Echocardiographic Diagnosis of Intraventricular Clot

Echocardiographic

Diagnosis

A 63-year-old recurrent

L. DcJo.seph, M.D.;O* Robert %V. Leverison, M.D.;#{176}#{176} C. Edward F. Zeus, M.D., I”.C.C.P4

The

literature

graphic

contains

findings

descriptions rare.

We

discuss

logically.

the

a large

confirmed

The

both

importance

ining the area left ventricle,

below where

of the and

clot;

thrombus left

and

the mitral valve near most of the thrombi

myxoma

left

the

the

and ventricular

here

are

the

a large graphic

Pennsylvania

S. Hershey a #{176}Assistant

Reprint Center.

clot,1

contains

in

pathoexam-

the apex of the are located, is

reports

Division State

Medical

Professor

Fellow.

of in

of Cardiology, University

Center,

School Hershey,

of

of Medicine, Pa.

and

murmurs

with

peripheral

findings

from

limits.

Milton 17033

S. Hershey

an

acute

palpitations,

paroxysmal

nocturnal

the

un(ler\vent

lated

left

thrombus

from

scending

Medical

was

venous coronary

essentially

mass.

the left bypass

artery.

The

The

and

were

studies

revealed

The

it

peetoris,

occlusion was

within

Because

angina

Total

ventriculotomy,

equal.

enzyme

artery

ventricular

was

full grossly

unstable

coronary

was

There

infarction.

performed.

was

left

had

patient

descending

radiolucent

Milton

and

myocardial

with-

abdomen

of organs. were

examination

of acute that

The

all pulses

and

electrocardiograms

catheterization

Medicine,

evident.

neurologie

aortocoronary

Physiology.

or

occasions.

denied

or enlargement

edema,

normal

believed

angio-

were

masses,

no evidence

of Medicine.

Dr. Dejoseph, Pennsylvania

No

anterior Department

He

orthopnea,

several

sustained

exaniination

Serial

Presented

in a patient thrombus, with

on

had

infarction.

exertion,

distention,

no

atrial

findings ‘

sleep

patient

distress.

present.

confirmation.

of Medicine

requests: Hershey,

such rare.

left

findings

ventricular

pathologic

reports

of

describing or tumor are

echocardiographic

left

numerous

findings

thrombus

apical and

#{176}Fromthe

+Cardiology Professor

literature

(‘chocardiographie

from

revealed an apprehensive man in no Blood pressure was 118/72 mm Hg, and the pulse rate was 76 l)eats per minute and regular. There was no jugular venous distention. The chest was clear to percussion and auscultation. Examination of the heart revealed no palpable or visible lifts or thrills. The point of maximal impulse was in the fifth intercostal space in the midclavieular line and ‘ ‘a s diffuse. On auscultation, an 53 and 54 gallop rhythm was

thrombus

angiographically

on

acute

out

Ithough

previously,

Physical

are

findings

of echocardiographically

past

him the

dyspnea.

however,

ventricular

the

in

had a one-month history of which at first occurred only two weeks had occurred at rest

pain,

myocardial

clyspnea

or tumor

man

awakened

years

REPORT

chest

I)Ut

had

also

Three

stressed.

A

exertion,

and

echocardio-

echocardiographic

apical

white

precordial

anteroseptal

myxoma

atrial

with

A. Sliirofl, M.D.;t Martin, M.D.; and

reports

ventricular

here

with

was

which

many

in left

of left

a patient

CASE

CIot*

Intraventricular Robert Leslie Robert

of

found, patient

of as

was

cardiac the

left

vell

as a

sul)sequently

with removal of a peduncuventricular apex, and a single graft

his

to

patient s

left

anterior

postoperative

decourse

uneventful.

Fmuiui 1. Echocardiograms taken prior to removal of clot. A. Echocardiogram taken with transduc-er angled to record position deep in left ventricular cavity. Distinct mass of echoes is seen ( between arrows ) , which lies bet veen the echoes of interventricular septum ( S ) and left yentricular posterior wall ( LV ) . B. Transducer is scanned upward from deeper position of left yentricle ( LV ) to area of mitral valve ( m ) . Note disappearance of echo-producing mass ( between arrows) scanning is same

operative

mitral valvular left to right from

echo comes area of mitral

as

area

scanned

tracing.

CHEST, 71: 3, MARCH, 1977

in

Figure

S, Septum.

B.

Note

into view. 5, Septum. valve ( m ) to deeper absence

of

mass

of

ECHOCARDIOGRAPHIC

portion

echocardiogram of left ventricle ( LV ) . This

echoes

which

C.

Postoperative

were

DIAGNOSIS OF

present

in

pre-

INTRAVENTRICULAR CLOT

411

METHODS

Echocardiograms were recorded with the patient lying quietly in the supine position. A 2.25-MHz transducer onehalf inch in diameter ( Aerotech ) with a 7.5-em internal focus was used with an ultrasonic scope ( Unirad 100 Diagnostic Echoscope ) . Permanent recordings were made on black and white film ( Polaroid type 107 ) using a camera ( HewlettPackard 197A ) attached to the oseilloscopie screen of the diagnosie eehocardiographie scope. Serial pictures were taken as the transducer was angled from aorta to cardiac apex in an inferolateral direction. Right and left cardiac catheterization and left ventricular angiographic studies were performed in the usual manner. Coronary artenographie studies were done using Sones’ technique. RESULTS

The

echocardiogram

in the the

apical

area

mitral

echo

septum

mass

was

separate and

and

with

to the

apex

was

surgery,

a large

diameter

was

mass

the was

area

of

a distinct

found

of the

left

radiolucent the

apex

3 to

aneurysm

the

3 to

apex

being

4 cm

(Fig

thrombus

from

mi-

enlarged

entire

mass

pedunculated

an

the

ventricle.

the

occupying

in

from

a moderately

with

removed

scanning

transducer

revealed

A large

diameter

This

.

upon

the

chamber

aneurysmal.

below

1B)

repeatedly

catheterization

ventricular

ventricle

from the echoes of the intervenleft ventricular posterior wall. The

direction area

an echo-producing

left 1A

identified

inferolateral tral valve Cardiac left

( Fig

valve

clearly

tricular

revealed of the

of the

2)

.

in At

4 cm

left

in

ventri-

cle. Postoperative echocardiograms of a distinct echo-producing mass

revealed (Fig 1).

no evidence

the

findings

in

Farooki

et al

myoma

in infants,

described

Both

ventricle.

were to the

tively,

of the

ventricular

echoes

presumably

cavity

also

septal

during

one

the

In

the

tumors

echoes. mitral

valve

The

echoes

et al8

and

intervendue

to a

ventricle.

The findings in our case were limited to the area of the left ventricle below the mitral valve. These correlated well with both the findings at angiographic study and at surgery,

where

points

in

movable. Mural percent914 approximately

418

the

the apex

thrombi

thrombus of

the

of the

of hearts at 5 percent

DEJOSEPH ET AL

was ventricle

heart

attached and

are

postmortem of patients

found

at was

not

in 21

examination undergoing

of left

nary occur

artenographie as a

that

the

the

left

area

be

tricular

studies.’ of

result

Since detected

emboli

are

most is

important that

mitral

valve

emboli are some

that

well

of these it is im-

one

deep

found in

in the

apex

of

performing

examine

within

the

carefully

the

the

left

yen-

cavity. REFERENCES

1 Popp atrial 2 Wolfe

RL, Harrison DC : Ultrasound for the diagnosis of tumor. Ann Intern Med 71 :785-787, 1969 SB, Popp RL, Feigenbaum HO: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 3 Finnegan RE, Harrison DC: Diagnosis of left atrial myoxma by echocardiograph. N Engl J Med 282: 10221023, 1970

freely

to 67

5 Srivastava TN, atrial myxoma.

and in coro-

systemic thrombi

searched for on routine Also, because it seems

commonly

it

4 Nasser WK, Davis 2. Phonocardiographie, and angiographic 83:810-82,4, 1972

several

taken in right anterior defect ( arrows) in

it appears that echocardiographically,

study

the

The these

be diligently examination.

ventricle,15

below

filling

large

ventricle.

di.ffi-

ventricular

were

apex

angiogram

showing

the

were

left

of

respecease

ventricular

echocardiographie

right

Levisman the

the

left

each

position,

portant that they echocardiographic

rhabdo-

sides,

echo.

within

of the

in

cluster

right

systole.

thrombus

tumor.7’8

an abnormal

by

of echoes between

septum

peduneulated

the

and

to the

septal

from

a cluster and

and

or

of ventricular

left by

left

produced

to separate

tricular

cases

in the

identified

adjacent

described

thrombus

two

one

echoes

cult

features of left atrial myxoma throughout the literature;’6 paucity of reports concerning

interventricular

2. Left

documented.1619 emboli can

DIScuSSIoN

The echocardiographie are described profusely however, there is a distinct

Ficuas oblique

RH,

Dillon JC, et al: Atrial myoxma: eehoeardiographie, hemodynamic features in nine eases. Am Heart

Fletcher E : The echocardiogram Am J Med 54:136-139, 1973

6 Kostis JB, Moghadam of left atrial myxoma.

AN : Echocardiographie Chest 58:550-552, 1970

and

J left

diagnosis

CHEST, 71: 3, MARCH,

1977

7 Farooki

ZQ,

Henry

JG,

of ventricular

pattern

Arciiegas

E, et al: Ultrasonic in two infants. Am

rhabdomyoma

J

Cardiol 34:842-844, 1974 8 Levisman JA, MacAlpin RN, Abbasi AS, et al: Echocardiographic diagnosis of a mobile, pedunculated tumor in the left 1975

ventricular

cavity.

J Cardiol

Am

36:957-959,

9 Garvin CF: Mural thrombi in the heart. Am Heart J 21:713-720, 1941 10 Jordan BA, Miller RD, Edwards JE, et al: Thrombal embohsm in acute and healed myocardial infarction: 1. Intracardiac mural thrombuses. Circulation 6:1-6, 1952 11 Yater WM, Welsh PP, Stapleton JE, et al: Comparison of clinical and pathological aspects of coronary artery disease in men of various age groups: A study of 950 autopsy cases from the Armed Forces Institute of Pathology. Ann Intern Med 34:352-392, 1951 12 Bean WB: Infarction of the heart: 3. CliniCal course and morphological findings. Ann Intern Med 12:71-94, 1938 13 Phares WS, Edwards BE, Burchell HB: Cardiac aneusysms: Clinical pathologic studies. Proc Staff Meetings Mayo Clin 28:264-271, 1953 14 Schlichter J, Hellerstein HK, Katz LN: Aneurysm of the heart: A correlative study of 102 proved cases. Medicine 33:43-78, 1954 15 Hamby RI, Wisoff BC, Davison ET, et al: Comnary artery disease and left ventricular mural thrombi: Clinical, hemodynamic and #{225}ngiocardiographic aspects. Chest 66:488494, 1974 16 Young JR, Humphres AW, DeWolfe DC, et al: Peripheral arterialembolism. JAMA 165:621-627,1963 17 Thompson JE, Weston AS, Sigler L, et al: Arterial embolectomy after acute myocardial infarction: Study of 31 patients. Ann Surg 171 :979-986, 1970 18 Darlene RC, Austen WG, Linton RR: Arterial embolism. Surg Gynecol Obstet 124:106-114, 1967 19 Miller RD. Jordan BA, Parker RL, et al: Thrombal embolism in acute and healed myocardial infarction: 2. Systemic and pulmonary arterial occlusion. Circulation 6:7-15, 1952

Idiopathic

Spontaneous *

a

Pneumotnorax Elecfron Edward

E. Tueller, and

Ph.D.;

A lung ond rax

Mkroscopic

of

the

R. Cnse; Jr.,

from

of idiopathic by electron

in septal

increase

Nancy

F. McLaughlin,

obtained

occurrence was studied

lion

M.D.;

Richard

biopsy

Sfudy

mass

was

interstitium

a patient

a notable due

and

elastic

fibers.

of type

1 and

type

2 epithelial

In

following A

remarkable

finding.

Prolifera-

to

an

abundance seen.

#{149}From the Peninsula Hospital, Burlingame, ler and McLaughlin), and California State ward ( Dr. Belton and Ms. Crise).

Calif

by

in

a contribution

memory

of

part

Martin

Reprint requests: Dr. fornia State University,

by the California Lung from R. F. McLaughlin, M. Kohn, M.D. Belton,

Hayward

CHEST, 71: 3, MARCH, 1977

Department

94542

of

a proliferation

was

Supported

a see-

pneumotho-

addition, cells

C. Belton,

F.C.C.P.

spontaneous microscopy.

was

collagen

John

M.D.,

pontaneous

pneumothorax, of air into

introduction

the

which results from the pleural spaces of the

thorax, has been observed in patients as a symptom of pulmonary diseases. Symptomatic spontaneous pneumothorax has been associated with a variety of pathologic conditions, including emphysema, bronchial asthma, chronic bronchitis, and Marfan’s syndrome.l 2 By contrast, idiopathic spontaneous pneumothorax appears to occur in the absence of consistently demonstrable pulmonary pathologic findings.3 The idiopathic condition has a marked tendency to recur and is most frequently seen in young men in the age range of 20 to 40 years old.1’4’5 It has been proposed that air escapes into the pleural space from a ruptured bleb in the visceral pleura. Such blebs are attributed to a dissection of air into the pleural tissue from a defect in the wall of a subpleural alveolus. ’ The cause of such a defect has never been established.

One

author

postulates

a chance

congenital

defect in the elastica of the alveolar wall.6 Another explanation involves a remote infection resulting in a check-valve obstruction of a small airway, distal distenlion, and subsequent rupture and dissection.’ A lung biopsy obtained from a patient undergoing treatment for a second occurrence of idiopathic spontaneous pneumothorax was examined with the light and electron microscopes. CASE

REPORT

On Jan 17, 1975, a 22-year-old man who was 180.3 cm (5 ft 11 in) tall and weighed 61 kg ( 135 lb) was admitted to the hospital with a right apical pneumothorax. He had smoked one pack of cigarettes per day for the past eight years. A chest tube was inserted, and the lung was expanded. On Jan 24, 1975, the patient was discharged from the hospital. Chest x-ray films taken at this time showed almost complete reexpansion of the right lung and otherwise normal pulmonary parenchyma. On the evening of March 24, 1975, the patient had a few coughs and developed what he thought was a muscular cramp in the right posterior portion of his chest. When he awoke the next morning, he smoked a cigarette and developed shortness of breath and difficulty in breathing with pain again in the right side of the chest. The patient entered the emergency room, and chest x-ray films taken at that time

showed

a medium-sized

4.0

of

pneumothorax, with approximately the visceral pleura and the chest wall in the superior portion of the right hemithorax. The size of the pneumothorax was estimated to be 10 to 15 percent. No other chest abnormalities or masses were seen. The patient was admitted to the hospital, at which time he stated that he had had no serious ChildhOod or adult illnesses cm

with

the

separation

exception

between

of the

first

collapsed

lung.

His

mother

died at the age of 40 years from lung cancer. His father and sister are in good health and have no history of pulmonary disease.

(Drs.

University, Association Jr.,

of

S

Biology,

TuelHay-

M.D.,

and in Cdi-

On the second

and

day

of hospitalization,

a right

thoracotomy

pleural abrasions were performed. At the time of surgery, fibrinous adhesions were seen medially in the upper right lobe, which suggested that this was the area of rupture of a bleb causing the pneumothorax. A lung biopsy was taken from an area adjacent to the area of suspected rupture. A portion of the tissue was fixed for routine pathologic examina-

IDIOPATHIC SPONTANEOUS PNEUMOTHORAX

419