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Tricuspid Valve Perforation By Endocardial Pacing Electrode
COMMUNICATIONS TO THE EDITOR Thomas Addison; Teacher, Diagnostician and Chest Physician To the Editor: Thomas Addison (1793-1860) holds a unique place in medical history as the discoverer of two important diseases, both of which are named after him. The two conditions are Addison's disease and Addison's anemia. After graduating, he became interested in diseases of the skin. But he really never liked the idea of specialism; his interests were too wide. He devoted considerably more attention to diseases of the lungs than to any other branch of medicine. It is ironic that this facet of his genius has not been appreciated by the medical profession. The collection of his papers includes five on various aspects of pulmonary disease. The knowledge of the structure of the lungs, before Addison's time, was scattered and inaccurate. Addison, after careful dissection of healthy lungs, gave an accurate account of the minute anatomy. In a paper read before the Guy's Physical Society in 1843, Addison wrote, "Accompanied by a corresponding branch of the pulmonary artery, I trace a filiform bronchial tube to a lobule or bunch of (air) cells, in which it abruptly terminates; the blood distributed over these cells being received by the pulmonary veins, which pass exteriorly to the air cells, in a loose and very distinct interlobular cellular tissue." Before Addison's time it was a general belief that pneumonia was an exudate into the structure of the lungs. Laennec defined pneumonia as "inflammation of the lung tissue." Although Addison had the tremendous respect and admiration for Laennec, he differed from the master in the teaching of pneumonia and phthisis. In 1837, before the Guy's Physical Society, he said, "1 entertain no doubt whatever of its (pneumonic inflammation) being primarily and essentially in the (air) cells themselves." He wrote an admirably detailed account of various stages of pneumonia ie engorgement, red hepatization, grey hepatization, based upon his diligent examination of autopsy material. In his book On the Pathology of Phthisis, Addison wrote that in phthisis there are two processes at work, the tubercles and ordinary inflammation. His other original discoveries have included fatty liver, appendicitis, carnification of the lung, and xanthoma. Thomas Addison was a brilliant teacher and an CHEST, VOL. 63, NO.1, JANUARY, 1973
exceptionally skillful diagnostician. He was an accomplished auscultator. On February 28, 1846, before the Physical Society, he read a paper "On the Difficulties and Fallacies Attending Physical Diagnosis of Diseases of the Chest," and enumerated 42 pitfalls. He also introduced the practice of making the clerks (students) systematically write case reports of the cases, and thus it is to him we owe the whole practice of clinical reports made by students. Om P. Sharma, M.D.· Los Angeles • Assistant Professor of Medicine, University of Southern California School of Medicine, Pulmonary Disease Service.
Tricuspid Valve Perforation By Endocardial Pacing Electrode To the Editor: An 86-year-old woman with known atherosclerotic heart disease who had a transvenous endocardial pacemaker implanted a year ago, presented with sudden onset of bradycardia. A temporary pacemaker was inserted successfully. It was not possible to pace the heart through the existing permanent electrode by an external pacemaker. Gentle traction on the electrode failed to dislodge the electrode from the endocardium. The patient expired the next day. The autopsy revealed a Silastic-coated pacing electrode wire extending from the superior vena cava perforating the inferior portion of the right anterior tricuspid leaflet at the junction. of the chordae tendinae. The tip of the electrode was embedded under a papillary muscle (Fig 1). At the site of perforation, the wire was covered with a distinct but separate endothelial sheath 3 cm in length. The right atrium and ventricle were slightly
FIGURE 1. Silastic-coated pacing electrode perforating inferior portion of right anterior tricuspid leaflet junction of chordae tendinae.
125
COMMUNICATIONS TO THE EDITOR
126 dilated. Any heroic I attempt to dislodge the electrode would have resulted in evulsion of the tricuspid leaflet or valve. Fibrous adhesions with the tricuspid ring have heen previously reported. 2 It is suggested that great care be taken under similar situations and that leaving the electrode in place may he a hetter part of valor. Sylcia R. Petterson, M.D.; lang B. Singh, M.D.; Guillermo Reeves, M.D.; Stanley L. Kocot, M.D.o \Vorcester, Massachusetts
the patient to IX'rfoml tht> required activity in as nahlral a fashion as possihle. Changes in pressure in the belt were recorded by a Statham transducer (PR23-2D-300) and recorded hy an Electronics for Medicine multichannel recorder. The patient was seated on a stool and records were made of nomlal relaxed breathing. He was then asked to bend down and tic his shoe laces, bmsh his teeth, or comb his hair. One patient was asked to bend down as if working a drilling machine and another pretended to reverse his car. These two latter maneuvers were used as these individuals particularly complained of shortness of hreath following these specific activities. The tracings were inspected as to the breathing pattern. RESULTS
·From the Departments of Pathology and Medicine, Saint Vincent Hospital, and the University of Massachusetts School of Medicine. REFERENCES
Belgutay AM, Jenson NK: Incarct'ration of transvenous pacemaker e1t'ctrode removal hy traction. Am Heart J 77:7.'5-77,1969 2 Hobboy SJ, Hawthorne JW: Autopsy findings with permanent pervenous pacemaker. Circulation (Suppl) 58: 164167, 1968
The Breathing Pattern in Chronic Obstructive Lung Disease during the Performance of Some Common Daily Activities To the Editor: Patients with chronic obstructive lung disease often complain of shortness of breath following simple activities such as bending, tying shoe laces, brushing teeth, brushing hair and shaving. It seemed unlikely that shortness of breath after hrushing teeth, for example, was due to the minor effort involved. The present study was designed to investigate this further by recording the breathing pattern during the performance of some of these common daily activities.
Examples of breathing patterns in individual patients are shown in the figure. Common to all the activities was irregular, rapid breathing. The activity was followed by a period of breathing that was faster than hefore the activity. The pneumobelt measures accurately only respiratory rate, and changes in functional residual capacity will change the calibration. However, the marked change in height of each respiration suggests that the breathing during the activity is shallow as well as frequent; and after the activity, the breathing appears to be deeper as well as more frequent than before the activity. To further investigate the breathing pattern, some patients were asked to do the activities while diaphragmatic movement was observed by fluoroscopy, with the patient in the standing position. Brushing hair and brushing teeth were the activities used. The same pattern of diaphragmatic movement, as shown on the pneumobelt tracings, was observed during the activity, namely shallow irregular diaphragmatic movements, and more frequent, deeper movements after the activity. Normal subjects, ignorant of the results of the study, were asked to perform some of the activities and to observe their breathing pattern. They noted irregular breathing or breath holding. However, there was no dyspnea following the activity. Some of the patients were asked to do simple
MATERIALS AND METIIODS
Six men and one woman took part in the shldy (age range 40-65 years). All complained of severe shortness of breath Iimitinll: them to less than two blocks of slow walking on the level. Clinical examination showed hyperinflated lungs and the breath sounds were distant. Pulmonary function tests confimled the clinical impression of advanced chronic obstmctive lung disease and showed very low results for forced expiratory volume (one second), maximal mid-expiratory flow rate, maximum voluntary ventilation, and pulmonary diffusing capacity. The breathing pattern was recorded hy means of a "pneumobelt"· tied at the level of the nipple. This enahled --------------------
-
10
sec.
10
sec.
1oooml] o mi. . . COMBING
HAIR . .
Patient No.4
5ooml] o mi.
.
-
·Electronics for :\Iedicine, \Vhite Plains, New York 10603. CHES~
VOL
COMBING
6~
HAIR
NO. 1,
.
JANUAR~
1973
exceptionally skillful diagnostician. He was an accomplished auscultator. On February 28, 1846, before the Physical Society, he read a paper "On the Difficulties and Fallacies Attending Physical Diagnosis of Diseases of the Chest," and enumerated 42 pitfalls. He also introduced the practice of making the clerks (students) systematically write case reports of the cases, and thus it is to him we owe the whole practice of clinical reports made by students. Om P. Sharma, M.D.· Los Angeles • Assistant Professor of Medicine, University of Southern California School of Medicine, Pulmonary Disease Service.
Tricuspid Valve Perforation By Endocardial Pacing Electrode To the Editor: An 86-year-old woman with known atherosclerotic heart disease who had a transvenous endocardial pacemaker implanted a year ago, presented with sudden onset of bradycardia. A temporary pacemaker was inserted successfully. It was not possible to pace the heart through the existing permanent electrode by an external pacemaker. Gentle traction on the electrode failed to dislodge the electrode from the endocardium. The patient expired the next day. The autopsy revealed a Silastic-coated pacing electrode wire extending from the superior vena cava perforating the inferior portion of the right anterior tricuspid leaflet at the junction. of the chordae tendinae. The tip of the electrode was embedded under a papillary muscle (Fig 1). At the site of perforation, the wire was covered with a distinct but separate endothelial sheath 3 cm in length. The right atrium and ventricle were slightly
FIGURE 1. Silastic-coated pacing electrode perforating inferior portion of right anterior tricuspid leaflet junction of chordae tendinae.
125
COMMUNICATIONS TO THE EDITOR
126 dilated. Any heroic I attempt to dislodge the electrode would have resulted in evulsion of the tricuspid leaflet or valve. Fibrous adhesions with the tricuspid ring have heen previously reported. 2 It is suggested that great care be taken under similar situations and that leaving the electrode in place may he a hetter part of valor. Sylcia R. Petterson, M.D.; lang B. Singh, M.D.; Guillermo Reeves, M.D.; Stanley L. Kocot, M.D.o \Vorcester, Massachusetts
the patient to IX'rfoml tht> required activity in as nahlral a fashion as possihle. Changes in pressure in the belt were recorded by a Statham transducer (PR23-2D-300) and recorded hy an Electronics for Medicine multichannel recorder. The patient was seated on a stool and records were made of nomlal relaxed breathing. He was then asked to bend down and tic his shoe laces, bmsh his teeth, or comb his hair. One patient was asked to bend down as if working a drilling machine and another pretended to reverse his car. These two latter maneuvers were used as these individuals particularly complained of shortness of hreath following these specific activities. The tracings were inspected as to the breathing pattern. RESULTS
·From the Departments of Pathology and Medicine, Saint Vincent Hospital, and the University of Massachusetts School of Medicine. REFERENCES
Belgutay AM, Jenson NK: Incarct'ration of transvenous pacemaker e1t'ctrode removal hy traction. Am Heart J 77:7.'5-77,1969 2 Hobboy SJ, Hawthorne JW: Autopsy findings with permanent pervenous pacemaker. Circulation (Suppl) 58: 164167, 1968
The Breathing Pattern in Chronic Obstructive Lung Disease during the Performance of Some Common Daily Activities To the Editor: Patients with chronic obstructive lung disease often complain of shortness of breath following simple activities such as bending, tying shoe laces, brushing teeth, brushing hair and shaving. It seemed unlikely that shortness of breath after hrushing teeth, for example, was due to the minor effort involved. The present study was designed to investigate this further by recording the breathing pattern during the performance of some of these common daily activities.
Examples of breathing patterns in individual patients are shown in the figure. Common to all the activities was irregular, rapid breathing. The activity was followed by a period of breathing that was faster than hefore the activity. The pneumobelt measures accurately only respiratory rate, and changes in functional residual capacity will change the calibration. However, the marked change in height of each respiration suggests that the breathing during the activity is shallow as well as frequent; and after the activity, the breathing appears to be deeper as well as more frequent than before the activity. To further investigate the breathing pattern, some patients were asked to do the activities while diaphragmatic movement was observed by fluoroscopy, with the patient in the standing position. Brushing hair and brushing teeth were the activities used. The same pattern of diaphragmatic movement, as shown on the pneumobelt tracings, was observed during the activity, namely shallow irregular diaphragmatic movements, and more frequent, deeper movements after the activity. Normal subjects, ignorant of the results of the study, were asked to perform some of the activities and to observe their breathing pattern. They noted irregular breathing or breath holding. However, there was no dyspnea following the activity. Some of the patients were asked to do simple
MATERIALS AND METIIODS
Six men and one woman took part in the shldy (age range 40-65 years). All complained of severe shortness of breath Iimitinll: them to less than two blocks of slow walking on the level. Clinical examination showed hyperinflated lungs and the breath sounds were distant. Pulmonary function tests confimled the clinical impression of advanced chronic obstmctive lung disease and showed very low results for forced expiratory volume (one second), maximal mid-expiratory flow rate, maximum voluntary ventilation, and pulmonary diffusing capacity. The breathing pattern was recorded hy means of a "pneumobelt"· tied at the level of the nipple. This enahled --------------------
-
10
sec.
10
sec.
1oooml] o mi. . . COMBING
HAIR . .
Patient No.4
5ooml] o mi.
.
-
·Electronics for :\Iedicine, \Vhite Plains, New York 10603. CHES~
VOL
COMBING
6~
HAIR
NO. 1,
.
JANUAR~
1973