Pseudolesion of the Chest

No necrotic myocardium was resected. A Teflon patch was placed inside the ventricle covering both the ruptures and the incision. The patch was trimmed to lie close to the wall so as not to reduce the volume of the ventricle. It was fixed with mattress sutures through both the septum and the right venbicular free wall, and with sutures through the free wall on the left side (Fig 1). The sutures were tied over a strip of Teflon felt on each side of the ventriculotomy. The area between the strips was then covered with a patch of dura mater. Postoperatively, there were no signs of heart liUlure and the systolic blood pressure was stable at 100 mm Hg. Pulmonary artery pressure ranged 25 to 35114 to 20 mm Hg. The patient developed a postpericardiotomy syndrome and was treated with steroids. Chest x-ray film 6ndings were normal. After a slmv recovery, the patient 6nally left the hospital 52 days after operation. At follmv-up 12 months after the operation, the patient was NYHAfunctional class 3 due to dyspnea. An echocardiogram shmved a left ventricle of normal dimensions with decreased contractility. On chest x-ray examination the heart volume was 560 ml/m1 BSA.

4 5 6 7

8 9 10

DISCUSSION

Initial conservative treatment of septal ruptures following myocardial infarction with delayed elective surgery is advocated by many surgeons. 1 Necrotic myocardium is difficult to suture and the risk dehiscence is considerable. However, some authon suggest early operation for patients with severe failure or shock. 1.3 Initial intra-aortic balloon pumping has been recommended, but the timing of operation is still controvenial and no definite guidelines are available from reported experiences. Our patient had a septal rupture and was in shock. After pericardiotomy, the inferior free wall of the left ventricle also ruptured. Opening the pericardium and allowing sudden dilatation of the failing heart was probably the immediate cause of the free wall rupture. In spite of the two ruptures, it was possible to perform an adequate repair. Many techniques for early repair of septal and free wall ruptures have been proposed. I." Almost all authon recommend in&rctectomy and reinforcement procedures of the friable tissues. Repair of posterior septal and free wall ruptures is most difficult. The present technique, without resection of myocardium, using a large Tefton patch placed inside the left ventricle, only slightly reduced the volume of the ventricles. The dura mater patch prevented dangerous postoperative bleeding through the in&rcted area. We have found only one previous report in the literature, where a patient has survived ruptures ofboth the ventricular septum and the free myocardial wall. 7 Ruptures of the free wall alone is almost invariably fBtal, although there are about 20 reported cases where operation saved the patient. 7' 1 The majority of these patients had subacute ruptures. a.w Our case shows that it is possible to repair combined ruptures and ensure adequate postoperative myocardial function. More efforts are needed to identify patients who would benefit from such early operative intervention. REFERENCES

1 Schumacher HB. Suggestions concerning operative management of postinfilrction septal defects. J Thorac Cardiovasc Surg 1972; 64:452-59 2 Loisance D~ Cachera JP, Poulain H, Aubry PH, Juvin AM, Galey Ventricular septal defect after acute myocardial infilrction. J Thorac Cardiovasc Surg 1980; 80:61-67 3 Daggett WN, Guyton RA, Mundth ED, Buckley MJ, McEnanay

n.

MT, Gold HK, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977; 186:260-71 Iben AB, Pupello DF, Stinson EB, Shumway NE. Surgical treatment of post-infiuction ventricular septal defects. Ann Thorac Surg 1969; 8:252-62 Hill JD, Lary D, Kerth WJ, Gerbode F. Acquired ventricular septal defects: evolution of an operation, surgical technique and results. J Thorac Cardiovasc Surg 1975; 70:440-50 Miyamoto A1; Lee ME, Kass RM, Chaux A, Sethna D, Gray R, et al. Post-myocardial infiuction venbicular septal defect. J Thorac Cardiovasc Surg 1983; 86:41-46 Piliarre R, Sullivan HJ, Grieco J, Montoya A, Bakhos M, Scanlon PJ, et al. Management of left ventricular rupture complicating myocardial infiuction. J Thorac Cardiovasc Surg 1983; 86:441-43 Feneley MP, Chang VP, O'Rourke MF. Myocardial rupture after myocardial infiuction. Br Heart J 1983; 49:550-56 O'Rourke MF. Subacute heart rupture follmving myocardial infiuction. Lancet 1973 2;124-26 Coma-Canella I, Lopez-Sendon J, Gonzales LN, Ferruflno 0. Subacute left ventricular free wall rupture follmving acute myocardial infiuction: bedside hemodynamics, dift"erential diagnosis and treatment Am Heart J 1983; 106:278-84

Pseudoleslon

of the Chest*

A Conglomerate Radiograph

Shadow on the Lateral

Paul Stark, M.D.; Richard G. Luter, M.D., F.C.C.P.; and &gjnald E. Greene, M.D., F.C.C.P.

A pseudolesion encountered in the lateral chest roent· genogram of normal patients is described. 'Ibis concatena· tion of shadows can produce an opacity which projects over the distal aortic arch and can simulate a mau or pneumonia. 'Ibis pseudolesion can be found in 4 to S percent of normal lateral chest 6lms and is formed by superimposition of normal upper lobe vascular structures.

O

ver several years each of us (authon) has periodically encountered a shadow, clearly visible on the lateral chest 6lm and simulating a mass lesion. This disturbing structure projects usually over the aortic arch in the lateral projection, yet no corollary can be identified on the frontal chest roentgenogram. This pseudolesion is perceived as a round, ovoid or triangular density superimposed on the aortic arch at the junction of the transverse and descending portion and is seen only on the lateral view. We have attempted to determine what structures actually contribute to the formation of this pseudomass and deteJ'o mine the frequency of this occurrence. MATERIALS AND METHODS

Five hundred seventy-five chest PA and lateral roentgenograms were examined prospectively by one of us and 39 cases of pseudolesion were isolated. After critical review, 12 cases were eliminated, leaving 27 which fulfilled our criteria. •From the Department of Radiology, University of Teus Health Science Center at Houston, and Massachusetts General Hospital, Harvard Medical School, Boston. Reprint requeats: Dr. Stark, VTMS, Radiology, 6431 Fannin Street, HotUton 7703()

CHEST I 87 I 4 I APRIL, 1885

541

FICURE lA (left). Lateral chest roentgenogram in otherwise normal patient. An irregu)arly marginated shadow is superimposed on the distal aortic arch (arrow). lB (center). Lateral linear tomogram through the right hilus displaying the anterior trunk of the right main pulmonary artery with its segmental branches, (arrow) as well as the superior pulmonary vein (arrowhe4d). IC (tight). Lateral linear tomogram through the left hilus, showing the epibronchlalleft pulmonary artery with apical posterior segmental branches to the left upper lobe (arrow) and the arterial branch to the left superior segment of the left lower lobe (arrowhe4d).

REsul.J'S

DISCUSSION

In 575 chest PA and lateral roentgenograms, 27 cases of this pseudolesion were found on the lateral film for a frequency of 4. 7 percent.

ows on the chest roentgenogram. This was recently empha-

FICURE 2. Lateral chest roentgenogram in otherwise normal patient demonstrating a triangu]ar shadow superimposed on the.distal aortic arch (arrow).

FICURE 3. Lateral chest roentgenogram in otherwise normal patient displaying an ill-defined density in close proximity to the distal aortic arch (arrow) .

Normal vascular structures can produce disturbing shad-

sized with respect to the upper lobe pulmonary veins. u One of our patients with a pseudotumor undeiWent tomography in the lateral projection (Fig 1). This allowed a convincing display of the component structures, which form

PMndoleekln of the Cheet (Static, L.eaflw.

~)

this shadow by superimposition. The right upper lobe arteries, especially the segmental branches to the posterior segment, contribute to the formation of this structure together with the apical-posterior arterial branches of the left upper lobe arteries. Branches of the superior pulmonary veins produce a superiorly jagged appearance to this shadow. The distal aortic arch creates an additional summation effect which lends more substance to the pseudotumor. For the uninitiated observer this concentration of shadows can be very disturbing since it can simulate a malignancy or pneumonia, yet be very disconcerting because of its elusive nature in the PA or oblique projections. This shadow can be expected in about 4 to 5 percent of normal chest PA and lateral roentgenograms. Once aware of its occurrence and its significance, it should not create any problem in detection and diagnosis. REFERENCES

1 Chasen MH, Yrizarry JM. Tomography of the pulmonary hili. Radiology 1983; 149:365-69 2 Genereux GP. Conventional tomographic hilar anatomy emphasizing the pulmonary veins. AJR 1983; 141:1241-57

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FIGURE 1. Wind velocities and barometric pressures for three days, centering on the day of the sandstorm. increasing winds and decreasing barometric pressures peaking about 3 to 4 PM on March 26.

REsuLTS

Immediate Effects of a Sandstorm on Asthma and Other Respiratory Problems Donald L. Unger, M.D., F.C.C .P.*

A violent sandstorm failed to provoke any immediate increase in asthma or other respiYatory problems, as measured by emergency room visits and patients hospitalized.

O

n March 26, 1984, the worst sandstorm in nine years struck the Southern California desert. Winds approached 100 MPH at the Palm Springs Airport that afternoon. Power lines snapped, trucks and recreational vehicles were overturned, and roads were closed. A search of the literature failed to reveal anything about the effects of a sandstorm on asthma or other respiratory problems. TherefOre, this study was undertaken. METHODS

A survey of the emergency rooms (ER) of the four area hsopitals

was done for a 14-day period, including the day of the sandstorm. The following information was obtained for each day: (1) The total number of patient visits, regardless of the reason. (2) The number for respiratory problems (asthma, bronchitis, pneumonia, COPD, etc). a. The number hospitalized. b. How many carne for asthma. Since some patients were not admitted through an ER, one hospital (EM C) was surveyed for the total number of admissions, those for respiratory problems, and especially those for asthma for the same two weeks. Figure 1 gives the wind velocities and barometric pressures for three days, centering on the day of the sandstorm, showing the • Attending Physician, Eisenhower Medical Center, Rancho Mirage; Desert Hospital, Palm Springs. Reprint requests: Dr. Unger, 225 Civic Drive, Palm Springs, California 92262

As seen in Table 1, nine patients with respiratory problems were seen in the local ERs on the day of the sandstorm, compared with an average of 11 fur the 14 days studied. The two hospitalized (average 2.36) were men of83 and 94, both of whom had pneumonia. The only asthmatic (average 3.14/ day) was a 71-year-old man with a possible pneumonia who was not admitted. With the intense sandstorm, some patients could have delayed seeking care until the next day. Five patients with respiratory problems were seen in the ERs then, of whom fuur bad asthma. The only admission to EMC fur a respiratory problem on the day of the sandstorm was a 30-year-old man with a right middle lobe pneumonia (Table 2). DISCUSSION

After driving through a devastating sandstorm with almost nonexistent visibility, past overturned trucks and recreational vehicles, I expected numerous calls from sick patients; they failed to come. This study confirms the absence of increased respiratory problems during and immediately after the sandstorm. Drops in barometric pressure and strong winds have long been accused of precipitating asthma, •·•• but did not do so here. In the Midwest, the first rainstorm after Labor Day is notoriously fuUowed by the worst asthma of the year. 15 The two main differences between this rainstorm and the desert sandstorm are the humidity and the poUen counts; high winds and drops in barometric pressure come with both, although not necessarily to the same degree. The humidity is about 100 percent in a rainstorm, but was only 27 percent in the sandstorm. While past studiesuo . u.~& have suggested that humidity is important in provoking asthma, the results have not been conclusive. The main reason fur the absence ofsymptoms could be that the patients were not primed. 1,..8 No rain had fallen here fur over three months, and the usual spring carpet of desert CHEST I 87 I 4 I APRIL. 1985

543