- Email: [email protected]
Omental Herniation Through the Foramen of Morgagni
mediastinal lymph node or extension from a pericanlial I<>ens, ' Clinical presentations of tuherculosis of the heart haw' includt'd pulmonary vein ohstruction due to left "lnal llIass lesions; ri~ht ventricular outflow tract ohstruction; superior vena cava ohstruction; aortic insnfficiency; and (:omplt'tt' heart hlock. Sdlllitzer reported a patient who presented with palpitations and ventricnlar tachycardia who died of ventricnlar arrhythmia and in whom extensivt' miliary involn'nwnt of the myl>eanlium was confirmed at autopsy. Behr t't ai' also reported two immi~rants from the Iudian suhcoutinent to Britain who died suddenly of probahle ventricular arrhythmias and in whom postmortt'm studies identified evidence of myocardial tuherculosis. Our dia~nostic ability has heen considerably enhanced hy the dew·lopnwnt of noninvasive ima~in~ modalitit's, such as two-dimensional echl>eardio~raphy, computed tomo~ra phy, and ma~nt'tic resonance ima~in~.· These technolo~ic advances art' particularly hdpful in the confirmation of mass lesions, hut their utility in tlw dia~nosis of diffuse infiltratin~ or miliary pr<>eesses remains to he determined. Althou~h tuherculous involvement of the heart is ran', it should 1)(' suspected in patients prt'sl'ntin~ with cardiac arrhythmias who are at risk for tuherculosis. ACK1':OWLEDGMENTS: The authors thank Ni~ar Rasheed fc'r prellaration of tilt' manuscript and Dr D. Johnston fc,r performance of t Ie ma~nelit' rt'sonance ima~in~ studies, REFERENCES
2
3
-t .5 6 7
Ii
9
Fad...r LS. Lowell AM, Meador MP. ExtrapulmclIlary tuherculosis in the United States. Am J Epidemiol1979; 109:205-17 Alvarez S, Ml{;ahc.· WR, Extrapullllonary tuherculosis revisitt'd: a n'view of experience at 80ston City and otlwr hospitals, Mt'dicine 191;4; 63:25-5.5 Kannan~ara DW, Salem FA, Rao 8S, Tlmdepalli II. Cardiac tuht'rculosis: 1'8 of the endcK'ardium, Am J Mt·d Sci 191;4; 21i7: -t.5--t7 Custer EN, Charr R. Tuhcrculosis of the myeK'ardium. JAMA 1939; 112: I 33.'3-3-t Gaulti"r Y, Alou A, Cenac A. Develoux M, Veller JM. TuhNculome dUl'lto'ur. Arch Mal CClto'ur 1987; 1iO:1413-16 Schnitzer R. MycK'ardialtuh,'rculosis with paroxysmal ""ntrkular tachycardia. 8r lIeart J 19-t7; 9:213-19 Murtada All, M,'r,'er EN, Guinn GA. Myocardialtuht'rculOlna with rupture and pseudoalwurysm fcmnation: sllcc"ssful sur~kal tn·atlllenl. 8r IIcart J 191i.5; .54:603-4 nehr C, Palin IIC, T"mpNley JM. MycK'ardial luh,·rculosis. Br Med J 1977; 9.51 Schwartz AB, Mill'hell HS, lIi~ins C8. LiplclIl MJ. Klallsll,'r SC. Innlsive calcific mllslrktive perkarditis simulatin~ a left \"t'ntricular mass. Am lIeart J 191>6; 112:1>61-6.'3
The fat accumulation most frequently seen in the peridiaphragmatic areas represents herniations of abdominal fat or epicardial fat pad. We present a patient with a large fatly mass after 10 months of corticosteroid therapy in which computed tomography demonstrated omental vessels, thus proving that it was omental herniation through (Chest 1991; 100:1469-70) Morgagni's foramen.
T
he hlllg fat accumulation in the peridiaphra~maticareas represents herniations of abdominal fat or epicardial fat. Distinction hetween them sometimes is difficult. \Ve report tht' (.'ase of a woman who developed herniation of abdominal fat throlJ~h Mor~a~nr~ f(,ramen after corticosteroid therapy. CASE REPORT
A 59-year-old woman presented with a chesl roenl~eno~nun showin~ a lar~e mass althe ri~ht hemithorax. The lateral projection determined till' anterior ICl(.'aticlIl of lhe mass. The plain chesl rclto'nt~ellCl~ram was nonnal one year a~o when she presented with pedal edema, The dia~nosis at that time was hydronephrosis dne to retroperitclIleal fihrosis. She received ~"rtit"steroid therapy (dexamethascme) al'etate 2 m~, three times daily) fc,r ten months and lhe symptoms disappeared. necause of the chest rclto'nt!(eno~raphil' findin~s, we performed chest computed tomo~raphy (CT). The superior mediastinum was normal. In the middle and lower ri~ht lobe there was a mass in mnlad with the pericardiulII; it was homo~eneous. with smcM,th mar~ins, and CT l\Iunhers those of fat (of -liS to - 95). Fine linear densities with several directions and len~ths were in the mass; these were enhanced after intravenous (IV) injection of l"ntrast medium (Fi~
I).
Al first we thcm~ht lhat it was an ul\llsually lar~e amount of epicardial fat pad hel'mlse of the l~,rlicosleroid therapy. LcM)kin~ at the pidures a~ain. we notil'ed that the fat ac~'umulaticlIl differed from the epil'ardial fat pad that was present at the l'ardial' apex. The fine linear densities were not present in the epicardial fat pad (Fi~ 2). Al the lower scan, a small part of IM,wellcM,p in front of the liver and heart and directly hehind the Xiphoid hecame ohvious, Our impression was, therefc're, that this mass represented herniation of ahdominal fat throu~h MClr~a~nj's foramen and the "nhanced serpi~incllls densities represented omental vessels. Fineneedle aspiration of the mass. under CT ~\Iidance. demonslrated
Omental Herniation Through the Foramen of Morgagni* Diagnosis with Chest Computed Tomography Kt,,~./tln/i,IO" At)rt/
J.
Go",.io". III.D.; Chris/o" K. Ttl/sis. III.D,;
l~jkttUri. .\t.D.; tlnil
S/m)",. H. Com1t1n10/KJUU.... III.D.• EC.C.P.
"From the Departments of Computed lhmo~raphy and Universily UnitofPneumoloJ.,~·, GenNal Hospital of loan nina (G. lIatzikosta). loannina. Greece.
FI<;[IKE 1. A lar~e paracardiac fally mass with serpi~ino\ls densities that represenl omental vessels (O/}('IIt1rrows), CHEST I 100 I 5 I NOVEMBER. 1991
1469
521-20 3 Williams PL. Warwiek R. Dyson M. Bannisler 1.11. t'ds. (;rays analClmy. Edinlmr1!,h: Chnrehill Livin1!,sIOlll': 19I59; 1344 4 Laner DP. Williams (:II. ThClrn (;W Dis..ases Clf Ihe adrenal ",rlex. In: Winlrolw MM. ThClrn C\V, Adams RO. B..nnel ILJr. Brannwald E. Isselhadler KJ. t'l al. eds, lIarrison's principles of inl..rnal medicine. New "Irk: McCraw-lIill B(Mlk CCl: 1970:47751S 5 B..in ME. Manenso AA. Mink JII. lIansen C<:' COIn pUled IClm01!,raphy in Iht' evaluatiCln Clf mediastinal IipClmalClsis. J Compnl Assisl Tc.mCl1!,r 1975; 2:379-&'3 o Teall'S CD. Sieroid indu,...d mediastinal IipomalClsis. RadiolCl!-"y 1970: 96:501-02 7 Sa1!,el SS. Clazer liS. Mediaslinum. In: JKT Lee, SS Sa1!,e1, RJ Sianley. eds. Compuled hCldy 10mCl1!,raphy wilh MRI ("rrelalion. N..w York: Rawn Pr..ss: 19I59; 245-94
Fitaillt: 2. Tlw Clnwnla! fal wilh vessels (lar1!,e open amnc) differs frClm Ihe Iwricardial fal pad (.\"'II(JU api'n amnv): Arrowhead indkales pt>rit·ardium. Ihe exislen,... Clf adipCls,' and fihrolls lissue. Barium enema shClw..d ahnClrmally hi1!,h localiCln Clf Iranswrse ,,,Ion silualt'd immedialely Iwnealh Ihe diaphra1!,m. One year laler. Ihe palienl represenl..d Ii,r a 1i,IIClw-up visil and Ihe ehesl rewnl1!,eno1!,ram shClwed an ClhviClus lar1!,t' ht'rniation Clf hClw..I I(M'ps Ihroll1!,h Mor1!,a1!,ni:s fClram..n. DISCUSSION
Large accumulation of adipose tissue in the peridiaphragmati<: area usually n'presents herniation of ahdominal fat either thnmgh a foramen or a defed in the diaphragm. A plain chest roent~t'no~ram in tht' frontal projt'ction shows paracardiac masses. and tIlt' identification of their naturt' is difficult. I HoweVt'r. tlwy are easily dia~nosed by CT! The omentum (,(lIltains adipose tissue which in the oh,·st', or after prolonge,1 us,' of gly('(x.'ortit..'(,ids· may 1)(' massive. This is the most ('(Immon ahdominal ('(lmpOlllld that ht'rniates throu~h Morga~nr, foramt'n and is almost always I'x'att'd at tIlt' right sidt' in tIlt' cardiophrt'nic angl,·. Fat is also at'('umulated in tht' cardiophrenic angl!' aud cardiac apex in mediastinal Iipomatosis_' Cushing's syndrome. and after prolon~ed cortk'(lst('roid therapy." When tht' amount of it in the right ('ardiophrt'nic augle is large. it is nt'c"ssary to makt' th,' distinction Ilt'tween herniated fat and f'pk'ardial fat pad. TIlt' idt'ntification of fin(~ linear df'nsiti,'s within tht' fat. which undouhtedly rt'prt'sent omental vt'ssf·ls. can lit' ust'ful for this distindion. 7 Barium studit's do not havt' pra(·tical valut' sinc,' the herniated fat dtlt's not (,(lIltain gastrointt'nstinal loop. TIlt' small hernia of Morgagnis foramen is asymptomatic and tIlt' difft'n'ntiation is of no clinical importallt·f·. Wt' (,(lIlsidf'r that our cast' rt'prf'st'nts h('rniation of onlt'ntal fat through Morgagni's foranlt'n causf'd hy fat acclllnulation from prolongf'd ('(lrtk'(lstt'roid t1lt'rapy. REFEREN( :ES
RClhlfin1!, BM. KClrohkin M. lIall AO. CClmplllt'd tomCl1!,raphy of inlrathuraci,' omt'nlal 11I'rnialiCln and Cllh..r mediastinal fatty rnasst's. J CClmp"1 Assisl Tcnno1!,r 1977: 1:ISI-1\.1 2 MCldi,' MT. Jankki PC. CClmpul..d ICllnography of mass I..sion Clf th.. ri1!,hl cardiClphn'nk an1!,It'. J CClmpul Assisl Tc.mo1!,r I!#I(): 4: 1470
Continuous Six-Month Infusion of Intravenous Nitroglycerin in a Patient Awaiting Cardiac Transplantation* (;"r"/lIm l: Perry. M.l).; Sriniva.< .\Iurali. M.I>.; and R"rry 1-: ('n·/"ky. M.I>.
We report a patient with ischemic cardiomyopathy who was treated with a continuous high dose infusion of intravenous nitroglycerin for six months while awaiting cardiac transplantation. Surprisingly, methemoglobinemia did not develop and nitroglycerin continued to be clinically effective in relieving an~na during the six-month period. We believe this to be the first reported instance of the safe use of such prolonged infusion of intravenous nitroglycerin.
(Chest 1991; 100:1470-71)
D
to an int'rt'asing numllt'r of t'ardiac transplant candidates and a rt'latively fix,·d donor pool size. the waitin~ pt'ritxl for transplantation has incrt'ast'd considerahly in n'''''nt years. I Mf'dical Illana~emf'nt of transplant candidatt's with t'n<1 stag{' congt'stivt' heart failun' dut' to f'itllt'r isdwlllic or nonischf'mic t'ardiomyopathy often involvt's (1l11tinlHllIS intravf'nous inotropic and vasodilator thf'rapy filr long periods of tinlt'. Intravf'nous nitroglycerin (NTG) has hf'f'n utilized in this st'tting filr tht· trf'atment of hoth unstahle ,1Il~ina pt'doris and severe CH F. Prolon~eduse of intraVt'nous NTG may haw limitations sincf' its hemodynamic effeds attenuatf' within 6 to 8 h of t.'ontinuous administration! Additionally. sustained infusions of lar~e doses of intravenous NTG can caust' metht'mo~lohinemia.l In this rt·port. WI' dt'scrihe a patient with ischt'mic cardiomyopathy who rf't.'f'ived a t'ontinuons six-month intravenous infusion of high dose NTG while awaitin~ transplantation. IIt.
CASE REPORT
A .'>4-year-old while man WaS Iransferr..d 10 our inslilulion for lransplanl evalualion. III' had previoos inferior and anleroseplal wall myfK'ardial infaretions and Iwo days prior 10 Iransfer. suffered an anlerim wall MI. Bt'CauSt' of persislenl postinfarction an/!,ina. he WaS Irealt'd wilh inlraVt'nous NTC (40 I1Wmin). Eleclrocardio1!,ram showed sinus rhylhm and ,,,mplele ri1!,hl hundle hranch hl(x-k. *From Ihe Oivision ofCardiolo,.,')'. University of Pittshur1!,h. School of Medicine. Pittshur1!,h.
Six-mon1h Inlusion of IV Nitroglycerin Prior to Cardiac Transplantation (Perry. Murali, Uretsky)
2
3
-t .5 6 7
Ii
9
Fad...r LS. Lowell AM, Meador MP. ExtrapulmclIlary tuherculosis in the United States. Am J Epidemiol1979; 109:205-17 Alvarez S, Ml{;ahc.· WR, Extrapullllonary tuherculosis revisitt'd: a n'view of experience at 80ston City and otlwr hospitals, Mt'dicine 191;4; 63:25-5.5 Kannan~ara DW, Salem FA, Rao 8S, Tlmdepalli II. Cardiac tuht'rculosis: 1'8 of the endcK'ardium, Am J Mt·d Sci 191;4; 21i7: -t.5--t7 Custer EN, Charr R. Tuhcrculosis of the myeK'ardium. JAMA 1939; 112: I 33.'3-3-t Gaulti"r Y, Alou A, Cenac A. Develoux M, Veller JM. TuhNculome dUl'lto'ur. Arch Mal CClto'ur 1987; 1iO:1413-16 Schnitzer R. MycK'ardialtuh,'rculosis with paroxysmal ""ntrkular tachycardia. 8r lIeart J 19-t7; 9:213-19 Murtada All, M,'r,'er EN, Guinn GA. Myocardialtuht'rculOlna with rupture and pseudoalwurysm fcmnation: sllcc"ssful sur~kal tn·atlllenl. 8r IIcart J 191i.5; .54:603-4 nehr C, Palin IIC, T"mpNley JM. MycK'ardial luh,·rculosis. Br Med J 1977; 9.51 Schwartz AB, Mill'hell HS, lIi~ins C8. LiplclIl MJ. Klallsll,'r SC. Innlsive calcific mllslrktive perkarditis simulatin~ a left \"t'ntricular mass. Am lIeart J 191>6; 112:1>61-6.'3
The fat accumulation most frequently seen in the peridiaphragmatic areas represents herniations of abdominal fat or epicardial fat pad. We present a patient with a large fatly mass after 10 months of corticosteroid therapy in which computed tomography demonstrated omental vessels, thus proving that it was omental herniation through (Chest 1991; 100:1469-70) Morgagni's foramen.
T
he hlllg fat accumulation in the peridiaphra~maticareas represents herniations of abdominal fat or epicardial fat. Distinction hetween them sometimes is difficult. \Ve report tht' (.'ase of a woman who developed herniation of abdominal fat throlJ~h Mor~a~nr~ f(,ramen after corticosteroid therapy. CASE REPORT
A 59-year-old woman presented with a chesl roenl~eno~nun showin~ a lar~e mass althe ri~ht hemithorax. The lateral projection determined till' anterior ICl(.'aticlIl of lhe mass. The plain chesl rclto'nt~ellCl~ram was nonnal one year a~o when she presented with pedal edema, The dia~nosis at that time was hydronephrosis dne to retroperitclIleal fihrosis. She received ~"rtit"steroid therapy (dexamethascme) al'etate 2 m~, three times daily) fc,r ten months and lhe symptoms disappeared. necause of the chest rclto'nt!(eno~raphil' findin~s, we performed chest computed tomo~raphy (CT). The superior mediastinum was normal. In the middle and lower ri~ht lobe there was a mass in mnlad with the pericardiulII; it was homo~eneous. with smcM,th mar~ins, and CT l\Iunhers those of fat (of -liS to - 95). Fine linear densities with several directions and len~ths were in the mass; these were enhanced after intravenous (IV) injection of l"ntrast medium (Fi~
I).
Al first we thcm~ht lhat it was an ul\llsually lar~e amount of epicardial fat pad hel'mlse of the l~,rlicosleroid therapy. LcM)kin~ at the pidures a~ain. we notil'ed that the fat ac~'umulaticlIl differed from the epil'ardial fat pad that was present at the l'ardial' apex. The fine linear densities were not present in the epicardial fat pad (Fi~ 2). Al the lower scan, a small part of IM,wellcM,p in front of the liver and heart and directly hehind the Xiphoid hecame ohvious, Our impression was, therefc're, that this mass represented herniation of ahdominal fat throu~h MClr~a~nj's foramen and the "nhanced serpi~incllls densities represented omental vessels. Fineneedle aspiration of the mass. under CT ~\Iidance. demonslrated
Omental Herniation Through the Foramen of Morgagni* Diagnosis with Chest Computed Tomography Kt,,~./tln/i,IO" At)rt/
J.
Go",.io". III.D.; Chris/o" K. Ttl/sis. III.D,;
l~jkttUri. .\t.D.; tlnil
S/m)",. H. Com1t1n10/KJUU.... III.D.• EC.C.P.
"From the Departments of Computed lhmo~raphy and Universily UnitofPneumoloJ.,~·, GenNal Hospital of loan nina (G. lIatzikosta). loannina. Greece.
FI<;[IKE 1. A lar~e paracardiac fally mass with serpi~ino\ls densities that represenl omental vessels (O/}('IIt1rrows), CHEST I 100 I 5 I NOVEMBER. 1991
1469
521-20 3 Williams PL. Warwiek R. Dyson M. Bannisler 1.11. t'ds. (;rays analClmy. Edinlmr1!,h: Chnrehill Livin1!,sIOlll': 19I59; 1344 4 Laner DP. Williams (:II. ThClrn (;W Dis..ases Clf Ihe adrenal ",rlex. In: Winlrolw MM. ThClrn C\V, Adams RO. B..nnel ILJr. Brannwald E. Isselhadler KJ. t'l al. eds, lIarrison's principles of inl..rnal medicine. New "Irk: McCraw-lIill B(Mlk CCl: 1970:47751S 5 B..in ME. Manenso AA. Mink JII. lIansen C<:' COIn pUled IClm01!,raphy in Iht' evaluatiCln Clf mediastinal IipClmalClsis. J Compnl Assisl Tc.mCl1!,r 1975; 2:379-&'3 o Teall'S CD. Sieroid indu,...d mediastinal IipomalClsis. RadiolCl!-"y 1970: 96:501-02 7 Sa1!,el SS. Clazer liS. Mediaslinum. In: JKT Lee, SS Sa1!,e1, RJ Sianley. eds. Compuled hCldy 10mCl1!,raphy wilh MRI ("rrelalion. N..w York: Rawn Pr..ss: 19I59; 245-94
Fitaillt: 2. Tlw Clnwnla! fal wilh vessels (lar1!,e open amnc) differs frClm Ihe Iwricardial fal pad (.\"'II(JU api'n amnv): Arrowhead indkales pt>rit·ardium. Ihe exislen,... Clf adipCls,' and fihrolls lissue. Barium enema shClw..d ahnClrmally hi1!,h localiCln Clf Iranswrse ,,,Ion silualt'd immedialely Iwnealh Ihe diaphra1!,m. One year laler. Ihe palienl represenl..d Ii,r a 1i,IIClw-up visil and Ihe ehesl rewnl1!,eno1!,ram shClwed an ClhviClus lar1!,t' ht'rniation Clf hClw..I I(M'ps Ihroll1!,h Mor1!,a1!,ni:s fClram..n. DISCUSSION
Large accumulation of adipose tissue in the peridiaphragmati<: area usually n'presents herniation of ahdominal fat either thnmgh a foramen or a defed in the diaphragm. A plain chest roent~t'no~ram in tht' frontal projt'ction shows paracardiac masses. and tIlt' identification of their naturt' is difficult. I HoweVt'r. tlwy are easily dia~nosed by CT! The omentum (,(lIltains adipose tissue which in the oh,·st', or after prolonge,1 us,' of gly('(x.'ortit..'(,ids· may 1)(' massive. This is the most ('(Immon ahdominal ('(lmpOlllld that ht'rniates throu~h Morga~nr, foramt'n and is almost always I'x'att'd at tIlt' right sidt' in tIlt' cardiophrt'nic angl,·. Fat is also at'('umulated in tht' cardiophrenic angl!' aud cardiac apex in mediastinal Iipomatosis_' Cushing's syndrome. and after prolon~ed cortk'(lst('roid therapy." When tht' amount of it in the right ('ardiophrt'nic augle is large. it is nt'c"ssary to makt' th,' distinction Ilt'tween herniated fat and f'pk'ardial fat pad. TIlt' idt'ntification of fin(~ linear df'nsiti,'s within tht' fat. which undouhtedly rt'prt'sent omental vt'ssf·ls. can lit' ust'ful for this distindion. 7 Barium studit's do not havt' pra(·tical valut' sinc,' the herniated fat dtlt's not (,(lIltain gastrointt'nstinal loop. TIlt' small hernia of Morgagnis foramen is asymptomatic and tIlt' difft'n'ntiation is of no clinical importallt·f·. Wt' (,(lIlsidf'r that our cast' rt'prf'st'nts h('rniation of onlt'ntal fat through Morgagni's foranlt'n causf'd hy fat acclllnulation from prolongf'd ('(lrtk'(lstt'roid t1lt'rapy. REFEREN( :ES
RClhlfin1!, BM. KClrohkin M. lIall AO. CClmplllt'd tomCl1!,raphy of inlrathuraci,' omt'nlal 11I'rnialiCln and Cllh..r mediastinal fatty rnasst's. J CClmp"1 Assisl Tcnno1!,r 1977: 1:ISI-1\.1 2 MCldi,' MT. Jankki PC. CClmpul..d ICllnography of mass I..sion Clf th.. ri1!,hl cardiClphn'nk an1!,It'. J CClmpul Assisl Tc.mo1!,r I!#I(): 4: 1470
Continuous Six-Month Infusion of Intravenous Nitroglycerin in a Patient Awaiting Cardiac Transplantation* (;"r"/lIm l: Perry. M.l).; Sriniva.< .\Iurali. M.I>.; and R"rry 1-: ('n·/"ky. M.I>.
We report a patient with ischemic cardiomyopathy who was treated with a continuous high dose infusion of intravenous nitroglycerin for six months while awaiting cardiac transplantation. Surprisingly, methemoglobinemia did not develop and nitroglycerin continued to be clinically effective in relieving an~na during the six-month period. We believe this to be the first reported instance of the safe use of such prolonged infusion of intravenous nitroglycerin.
(Chest 1991; 100:1470-71)
D
to an int'rt'asing numllt'r of t'ardiac transplant candidates and a rt'latively fix,·d donor pool size. the waitin~ pt'ritxl for transplantation has incrt'ast'd considerahly in n'''''nt years. I Mf'dical Illana~emf'nt of transplant candidatt's with t'n<1 stag{' congt'stivt' heart failun' dut' to f'itllt'r isdwlllic or nonischf'mic t'ardiomyopathy often involvt's (1l11tinlHllIS intravf'nous inotropic and vasodilator thf'rapy filr long periods of tinlt'. Intravf'nous nitroglycerin (NTG) has hf'f'n utilized in this st'tting filr tht· trf'atment of hoth unstahle ,1Il~ina pt'doris and severe CH F. Prolon~eduse of intraVt'nous NTG may haw limitations sincf' its hemodynamic effeds attenuatf' within 6 to 8 h of t.'ontinuous administration! Additionally. sustained infusions of lar~e doses of intravenous NTG can caust' metht'mo~lohinemia.l In this rt·port. WI' dt'scrihe a patient with ischt'mic cardiomyopathy who rf't.'f'ived a t'ontinuons six-month intravenous infusion of high dose NTG while awaitin~ transplantation. IIt.
CASE REPORT
A .'>4-year-old while man WaS Iransferr..d 10 our inslilulion for lransplanl evalualion. III' had previoos inferior and anleroseplal wall myfK'ardial infaretions and Iwo days prior 10 Iransfer. suffered an anlerim wall MI. Bt'CauSt' of persislenl postinfarction an/!,ina. he WaS Irealt'd wilh inlraVt'nous NTC (40 I1Wmin). Eleclrocardio1!,ram showed sinus rhylhm and ,,,mplele ri1!,hl hundle hranch hl(x-k. *From Ihe Oivision ofCardiolo,.,')'. University of Pittshur1!,h. School of Medicine. Pittshur1!,h.
Six-mon1h Inlusion of IV Nitroglycerin Prior to Cardiac Transplantation (Perry. Murali, Uretsky)