Rheumatoid Spondylitis, Aortic Insufficiency, and Coronary Artery Disease

pleural effusion soon disappeared. Seven months later, symptoms of active aortitis became evident, and at the same time a pleuropericardial effusion reappeared despite continuation of isoniazid and paraaminosalicylic acid therapy. This fact indicates that the pleural effusion was probably not tuberculous in origin. There was also no evidence of infection or valvular heart disease to account for the pleuropericardial effusion, and the character of the fluid was that of an exudate, which did not support the presence of cardiac failure. With the initial pleural effusion, cardiac size was normal on chest roentgenogram, but the second episode was associated with definite pericardial effusion. Based on these observations, pericarditis was not thought to be the cause of the pleural effusion. There is only one report dealing with the coexistence of aortitis syndrome and pleural effusion; 1 in that report, nine out of 197 cases revealed pleural effusion as a clinical manifestation. The pathogenesis, etiology, and character of the pleural effusion were not mentioned in the report. Cardiac failure with valvulitis is known to be present in some cases of aortitis syndrome, and some of the reported cases might be directly related to heart failure. The similarities between aortitis syndrome and some diffuse connective tissue diseases have been discussed.s' and pleural effusion is one of the prominent extraarticular manifestations of rheumatoid arthritis. The character of the pleural effusion in the present case differed, however, from that of rheumatoid arthritis with regard to glucose concentration.P-" In view of the previously mentioned clinical and laboratory features of our case, we feel that the pleural effusion was likely a clinical manifestation of the aortitis syndrome per se rather than a secondary manifestation of an underlying undiagnosed infectious, autoallergic, or related disease. REFERENCES

1 Committee Report (Chairman Veda H): Clinical and pathological studies of aortitis syndrome. lap Heart J 9:7696, 1968 2 Nakao K, Ikeda M, Kimata S, et al: Takayasu's arteritis. Clinical report of eighty four cases and immunological studies of seven cases. Circulation 35: 1141-1155, 1967 3 Cheitlin MD, Carter PB: Takayasu's disease. Unusual manifestations. Arch Int Med 116:283-288, 1965 4 Sandring H, Welin G: Aortic arch syndrome with special

reference to rheumatoid arthritis. Acta Med Scand 170: 119, 1961 5 Carr OT, Mayne JG: Pleurisy with effusion in rheumatoid arthritis with reference to the low concentration of glucose in pleural fluid. Am Rev Respir Dis 85:345-350, 1962 6 Russakoff AH, LeMaistre CA, Dewlett HJ: An evaluation of the pleural fluid glucose determination. Am Rev Respir Dis 85:220-223,1962

828 SPITZER, PEGUERO, MASON

Rheumatoid Spondylitis, Aortic Insufficiency, and Coronary Artery O·rsease * An Operable Combination Stanley Spitzer, M.D., F.C.C.P.; Federico Peguero, M.D.; and Daniel Mason, M.D., F.C.C.P.

A case of rheumatoid (ankylosing) spondylitis with aortic insufficiency and arteriosclerotic coronary heart disease is presented. Surgical replacement of the aortic valve and aortocoronary bypass grafts were successfully accomplished. he interrelation between rheumatoid (ankylosing) T spondylitis, aortitis, and aortic valvulitis is well rec-

nized. In addition, varying degrees of heart block have also been associated with rheumatoid spondylitis.i-" The distinctive cardiovascular abnormalities have also been associated with rheumatoid spondylitis.t-" The distinctive cardiovascular abnormalities in rheumatoid spondylitis have been described and the unique features of the cardiovascular lesions illustrated (Fig 1) . We report the clinical findings and surgical results in a patient with rheumatoid spondylitis, aortic insufficiency, and intermittent complete heart block, as well as severe coronary artery disease. The coronary artery obstructions were successfully bypassed with saphenous vein aortocoronary grafts; we, therefore, suggest that this procedure is technically feasible in patients with rheumatoid spondylitis. CASE REPORT

The patient was a 54-year-old man with a 20-year history of rheumatoid (ankylosing ) spondylitis (still quiescent). He was initially admitted to Hahnemann Hospital, Philadelphia, on Jan 3, 1972 after a severe bout of precordial chest pain. The patient had first-degree heart block and had been taking a digitalis preparation. On admission, physical examination revealed an early diastolic murmur heard best along the left sternal border; an electrocardiogram showed complete atrioventricular (A V) heart block. The patient was treated with temporary transvenous pacing, and the digitalis therapy was discontinued. On the second day, complete heart block was intermittent. On the third day, sinus rhythm returned, with the first-degree heart block still present. The patient was then discharged and instructed to return for further evaluation. The patient was readmitted to Hahnemann Hospital in February 1972. Cardiac catheterization revealed 3+ aortic insufficiency and triple-vessel coronary artery disease: left main coronary artery, 50 percent occlusion; the left anterior descending artery, 95 percent occlusion; the left circumflex artery, 80 percent narrowing; and the right coronary artery, 75 percent occlusion. During the course of the catheterization, intermittent AV dissociation occurred several times. After catheterization, a demand pacemaker was inserted without difficulty. The patient was discharged shortly afterward. °From the Division of Cardiology, Hahnemann Medical College and Hospital, Philadelphia. _ Reprint requests: Dr. Spitzer, 1333 Race Street, Philadelphia

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CHEST, 68: 6, DECEMBER, 1975

This case illustrates the value of coronary arteriography in patients with aortic valvular disease.":" We thank Alexander Nedwich, M.D ., who reviewed the pathologic specimen.

ACK1':OWLEDG~IENT :

REFERENCES

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FIGUHE 1. Resected aortic valve from base to tip shows thickening due to hyalinization. Distal end is extremely cellular, with proliferation of young spindle-type cells. Subvalvular fibrous bump described by Bulkley and Hoberts'' is present. The patient was readmitted to Hahnemann Hospital in April IH72, when he underwent aortic valve replacement with a 1\:0. 27 Bjork-Shiley aortic valve prosthesis; triple aortocoronary vein grafts were done to the right coronary artery, the left anterior descending artery, and the left circumflex coronary artery. His postoperative course was uncomplicated, and the patient was discharged on May 6, IH72 in good condition. On Sept 21, HJ73, the patient's pacemaker failed, and he had to be readm itted for replacement of his pacemaker generator During the time when the pacemaker was not functioning, sinus rhythm was present, with first-degree heart block . COMMENT

The combination of complete heart block and aortic insufficiency has been regarded as rare in patients with rheumatoid spondylitis.' However, subsequent reports" have emphasized that this combination may not be as rare as previously thought. Our patient has an additional cardiac lesion, that is, coronary arteriosclerosis. Innumerable articles have been written describing the surgical approach to coronary arteriosclerosis by aortocoronary bypass graft; but, so far as we know, this is the first case in which such surgery has been performed in a patient with rheumatoid spondylitis. Three patients in another series' had angina pectoris ; however, they had just undergone aortic valve replacement but did not undergo hypass grafting. Aortic valve replacement in rheumatoid spondylitis has been described ." In the case of our patient, the aortic valve was replaced in addition to the bypass graft. One ye~r after operation, the patient is asymptomatic.

CHEST, 68: 6, DECEMBER, 1975

Liu SM, Alexander CS : Complete heart block and aortic insufficiency in rheumatoid spondylitis. Am J Cardiol 23 : 888-892, 1969 Bottiger LE , Edhag 0 : Heart block in ankylosing spondylitis and uropolyarthritis. Br Heart J 34 :487-492, 1972 Bulkley BH, Roberts WC : Ankylosing spondylitis and aortic regurgitation. Circulation 48 :1014-1027, 1973 Malette RA, Eiseman B, Danielson GK, et al : Rheumatoid spondylitis and aortic insufficiency. J Thorac Cardiovasc Dis 57:471-474,1969 Spangler RD, McCallister BD, McCoon DC : Aortic valve replacement in patients with severe aortic valve incompetence associated with rheumatoid spondylitis. Am J Cardiol 26 :130-134, 1972 Anderson RP, Bonchek LI, Wood JA, et al : The safety of combined aortic valve replacement and coronary bypass grafting. Ann Thorac Surg 15:249-255, 1973 Bonchek LI, Anderson RP, Rosch J : Should coronary art eriography be performed routinely before valve replacement? Alii J Cardiol 31 :462-466, IH73

An Unusual Precordial Pulse and Sound Associated with Large Pericardial Effusion * Anthom] J. Bonner, lr., .\I .D.; Carlos M. Estevez, M.D .; Jame s C. Dillon, M .D.; R. Joe Noble, M.D .; and Morton E. Tat;el, M .D., F.C.C.P.

An unusual, high-pitched, early diastolic sound coinciding with a prominent, sharp precordial pulse was observed in a patient with a large chronic pericardial effusion. The pulse and sound coincided exactly with the anterior excursion of the heart within the fluid-filled pericardial sac, suggesting that the sound and pulse result from the ballistic effect of the heart striking the anterior pericardium and chest wall. This finding may be specific for large pericardial effusion with a "swinging heart."

P

hysica l findings associated with large pericardial effusion are often sparse and nonspecific.':" We have recently observed a patient with a large pericardial effusion who demonstrated an unusual early diastolic precordial pulsation associated with a high-pitched

°From the Department of Med icine, Indiana University School of Medicine, and the Krannert Institute of CardielOl!:Y, Indianapolis. Supported in part by the Herman C. Krannert Fund and by grants HL..{)6308, HL ..05:3fi3, and HL-Q5749 from the National Ileart and Lung Institute of the National Institutes of Health, Puhlic Health Service . This study was carried out during the tenures of Dr. Bonner and Dr . Estevez as Public Health Service Trainees in Cardiology. Re/ITint requests: Dr. Taccl, Indiana Unicersitu , 1/30 West Michigan, Indianapolis 46202

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