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Patent Ductus Arteriosus with Hypoplastic Lung
61:104-116, 1972 8 Selzer A, Gerbode F, Kerth WJ: Clinical, hemodynamic and surgical considerations of rupture of the ventricular septum after myocardial infarction. Am Heart J 78:5986CY1,I969 9 Heilddla J, Karesoja M, Luomanmiiki K: Ruptured interventricular septum complicating acute myocardial infarction: Clinical spectrum and hemodynamic evaluation with rapid bedside cardiac catheterization. Chest 66:675-681, 1974 10 Iben,. AB, Miller RR, ~terdam EA, et al: Successful immediate repair of acquired ventricular septal defect and survival in patients with acute myocardial infarction shock using a new double patch technique. Chest 66:665670,1974 11 Swan HJC, Ganz Q, Forrester J, et al: Catheterization of the heart in man with the use of a flow directed balloon tipped catheter. N Engl J Med 283:447-451,1970 12 Kitamura S, Mendez A, Kay JH: Ventricular septal defect following myocardial infarction: Experience with surgical repair through a left ventriculotomy and a review of the literature. J Thorac Cardiovasc Surg 61:186-199, 1971 13 Roberts WC, Ronan JA, Harvey WP: Rupture of the left ventricular free wall or ventricular septum secondary to acute myocardial infarction: An occurrence virtually limited to the first transmural myocardial infarction in a hypertensive individual Am J Cardiol35:166, 1975 14 Lee lIT, O'Neal RM: Anticoagulant therapy of acute myocardial infarction. Am J Med 21 :555-559, 1956 15 Lautscb EV, Lanb KW: Pathogenesis of cardiac rupture. Arch Pathol84:264-271, 1967 16 Naeim F, DeLaMaza LM, Robbins SL: Cardiac rupture during myocardial infarction. Circulation 45: 1231-1239, 1972 17 Kavelman DA: Myocardial rupture: A study in psydlotic and nonpsychotic patients. Can Med Assoc J 82:11051107,1960
Patent Ductus Arteriosus with Hypoplastic lung *
FIGURE 1. Chest roentgenogram suggesting hypoplastic right lung and cardiac silhouette in right side of chest. cardiac surgery3 encouraged us to use this approach for a child with patent ductus arteriosus and a hypoplastic right lung.
CASE REPoRT The patient was a 4l-year-old white girl. She had been born to a diabetic mother by cesarean section after seven months of gestation. The patient's birth weight was 3,175 gm (7 lb). She presented with mild respiratory distress, and a hypoplastic right lung was diagnosed clinically and radiologically. A heart murmur had been noticed when the patient was 27 months of age, and she was referred for a cardiac evaluation. The family history was noncontributory for congenital or rheumatic heart disease. The patient had no cyanosis or clubbing. Pulses were equal in all extremities, and the blood pressure was 90/40 mm Hg. The trachea was shifted to the right side. The chest was asymmetric, with flattening of the wall on !:lJ,e right side of the chest. The cardiac impulse was situated in
Bode Roo. M.D.; Norman Gootman. M.D.; Daniel Silbert. M.D.; and B. Gecwge Wisoff. M.D.• F.C.C.P.
A median sternotomy approach W8I used for closure of ....ent ductus arteriosus lISSOdated with a hypoplastic right ...... De anterior approach to the left ductus is Indicated If left thoncotomy Is coutraiudicated. patent ductus arteriosus is an anomaly commonly associated with a hypoplastic lung.! If this hypoplastic lung is on the left, then a standard left-sided approach to ductal closure is feasible. 2 The presence of a right hypoplastic lung and a left-sided ductus poses the problem of safe approach to the ductus. The experience in ductal closure via a median sternotomy done for -From the Departments of Surgery and Pediatrics and the Divisions of Pediatric Cardiology and Cardia-Thoracic Surgery, Long Island Jewish-Hillside Medical Center, New Hy(le Park. NY, and the School of Medicine, the StateUniversity of New York, Stony Brook. NY. Reprint requem: Dr. Roo. Long I,land Jewish-Hillside MedIcal Center, New Hilde Park. New Ycwk 11040
CHEST, 69: 6, JUNE, 1976
FIcURE 2. Left ventricular cineangiogram showing patent ductus arteriosus.
PDI WITH HYPOPLAmC LUNG 785
the fourth intercostal space, 2 inches inside the midclavicular
line. The first and second heart sounds were normal. A
continuous murmur was heard along the right sternal border. Breath sounds were diminished over the wall of the right side of the chest. The patient's electrocardiogram revealed right axis deviation and mild ventricular hypertrophy. A chest roentgenogram and barium swallow suggested hypoplastic right lung and a cardiac silhouette located in the right side of the chest (Fig 1). The clinical impression was patent ductus arteriosus with hypoplastic right lung. Cardiac catheterization and angiographie studies revealed patent ductus arteriosus which was entered from the pulmonary artery. The right pulmonary artery appeared hypoplastic and the left normal. The presence of the patent ductus arteriosus was further demonstrated by left ventricular cineangiogram (Fig 2). The right upper pulmonary vein entered the right atrium. Arterial oxygen saturation was 92 volumes percent, suggesting mild intrapulmonary shunting. Pulmonary arterial pressure was mildly elevated to 41/26 mm Hg. The patent ductus arteriosus was approached via a median sternotomy. The pericardium was opened, and ductal closure was achieved with two ligatures of heavy silk. The postoperative course was uneventful DISCUSSION
Fifty-nine . cases of patent ductus arteriosus were found on Schechter'sl review of 414 patients with congenital subtractive bronchopulmonic maHonnation. Six of this group underwent ductal closure. The usual surviving patient with an absent lung and persistent patent ductus arteriosus has the left lung absent and the patent ductus on the left. Closure of such a patent ductus is easily achieved through the left side of the chest. 2 ,4 In two patients with absent left lung and right-sided patent ductus arteriosus, the patent ductus was approached via bilateral anterior thoracotomy and via right anterolateral thoracotomy by Swan et aI. 5 . The feasibility and safety of an approach to the patent ductus arteriosus via a median sternotomy was demonstrated both by Kirklin and Silvera and by McGoon a in their experience with patients undergoing open-heart surgery. An approach via median sternotomy was chosen for our patient in order to avoid opening the left pleural space and compressing the single left lung during the ductal closure. Closure of a patent ductus arteriosus is indicated in the presence of a single pulmonary artery. This is especially important if there is pulmonary hypertension, as in our patient. The overloaded pulmonary circuit is exposed to the risk of pulmonary vascular disease if the left-to-right shunt is allowed to persist.
REF'ERENCFS 1 Schechter DC: Congenital absence or deficiency of lung tissue. Ann Thorac Surg 6:286, 1971 2 Nicks R: Agenesis of the lung with persistent ductus arteriosus. Thorax 12: 140, 1957 Closure of patent ductus during open heart 3 McGoon ~: surgery. J Thorae Cardiovasc Surg 48:456, 19644 Jimenez-Martinez M, Perez-Alvarez J, Perez-Trevino C, et al: Agenesis of the lung with patent ductus arteriosus
786 KILPATRICK, KOONTZ, NELSON
during open heart surgery. J Thorae Cardiovasc Surg 50:59,1965 5 Swan H., Owens JC, Pool PE, et al: Absent left pulmonary artery and right-sided patent ductus arteriosus. Arch Surg 87:196; 1963 6 Kirklin]W, Silver AW: Technique of exposing the ductus arteriosus prior to establishing extracorporeal circulation. Proc Staff Meetings Mayo Coo 33:423, 1958
Nocardia Infedion in a Bronchopulmonary Sequestration * MAl George R. Kilpatrick, /r., MC, USA;·· MAl C. H. Koontz, MC, USA;·· and COL Roald A. Nelson, MC, USA, F.C.C.P.
_III,
A C8Ie of iDtnIob8r broaehopubDoamy _ II reported ill wbleb the sequestered hmg W8S lDfeeted with Noeardia sp. Although reeurreDt PYOIeDk lDfeetlo.. .e. commOD in palmoamy tIdI Is tbe 8nt ease report with documented noem-diOllL Bronchopulmonary sequestration is an uncommon disorder. In fact, in our 600-bed referral hospital, there have been only 21 documented cases spanning the last two decades. A striking finding in our experience and in a review of the literature is the signfficant number of patients with this condition who have a history of recurrent pulmonary infections, cough, expectoration, and fever for many years before the diagnosis of sequestration is suspected or proved. 1 For this reason, even though bronchopulmonary sequestration is rare, it is important for clinicians to be aware of this entity and how these cases may present clinically. We present herein the first reported case of recurrent nocardiosis involving a sequestered area of lung. CASEREroRT On a routine chest x-ray film in October 1972, a 26-yearold asymptomatic white man was found to have multiple large pulmonary nodules in the right lower lobe (Fig 1A). There was no past history of recurrent pulmonary infections, and previous chest x-ray films were reported as normal. He had served overseas tours in Europe and southeast Asia, but had been in the United States for one year prior to this chest x-ray examination. Examination of the lungs revealed localized 8ne rAles over the right lower lung field posteriorly, along with percussion dullness. Findings from the remainder of the physical examination, including careful palpation of the testicles and lymph nodes, were normal. The hematocrit, white blood cell count, urinal~ and blood chemistry studies were normal, except for a slightly ·From the Department of Medicine and Pulmonary Disease Service, Fitzsimons Army Medical Center, Denver. The opinions and assertions contained herein are the private views of the authors and do not necessarily reflect the position of the Department of the Army or the Deparbnent of Defense. • • Subspecialty Residents in Pulmonary Disease. Reprint requests: Col. Nelson, Fitzsimons Anny Medical Center, Denver 80240
CHEST, 69: 6, JUNE, 1976
Patent Ductus Arteriosus with Hypoplastic lung *
FIGURE 1. Chest roentgenogram suggesting hypoplastic right lung and cardiac silhouette in right side of chest. cardiac surgery3 encouraged us to use this approach for a child with patent ductus arteriosus and a hypoplastic right lung.
CASE REPoRT The patient was a 4l-year-old white girl. She had been born to a diabetic mother by cesarean section after seven months of gestation. The patient's birth weight was 3,175 gm (7 lb). She presented with mild respiratory distress, and a hypoplastic right lung was diagnosed clinically and radiologically. A heart murmur had been noticed when the patient was 27 months of age, and she was referred for a cardiac evaluation. The family history was noncontributory for congenital or rheumatic heart disease. The patient had no cyanosis or clubbing. Pulses were equal in all extremities, and the blood pressure was 90/40 mm Hg. The trachea was shifted to the right side. The chest was asymmetric, with flattening of the wall on !:lJ,e right side of the chest. The cardiac impulse was situated in
Bode Roo. M.D.; Norman Gootman. M.D.; Daniel Silbert. M.D.; and B. Gecwge Wisoff. M.D.• F.C.C.P.
A median sternotomy approach W8I used for closure of ....ent ductus arteriosus lISSOdated with a hypoplastic right ...... De anterior approach to the left ductus is Indicated If left thoncotomy Is coutraiudicated. patent ductus arteriosus is an anomaly commonly associated with a hypoplastic lung.! If this hypoplastic lung is on the left, then a standard left-sided approach to ductal closure is feasible. 2 The presence of a right hypoplastic lung and a left-sided ductus poses the problem of safe approach to the ductus. The experience in ductal closure via a median sternotomy done for -From the Departments of Surgery and Pediatrics and the Divisions of Pediatric Cardiology and Cardia-Thoracic Surgery, Long Island Jewish-Hillside Medical Center, New Hy(le Park. NY, and the School of Medicine, the StateUniversity of New York, Stony Brook. NY. Reprint requem: Dr. Roo. Long I,land Jewish-Hillside MedIcal Center, New Hilde Park. New Ycwk 11040
CHEST, 69: 6, JUNE, 1976
FIcURE 2. Left ventricular cineangiogram showing patent ductus arteriosus.
PDI WITH HYPOPLAmC LUNG 785
the fourth intercostal space, 2 inches inside the midclavicular
line. The first and second heart sounds were normal. A
continuous murmur was heard along the right sternal border. Breath sounds were diminished over the wall of the right side of the chest. The patient's electrocardiogram revealed right axis deviation and mild ventricular hypertrophy. A chest roentgenogram and barium swallow suggested hypoplastic right lung and a cardiac silhouette located in the right side of the chest (Fig 1). The clinical impression was patent ductus arteriosus with hypoplastic right lung. Cardiac catheterization and angiographie studies revealed patent ductus arteriosus which was entered from the pulmonary artery. The right pulmonary artery appeared hypoplastic and the left normal. The presence of the patent ductus arteriosus was further demonstrated by left ventricular cineangiogram (Fig 2). The right upper pulmonary vein entered the right atrium. Arterial oxygen saturation was 92 volumes percent, suggesting mild intrapulmonary shunting. Pulmonary arterial pressure was mildly elevated to 41/26 mm Hg. The patent ductus arteriosus was approached via a median sternotomy. The pericardium was opened, and ductal closure was achieved with two ligatures of heavy silk. The postoperative course was uneventful DISCUSSION
Fifty-nine . cases of patent ductus arteriosus were found on Schechter'sl review of 414 patients with congenital subtractive bronchopulmonic maHonnation. Six of this group underwent ductal closure. The usual surviving patient with an absent lung and persistent patent ductus arteriosus has the left lung absent and the patent ductus on the left. Closure of such a patent ductus is easily achieved through the left side of the chest. 2 ,4 In two patients with absent left lung and right-sided patent ductus arteriosus, the patent ductus was approached via bilateral anterior thoracotomy and via right anterolateral thoracotomy by Swan et aI. 5 . The feasibility and safety of an approach to the patent ductus arteriosus via a median sternotomy was demonstrated both by Kirklin and Silvera and by McGoon a in their experience with patients undergoing open-heart surgery. An approach via median sternotomy was chosen for our patient in order to avoid opening the left pleural space and compressing the single left lung during the ductal closure. Closure of a patent ductus arteriosus is indicated in the presence of a single pulmonary artery. This is especially important if there is pulmonary hypertension, as in our patient. The overloaded pulmonary circuit is exposed to the risk of pulmonary vascular disease if the left-to-right shunt is allowed to persist.
REF'ERENCFS 1 Schechter DC: Congenital absence or deficiency of lung tissue. Ann Thorac Surg 6:286, 1971 2 Nicks R: Agenesis of the lung with persistent ductus arteriosus. Thorax 12: 140, 1957 Closure of patent ductus during open heart 3 McGoon ~: surgery. J Thorae Cardiovasc Surg 48:456, 19644 Jimenez-Martinez M, Perez-Alvarez J, Perez-Trevino C, et al: Agenesis of the lung with patent ductus arteriosus
786 KILPATRICK, KOONTZ, NELSON
during open heart surgery. J Thorae Cardiovasc Surg 50:59,1965 5 Swan H., Owens JC, Pool PE, et al: Absent left pulmonary artery and right-sided patent ductus arteriosus. Arch Surg 87:196; 1963 6 Kirklin]W, Silver AW: Technique of exposing the ductus arteriosus prior to establishing extracorporeal circulation. Proc Staff Meetings Mayo Coo 33:423, 1958
Nocardia Infedion in a Bronchopulmonary Sequestration * MAl George R. Kilpatrick, /r., MC, USA;·· MAl C. H. Koontz, MC, USA;·· and COL Roald A. Nelson, MC, USA, F.C.C.P.
_III,
A C8Ie of iDtnIob8r broaehopubDoamy _ II reported ill wbleb the sequestered hmg W8S lDfeeted with Noeardia sp. Although reeurreDt PYOIeDk lDfeetlo.. .e. commOD in palmoamy tIdI Is tbe 8nt ease report with documented noem-diOllL Bronchopulmonary sequestration is an uncommon disorder. In fact, in our 600-bed referral hospital, there have been only 21 documented cases spanning the last two decades. A striking finding in our experience and in a review of the literature is the signfficant number of patients with this condition who have a history of recurrent pulmonary infections, cough, expectoration, and fever for many years before the diagnosis of sequestration is suspected or proved. 1 For this reason, even though bronchopulmonary sequestration is rare, it is important for clinicians to be aware of this entity and how these cases may present clinically. We present herein the first reported case of recurrent nocardiosis involving a sequestered area of lung. CASEREroRT On a routine chest x-ray film in October 1972, a 26-yearold asymptomatic white man was found to have multiple large pulmonary nodules in the right lower lobe (Fig 1A). There was no past history of recurrent pulmonary infections, and previous chest x-ray films were reported as normal. He had served overseas tours in Europe and southeast Asia, but had been in the United States for one year prior to this chest x-ray examination. Examination of the lungs revealed localized 8ne rAles over the right lower lung field posteriorly, along with percussion dullness. Findings from the remainder of the physical examination, including careful palpation of the testicles and lymph nodes, were normal. The hematocrit, white blood cell count, urinal~ and blood chemistry studies were normal, except for a slightly ·From the Department of Medicine and Pulmonary Disease Service, Fitzsimons Army Medical Center, Denver. The opinions and assertions contained herein are the private views of the authors and do not necessarily reflect the position of the Department of the Army or the Deparbnent of Defense. • • Subspecialty Residents in Pulmonary Disease. Reprint requests: Col. Nelson, Fitzsimons Anny Medical Center, Denver 80240
CHEST, 69: 6, JUNE, 1976