mm 130/80 mm 130/10 mm
Hg Hg Hg Hg Hg Hg
90.0%
Mter Surgery* (3/10/67) 4 Days (mean) 10 mm Hg 98/5 mm Hg 27/3 (mean) mm Hg
(2/5/69) 2 Years (mean) 6 mm Hg 38/6 mm Hg 28/9 (mean 20) mm Hg*
140/90 mm Hg 143/6 mm Hg (mean) 10 mm Hg 98%
130/70 mm Hg 105/10 mm Hg (mean) 3 mm Hg 93.8%
*Pulmonary artery pressure was obtained indirectly by wedging a No. 7 Gensini catheter into the left superior pulmonary vein. Surgery was performed on March 14, 1967. had been placed on the right ventricle so that external pacing could be performed if the heart rate fell further. On the ninth postoperative day, he suddenly developed a temperature of 103•F. Complete blood count showed Hct 35 percent; the Hgb 10.4 grams percent, and the white cells 19,000 with 70 percent polys, 29 percent bands, and 1 percent lymphocytes. Because of the vegatations on the tricuspid valve, and growth of coagulase negative Straphylococcus albus from the resected valve, it was assumed that bacterial endocarditis had recurred. Blood cultures were again negative. He was however, treated with aqueous penicillin 25 million units every 12 hours with cephalothin ( Keflin) 2 grams every six hours intravenously. During this period, cardiac pacing was not required. A spontaneous idioventricular rate of 60 with complete heart block was the predominant rhythm. The temporary pacing wires were removed on the 19th postoperative day. Cardiac arrest occurred the next day. Resuscitation procedures were started immediately and subsequent ventricular tachycardia (Fig lB) was terminated by a 400 watt-
second DC shock. Under fluoroscopic guidance, a No. 3.5 F bipolar pacing catheter was passed via an antecubital vein through the tricuspid prosthesis into the RV where good capture was obtained. Four days later, a P-wave synchronous pacemaker was implanted by thoracotomy. The patient, thereafter, made excellent recovery. The patient was re-examined two years postoperatively. Cardiac examination on February 4, 1969, revealed a thrill felt most prominently in the 3rd and 4th intercostal spaces at the left sternal border. The point of maximal impulse remained unchanged. A grade V on a scale of VI, holosystolic murmur was heard best over the 3rd left intercostal space. Tricuspid prosthetic valve sounds were heard all over the precordium. S2 was physiologically split, and the aortic component was greater than the pulmonic component. The electrocardiogram revealed normal P-waves followed at regular intervals by pacemaker induced ventricular complexes and the P-R interval remained fixed at 0.18 sec (Fig 1C). On February 5, 1969, a follow-up cardiac catheterization revealed normal left heart pressures and 98 percent aortic ~ saturation (Table 1 ). A No. 7 Gensini catheter, advanced from the right atrium through probe-patent foramen ov'ale, was wedged into the left superior pulmonary vein to record the PA pressure indirectly. There was a 10 mm Hg recidual gradient across the pulmonic valve. The RV pressure was obtained two ways: via the tricuspid prosthetic valve with a No. 50 polyethylene tubing and with a Gensini catheter passed from the. left ventricular outflow tract through a residual VSD. Left ventriculography demonstrated the residual VSD and right atrial contrast injection showed a large atrium and a relatively large RV outflow tract. DISCUSSION
FIGURE 2. A posteroanterior view of the chest shows a rightsided aortic arch, marked right atrial and ventricular hypertrophy and diminished main pulmonary artery shadows.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971
Most congenital cardiovascular maHormations increase the risk of bacterial endocarditis. 1 • 2 A tabulation of congenital cardiac defects listed according to frequency of associated SBE would include: VSD, congenital pulmonic stenosis, patent ductus arteriosus, tetralogy of Fallot, congenital bicuspid aortic valve, atrial septal defect, coarctation of the aorta, truncus arteriosus, and fibroelastosis. 1 • 2 To our knowledge, however, the association of isolated SBE involving the tricuspid valve with Fallot's tetralogy has not been reported before. "High pressure or jet areas" such as the outflow tract of the right ventricle, the pulmonary and aortic valves, edges of the VSD, and more recently sites of Blalock
230
LULENSKI, PIFARRE AND NEVILLE
anastomoses are commonly reported as sites of vegetations of SBE in tetralogy of Fallot.:l Right-sided SBE is rare and is said to comprise 4-5 percent of the general incidence of endocarditis. 4 It is frequently encountered among heroin addicts. There have been only 68 previously reported cases of tricuspid insufficiency due to SBE. 5 Isolated SBE of the tricuspid valve in tetralogy of Fallot is, however, distinctly unusual. The proper use of antibiotics have clearly improved the prognosis of SBE. 4 However, resulting complications like "refractory" congestive heart failure require more definitive life-saving measures.~ Recently, Kennedy et al 5 reported a 28-year-old woman with SBE and in congestive heart failure in whom prosthetic replacement of the tricuspid valve was perforined with good results. Subsequently, emergency and/or elective valvular replacement was shown to be a safe and effective procedure during and/or shortly after antibiotic treatment for SBE.U- 7 Thus, our patient who had evolved into a classic tetralogy of Fallot, 11 complicated by SBE of the tricuspid valve, underwent surgery with prosthetic replacement of the valve. The excellent clinical recovery observed further indicates that prosthetic valves can be seated in areas of infection and heal properly. Thus far, there is no recurrence of sepsis.
REFERENCES
Vogler WR, Dorney ER: Bacterial endocarditis in congenital heart disease. Amer Heart J 64:198-206, 1962 2 t>.loss AJ, Adams FH: Heart Disease in Infants, Children and Adolescents. Baltimore, William and Wilkins, 1968, pp 840-49
Rapid Growth of a Pleural Mesothelioma* Ga~ C. Lulenski, M.D., Roque Pifarre, M.D., F.C.C.P., and WiUiam E. Neville, M.D., F.C.C.P.
A patient with diffuse pleural mesotheUoma presenting as a large mass in the left hemithorax is described. Despite a normal chest roentgenogram three months earUer and symptoms of only three days' duration, the patient expired within three weeks of admission. This confirms the potential rapid growth of this malignancy. the description of pleural mesothelioma as a F ollowing distinct entity, Klemperer and Rabin separated the 1
tumor into two varieties on a histologic basis. Godwin 2 emphasized the differences between these two types of mesothelioma. The first was a slow growing, well encapsulated, and often resectable form which he called "localized fibrous mesothelioma." The second was more malignant in nature, both clinically and pathologically, with widespread metastases commonly found within the pleural space. These lesions were rarely surgically removable, and were referred to as "diffuse." Both types of mesothelioma seem clearly related to exposure to asbestos, whether the fiber be crocidolite, amosite, or crysolite.a-6 While the incidence of this tumor is very low ( 0.07 percent) 7 there have been several cases in which the interval between the onset of symptoms and death has been less than three months. 2 •5 · 7 · 8 This somewhat enforces the malignant nature of the diffuse type of °From the Cardiopulmonary Surgical Section, Veterans Administration Hospital, Hines, I!linois and the De~a~tment of Surgery, Loyola University Stntch School of Medicme, Maywood, Illinois.
3 Kerr A Jr: Subacute Bacterial Endocarditis, Springfield, Illinois, Charles C Thomas, 1955 4 Lerner PI, Weinstein L: Infective endocarditis in the antibiotic era. New Eng J Med 274:199-206, 259-266, 323331, 1966
.5 Kennedy JH, Sabga GA, Fisk AA, et a!: Isolated tricuspid valvular insufficiency due to subacute bacterial endocarditis: Report of a case with recovery following prosthetic replacement of the tricuspid valve. J Thorac Cardiovas Surg 51:498-506, 1966 6 Windsor HM, Shanahan MS: Emergency valve replacement in bacterial endocarditis. Thorax 22:25-33, 1967
7 Stason WB, DeSanctis RW, Weinberg AN, et a!: Cardiac surgery in bacterial endocarditis. Circulation 38:514-523, 1968 8 Gasul BM, Dillon RF, Urla V, et a!: Ventricular septal defect~: Their natural transformation into those with infundibular stenosis or into the cyanotic or noncyanotic type of tetralogy of Fallot. JAMA 164:847-858, 1957 Reprint requests: Dr. Hildner, 4300 Alton Road, Miami Beach 33138
FIGURE 1. Radiograph of the chest four weeks after right upper lobectomy for emphysematous bleb ( 12 weeks prior to last admission). No evidence of mass in left chest.
CHEST, VOL. 59, NO. 2, FEBRUARY 1971