- Email: [email protected]
Aortic stenosis vs. syphilitic aortitis∗
Diagnostic Aortic
Shelf Stenosis
vs. Syphilitic
Aortitis*
ALDO A. LLJISADA, M.D., F.A.C.C. and JAN SZATKOWSKI, nf.D. Chicago,
THIRTY-SIX year old Negro woman was admitted to the hospital in December 1958 complaining of increasing dyspnea on exertion and rather severe orthopnea of approximately two years’ duration. She also had frequent attacks of paroxysmal nocturnal dyspnea. No swelling of the legs or pain in the chest had been noted. The patient had contracted syphilis in 1946 for which she received injections of a heavy metal for a period of six months. More recent complaints were persistent, throbbing, frontal headache, accompanied by mild dizziness and occasional nausea and vomiting.
Wasserman reaction was negative. The urine contained a trace of protein, and the sediment, a few white blood cells and, on one occasion, 8 to 10 red blood cells. The protein-bound iodine was 6 pg. per 100 ml. of serum. The basal metabolic rate was plus 14. Spinal fluid pressure was 90 mm. water; white blood cells, 0; and protein, 27. Results of the Pandy and Kahn tests were negative. Chlorides were 740. The gold curve was 0 (10). Venous pressure was 174 mm. water and the Decholin@ circulation time was 15 seconds.
A
GRAPHIC RECORDS examination, inRoentgenograms: X-ray cluding fluoroscopy and barium swallow, revealed diffuse cardiac enlargement with predominant enlargement of the left ventricle and some degree of diffuse dilatation of the aorta; no left atria1 enlargement. The aortic indentation over the barium-filled esophagus was prominent. Electrocardiogram: The record showed sinus rhythm, left axis deviation, and inverted T waves in leads I, II, aVL, Vd, Vb and Vs. Phonocardiogram: This tracing revealed a short systolic murmur with a few larger vibrations at mid-systole, over the aortic area. Over the
PHYSICAL EXAMINATION Physical examination revealed a well nourished and well developed patient in no acute distress. Blood pressure was 180/60 mm. Hg; the pulse was regular, 80 and bounding (Corrigan pulse). There was no distention of the veins of the neck and peripheral edema was not present. The liver was not palpable. The lungs were clear. The heart was enlarged to the left on percussion and the apical impulse was in the sixth intercostal space in the anterior axillary line. No thrills were palpable. There was a grade 3, harsh systolic murmur heard over the entire precordium. This was loudest along the left sternal border and transmitted upwards to the carotid arteries. This was followed by a grade 2, softer, blowing early diastolic murmur in decrescendo with similar distribution.
ECG
LABORATORY DATA
1st
Phone- 240480
The hemogram was normal. The result of the serologic test for syphilis was 2 plus. The * From the Division of Cardiology,
Illinois
2nd
over aortic area. FIG. 1. Phonocardiogram electrocardiogram. Below, phonocardiogram.
The Chicago Medical School, Chicago, 860
THE
Above,
Illinois. AMERICAN
JOURNAL
OF
CARDIOLOGY
-4ortic
Stenosis
vs. Syphilitic
ECG , , .,-.
861
Aortitis
-1111.
FIG. 2. Retrograde aortic and left ventricular catheterization. Advancement of catheter from aorta (first two waves) to left ventricle (last two waves). From above, intracardiac and vascular phonocardiogram ; pressure tracing : zero line ; precordial phonocardiogram ; electrocardiogram. The arrow indicates the crossing of the aortic valve.
same area, there was a high-pitched, early diastolic murmur in decrescendo. The second sound was hardly visible over the aortic area, but the aortic component of this sound was well developed at the apex (Fig. 1). Carotid Pulse Tracings: There was a rapid rise followed by an anacrotic depression and a late peak. COMMENTS The most likely diagnosis seemed that of “syphilitic aortitis, relative aortic stenosis, aortic However, several cardiologists insufficiency.” questioned this diagnosis and thought the patient had rheumatic heart disease, aortic stenosis and insufficiency. For this reason, it was decided to perform retrograde left heart catheterization via the left brachial artery. Left Heart Catheterization: Pressures: There was no systolic gradient across the aortic valve. This proved that there was no hemodynamically significant aortic stenosis (actually, the aortic systolic pressure [158 mm. Hg] was higher than that of the left ventricle [145 mm. Hg]). A low diastolic pressure in the aorta (42 mm. Hg) and
JUNE
1960
a high diastolic pressure in the left ventricle (0.7 to 25.3 mm. Hg) were explained by the aortic insufficiency. The pressure pattern of the left ventricle showed a typical slow rise which was explained as the result of incomplete closure of the aortic valve (valvular insufficiency) during the period of tension, plus the effect of a dilated and damaged aortic wall (Fig. 2). The intracardiac and intravascular phonocardiograms revealed not only the systolic murmur, but also some vibrations in early diastole. CONCLUSION The final diagnosis was syphilitic aortitis, relative aortic stenosis and aortic insufficiency. It should be stressed that in patients having a small AZ with no history of syphilis, and in whom diagnosis is uncertain, retrograde aortic catheterization may be necessary. It is a harmless procedure if there is aortic insufficiency. It reveals whether or not there is a systolic gradient across the aortic valve, this gradient being evidence of an obstructive lesion.
Shelf Stenosis
vs. Syphilitic
Aortitis*
ALDO A. LLJISADA, M.D., F.A.C.C. and JAN SZATKOWSKI, nf.D. Chicago,
THIRTY-SIX year old Negro woman was admitted to the hospital in December 1958 complaining of increasing dyspnea on exertion and rather severe orthopnea of approximately two years’ duration. She also had frequent attacks of paroxysmal nocturnal dyspnea. No swelling of the legs or pain in the chest had been noted. The patient had contracted syphilis in 1946 for which she received injections of a heavy metal for a period of six months. More recent complaints were persistent, throbbing, frontal headache, accompanied by mild dizziness and occasional nausea and vomiting.
Wasserman reaction was negative. The urine contained a trace of protein, and the sediment, a few white blood cells and, on one occasion, 8 to 10 red blood cells. The protein-bound iodine was 6 pg. per 100 ml. of serum. The basal metabolic rate was plus 14. Spinal fluid pressure was 90 mm. water; white blood cells, 0; and protein, 27. Results of the Pandy and Kahn tests were negative. Chlorides were 740. The gold curve was 0 (10). Venous pressure was 174 mm. water and the Decholin@ circulation time was 15 seconds.
A
GRAPHIC RECORDS examination, inRoentgenograms: X-ray cluding fluoroscopy and barium swallow, revealed diffuse cardiac enlargement with predominant enlargement of the left ventricle and some degree of diffuse dilatation of the aorta; no left atria1 enlargement. The aortic indentation over the barium-filled esophagus was prominent. Electrocardiogram: The record showed sinus rhythm, left axis deviation, and inverted T waves in leads I, II, aVL, Vd, Vb and Vs. Phonocardiogram: This tracing revealed a short systolic murmur with a few larger vibrations at mid-systole, over the aortic area. Over the
PHYSICAL EXAMINATION Physical examination revealed a well nourished and well developed patient in no acute distress. Blood pressure was 180/60 mm. Hg; the pulse was regular, 80 and bounding (Corrigan pulse). There was no distention of the veins of the neck and peripheral edema was not present. The liver was not palpable. The lungs were clear. The heart was enlarged to the left on percussion and the apical impulse was in the sixth intercostal space in the anterior axillary line. No thrills were palpable. There was a grade 3, harsh systolic murmur heard over the entire precordium. This was loudest along the left sternal border and transmitted upwards to the carotid arteries. This was followed by a grade 2, softer, blowing early diastolic murmur in decrescendo with similar distribution.
ECG
LABORATORY DATA
1st
Phone- 240480
The hemogram was normal. The result of the serologic test for syphilis was 2 plus. The * From the Division of Cardiology,
Illinois
2nd
over aortic area. FIG. 1. Phonocardiogram electrocardiogram. Below, phonocardiogram.
The Chicago Medical School, Chicago, 860
THE
Above,
Illinois. AMERICAN
JOURNAL
OF
CARDIOLOGY
-4ortic
Stenosis
vs. Syphilitic
ECG , , .,-.
861
Aortitis
-1111.
FIG. 2. Retrograde aortic and left ventricular catheterization. Advancement of catheter from aorta (first two waves) to left ventricle (last two waves). From above, intracardiac and vascular phonocardiogram ; pressure tracing : zero line ; precordial phonocardiogram ; electrocardiogram. The arrow indicates the crossing of the aortic valve.
same area, there was a high-pitched, early diastolic murmur in decrescendo. The second sound was hardly visible over the aortic area, but the aortic component of this sound was well developed at the apex (Fig. 1). Carotid Pulse Tracings: There was a rapid rise followed by an anacrotic depression and a late peak. COMMENTS The most likely diagnosis seemed that of “syphilitic aortitis, relative aortic stenosis, aortic However, several cardiologists insufficiency.” questioned this diagnosis and thought the patient had rheumatic heart disease, aortic stenosis and insufficiency. For this reason, it was decided to perform retrograde left heart catheterization via the left brachial artery. Left Heart Catheterization: Pressures: There was no systolic gradient across the aortic valve. This proved that there was no hemodynamically significant aortic stenosis (actually, the aortic systolic pressure [158 mm. Hg] was higher than that of the left ventricle [145 mm. Hg]). A low diastolic pressure in the aorta (42 mm. Hg) and
JUNE
1960
a high diastolic pressure in the left ventricle (0.7 to 25.3 mm. Hg) were explained by the aortic insufficiency. The pressure pattern of the left ventricle showed a typical slow rise which was explained as the result of incomplete closure of the aortic valve (valvular insufficiency) during the period of tension, plus the effect of a dilated and damaged aortic wall (Fig. 2). The intracardiac and intravascular phonocardiograms revealed not only the systolic murmur, but also some vibrations in early diastole. CONCLUSION The final diagnosis was syphilitic aortitis, relative aortic stenosis and aortic insufficiency. It should be stressed that in patients having a small AZ with no history of syphilis, and in whom diagnosis is uncertain, retrograde aortic catheterization may be necessary. It is a harmless procedure if there is aortic insufficiency. It reveals whether or not there is a systolic gradient across the aortic valve, this gradient being evidence of an obstructive lesion.