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For patients in shock, decisions regarding administering or withholding IV fluids are both difficult and important. Although a strategy of relatively liberal fluid administration has traditionally been popular, recent trial results suggest that moving to a more fluid-restrictive approach may be prudent. The goal of this article was to outline how whole-body point-of-care ultrasound can help clarify both the possible benefits and the potential risks of fluid administration, aiding in the risk/benefit calculations that should always accompany fluid-related decisions.

Transesophageal echocardiography (TEE) is a safe and minimally invasive tool that can routinely provide high-quality anatomic and hemodynamic information in the severely ill. Despite its potential for frontline acute care clinicians, TEE use has typically been reserved for diagnostic experts in the cardiac-surgical milieu. With the continued evolution of point-of-care ultrasound into increasingly sophisticated domains, TEE has gained steady uptake in many nontraditional environments for both advanced echocardiographic assessment as well as answering more goal directed, fundamental questions. This article introduces the workings of the TEE transducer, presents a systematic approach to a goal-directed hemodynamic assessment, and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.

Item does not contain fulltext Antiphospholipid syndrome is an autoimmune disorder characterized by a hypercoagulable state, leading to arterial and venous thrombosis. We present a 23-year-old patient, suspected of having Budd-Chiari syndrome due to antiphospholipid syndrome, who developed severe and progressive hypoxemia, requiring prolonged mechanical ventilation. After a detailed but unsuccessful workup, a contrast CT scan revealed an occluded superior vena cava and azygos vein-superior vena cava junction and massive right-to-left shunting through a network of systemic to pulmonary venous collaterals. Restoring normal blood flow from the azygos vein into the right atrium by stenting the azygos-superior vena cava junction resolved the hypoxemia immediately. Within the same procedure, the hepatic outflow obstruction was successfully treated by stenting a severe stenosis of the suprahepatic inferior vena cava caused by calcified thrombus.

Patients with heparin-induced thrombocytopenia (HIT) can have a dramatic presentation and often an unfortunate outcome. Each episode has the real potential to result in clinical catastrophe. From the > 100 such patients that we see yearly, patients have been selected to illustrate aspects of HIT such as history, epidemiology, clinical features, and improving treatment strategies. Delayed recognition continues to contribute to the morbidity and mortality of these patients. It is not adequate to just stop heparin therapy even with isolated HIT, therapy with low-molecular-weight heparins is contraindicated, and care must be used not to initiate warfarin therapy early or unopposed. A moderate suspicion for HIT should trigger the institution of therapy with an alternative anticoagulant even before laboratory confirmation. The potential beneficial impact of therapy with direct thrombin inhibitors makes it more important to maintain awareness of and vigilance for this syndrome Drug-Induced Thrombocytopenia: Focus on Heparin-Induced Thrombocytopenia

Introduction: Most experimental studies of orthotopic heart and lung graft failure are complicated by an inability to eliminate the rejection-specific inflammatory mediator from the cardiopulmonary bypass. Methods: The following model was developed in our laboratory to investigate the feasibility of performing an orthotopic heart and bilateral lung transplantation without performing a cardiopulmonary bypass. Nineteen transplants were attempted using 19 pairs of mongrel dogs. The recipient dog (mean weight, 23 kg) was anesthetized, and the ascending aorta, the superior vena cava (SVC), the inferior vena cava (IVC), and the main bronchus were dissected. Then, the donor dog (mean weight, 20 kg) was anesthetized, and the heart and lung block was prepared and explanted from the chest under cardioplegic arrest. A Gore-tex shunt (W. L. Gore; Flagstaff, AZ) was placed side-to-side between the recipient IVC and SVC, and then the donor right atrium was anastomosed to the Gore-tex shunt. The donor ascending aorta was anastomosed to the recipient ascending aorta with a partial clamp. On completion of these anastomoses, the donor heart was reperfused by the recipient heart and allowed to beat. When hemodynamic conditions were stable with double hearts, the recipient SVC and IVC were ligated just proximal to the venous anastomosis and the recipient aorta was ligated proximal to the anastomotic site. The recipient trachea was anastomosed to the donor trachea with an end-to-end anastomosis. Finally, the recipient heart and lungs were removed from the chest and the sternum was closed. Results: Four of the 19 transplants failed. Three died due to left ventricular dysfunction, and one died due to bleeding. Mean (6 SD) ischemic time was 67 6 11 min with a mean (6 SD) anastomotic time of 54 6 12 min. The 15 survivors were hemodynamically stable with or without the minimal use of inotropic support (dopamine, 2 to 3 mg/kg/min) 6 h after grafting, with normal cardiac output, satisfactory oxygenation, and normal wall motion. The sternotomy was repaired without loss of cardiopulmonary function. Conclusions: On the basis of our experiences, the experimental model of orthotopic heart and bilateral lung transplantation completed “off pump” can be technically feasible without the loss of cardiac and pulmonary functions. (CHEST 1999; 116:1360‐1364)

Study objectives The aims of this study were: to evaluate the performance of a novel arterial biopsy catheter in obtaining pulmonary endovascular samples in hypertensive dogs; to compare the results of pulmonary endoarterial biopsy in hypertensive vs normotensive dogs; and to assess the histologic changes in the hypertensive model. Design and interventions Thirty-four dogs (27 with normal pulmonary arterial pressures and seven with pulmonary hypertension) were catheterized through an external jugular vein to obtain endovascular biopsy samples from distal pulmonary arteries 2 to 3 mm in luminal diameter. To induce pulmonary hypertension, seven dogs were given repeated infusions of 0.6- to 0.9-mm ceramic microspheres into the superior vena cava. Endoarterial samples were obtained at pulmonary systolic arterial pressures ranging from 10 to 110 mm Hg. Measurements and results Sixty-two biopsy catheterization procedures were performed in the 34 dogs. After 12 initial procedures of technique refinement, endoarterial samples were obtained in each of the last 50 procedures (21 in normotensive dogs and 29 in hypertensive dogs). The average number of endovascular biopsy samples retrieved was 7.1 (range, 2 to 12) from a mean of 8.6 (range, 2 to 15) biopsy attempts per catheterization (success rate=83%). The average biopsy piece measured 1.13 mm in length, 0.33 mm in depth, and up to 1.0 mm in width. The biopsy success rates and endoarterial sample sizes were similar in normotensive and hypertensive dogs. Smooth muscle cells and endothelial cells were grown from the biopsy samples. There were no significant procedural complications, except for one self-limited hemorrhage. Histologically, samples obtained from dogs with pulmonary hypertension showed characteristic changes when compared with biopsies from normotensive dogs. Conclusion This new endoarterial biopsy catheter was safe and effective when used to obtain pulmonary endoarterial samples in dogs with normal and experimentally elevated pulmonary arterial pressures. The quality and quantity of the biopsy samples allowed identification of pathologic changes.

Study objective To compare the performance of continuous fiberoptic blood gas monitoring with standard, intermittent blood gas sampling in the measurement of arterial and central venous blood gases during marked hemodynamic changes. Design Prospective, consecutive, enrollment, experimental study. Setting Research laboratory at a university medical center. Participants Seven anesthetized, mechanically ventilated pigs. Interventions Severe shock was induced by hemorrhage in pigs monitored by a pulmonary artery catheter, an arterial line, and two fiberoptic blood gas sensors: one intra-arterial, and the other inserted into the superior vena cava via right internal jugular vein cutdown. Fiberoptic blood gas monitor measurements were compared with standard intermittent blood gas sampling. Measurements and results A total of 184 blood gas samples were compared in seven animals at baseline, during shock, and after resuscitation. The baseline mean (±1 SD) cardiac output decreased from 4.0±0.9 to 1.2±0.6 L/min during shock and returned to baseline after retransfusion (3.9±1.3 L/min). The comparison of continuous fiberoptic blood gas monitoring with intermittent blood gas sampling showed a bias±precision of 0.035±0.047 for arterial pH, 0.021 ±0.031 for central venous pH, −4.09±2.96 mm Hg (−0.55 ±0.39 kPa) for arterial Pco 2 , −3.67±2.44 mm Hg (−0.49±0.33 kPa) for central venous Pco 2 , −5.79±9.64 mm Hg (−0.77±1.29 kPa) for arterial Po 2 , and −7.85±8.52 mm Hg (−1.05±1.14 kPa) for central venous Po 2 . Conclusions Continuous fiberoptic blood gas monitoring agrees closely with standard intermittent blood gas sampling during severe hemodynamic shifts and has a comparable accuracy for both arterial and venous blood gas measurements. Changes in venous Pco 2 have recently been shown to correlate with changes in global tissue perfusion (eg, changes in cardiac output). Such data, available immediately via continuous venous blood gas monitoring, may be useful for monitoring shock and the response to resuscitation.

Relief of superior vena cava (SVC) syndrome due to non-neoplastic mediastinal disease presents a formidable challenge. Long-term patency of surgically created bypass grafts has been poor, and the morbidity associated with these procedures is substantial. We report a case of SVC syndrome, caused by fibrosing mediastinitis, treated with Palmaz balloon expandable intravascular stents. Intravascular stents are a promising alternative for relief of non-neoplastic SVC obstruction.

Anatomic right-to-left shunt causes hypoxemia that can pose a diagnostic challenge to clinicians. Among the many possible causes of right-to-left shunt, persistent left-sided superior vena cava (PLSVC) with an "unroofed" coronary sinus represents an uncommon congenital anomaly in which detection by saline-contrast echocardiogram (bubble echo) or contrast-enhanced CT scan requires injection of contrast in the left arm. We present the case of an elderly man with hypoxemia on the basis of a right-to-left shunt accompanying a PLSVC with unroofed coronary sinus in whom the shunt escaped initial detection following a bubble echo with contrast injected into the right arm. This case reminds pulmonary clinicians, who are frequently called on to assess the cause of hypoxemia, that specifying a contrast injection into the left arm is required in the pursuit of this specific shunt-producing anomaly.

We performed a retrospective review of echocardiographic data files of infants and children hospitalized in the Newborn and Pediatric Intensive Care Units. Echocardiograms were examined to detect the presence and evolution of great vein and right atrial thrombosis in patients with central venous lines. Thirty-seven patients were identified over a five-year period. Echocardiograms were performed, not routinely, but in response to specific indications including catheter malfunction, thrombocytopenia, persistent chylothorax, bacterial or fungal sepsis, and superior vena cava syndrome. Fifteen of 37 patients died, 13 of them during the hospitalization in which the thrombus was discovered. Thrombolytic agents and surgery were used to treat selected patients, with mixed results. Two of the 22 survivors have significant disability related to the thrombus or complications arising from it. We conclude that great vein and/or right atrial thrombosis is a common complication of central venous catheterization in small infants and children; moreover, the morbidity and mortality relating to this complication is substantial.

The use of cardiopulmonary bypass (CPB) for locally advanced thoracic malignancies is highly controversial. The purpose of this study was to document the techniques and results of CPB to facilitate the resection of complex thoracic malignancies and to identify common themes that provided for successful outcomes. This was a retrospective study that took place from January 1992 to September 2002. Fourteen consecutive patients (median age, 59 years; age range, 18 to 69 years; seven men and seven women) underwent CPB during the resection of locally advanced thoracic malignancies at two Boston hospitals. CPB was planned in 8 of 14 patients (57%) with centrally located tumors, while 6 of 14 patients (43%) required emergent institution of CPB due to injury of the superior vena cava (2 patients), inferior vena cava (2 patients), or pulmonary artery (2 patients). Complete microscopic resection was achieved in 12 of 14 patients (86%). The operative mortality rate was 1 of 14 patients (7%) due to pulmonary embolism (ie, the elective group). The median ICU and hospital lengths of stay were 5 and 9 days, respectively. The overall 1-year, 3-year, and 5-year survival rates were 57%, 36%, and 21%, respectively. The planned use of CPB to facilitate complete resection of thoracic malignancies should be considered only after careful patient selection. The availability of CPB also provides a safety net in the event of injury to vascular structures during tumor resection.

A case of a rare partial anomalous pulmonary venous return of the right upper lobe into the superior vena cava is reported. Multiple three-dimensional image reconstructions in association with spiral CT are used in the aim of clarifying this abnormality of pulmonary venous drainage.

Hemodialysis (HD) is often administered in critical care areas to patients with chronic renal failure as a continuation of the HD they are receiving on an ambulatory basis, and to patients who develop such a need for the first time or may require HD only transiently. The double-lumen Shiley central venous catheter (SCVC), inserted via the brachiocephalic veins, is often employed for HD, and it is customary to obtain a chest radiograph to ensure proper positioning of the tip of the SCVC within the superior vena cava (SVC) or high right atrium (RA). This practice is implemented to evaluate for complications stemming from the insertion of the SCVC and subsequent mishaps due to low positioning of the tip of the catheter in the RA or right ventricle. Intracardiac ECGs obtained via a saline solution-filled SCVC as the conductive medium can be easily recorded serially and periprocedurally to ensure proper positioning of the tip of the SCVC in the SVC or high RA based on the evaluation of the appearance and amplitude of atrial depolarization, thus rendering chest radiographs redundant.

The persistence of a left superior vena cava (LSVC) has been observed in 0.3% of the general population as established by autopsy. In the adult population, it is an important anatomic finding if a left superior approach to the heart is considered. The aim of the study was to evaluate the prevalence of a LSVC in patients undergoing pacemaker (PM) and cardioverter-defibrillator (CD) implantation.We observed the prevalence of LSVC during a 10-year period; each patient undergoing PM or transvenous CD implantation received a left cephalic/left subclavian venous approach to the heart. With this technique, LSVC persistence is easily diagnosed during lead placement.A total of 1,139 patients consecutively underwent PM implantation during 10 years: 4 patients had persistent LSCV (0.34%). Among 115 patients undergoing CD implantation, 2 patients with LSVC (1.7%) were observed. Overall LSVC persistence was found in 6 of 1,254 patients (0.47%). Two patients, one of whom had no right superior vena cava (RSVC), received a left-sided PM, whereas two other patients received right-sided devices. Both CD patients received a left-sided active-can device: the first patient with a right-sided lead tunneled to the left pectoral pocket, as a result of poor catheter handling through the LSVC and coronary sinus, and the second patient with a screw-in lead from LSVC. Long-term follow-up of these patients (average +/- SD, 41 +/- 26 months) revealed absence of lead dislodgment and appropriate device function regardless of lead implantation site.Persistence of LSVC in adults undergoing PM/CD implantation is similar to that of the general population (0.47% in our study). The left-sided implant can be achieved by stylet shaping and by use of active fixation leads in most patients, with a reliable outcome at short term in addition to appropriate device performance at follow-up. Assessment of the RSVC is advisable when planning a right-sided implantation, since a minority of patients lacks this vessel.

To determine normative values for superior vena cava (SVC) length and the utility of radiographic landmarks for identifying the boundaries of the SVC for assisting central line placement.Cross-sectional study.Urban tertiary care medical centers.Patients undergoing thoracic MRI scanning for various indications.None.The SVC dimensions and relationship to radiographic landmarks were determined from MRI scans of 42 patients (22 men, 20 women; median age, 57 years). The median length of the SVC was 6.8 cm (range, 4.4 to 10.0 cm) and did not correlate with gender or other measured cardiovascular dimensions. The right tracheobronchial angle was the best radiographic landmark for determining the cephalad origin of the SVC being always caudad and within a median of 1.5 cm (range, 0.1 to 3.8 cm) of the upper SVC. It was always at least 2.9 cm above the atriocaval junction. The right superior heart border was formed by the left atrium in 38% (95% confidence interval, 23 to 53%) of patients and did not reliably identify the atriocaval junction.The right tracheobronchial angle is the most reliable landmark for the upper margin of the SVC. Venous catheters placed caudad to this landmark and cephalad to the right superior cardiac silhouette or no more than 2.9 cm caudad to the tracheobronchial angle result in catheter tips within the SVC.

Although the indications for extracorporeal membrane oxygenation (ECMO) have been extended, ECMO has yet to be used as a respiratory support system during thoracic surgery. The purpose of this experimental study was to investigate whether veno-right ventricular (veno-RV) ECMO can be used for thoracic surgery without mechanical ventilation.Acute experimental study: Veno-RV ECMO as total lung support was maintained for 60 min without mechanical ventilation in six dogs. A venous drainage cannula was inserted in the superior cavoatrial junction through the right femoral vein and a venous return cannula was inserted in the right ventricle through the right jugular vein. The veno-RV ECMO system comprised a centrifugal pump and membrane oxygenator. Survival model: After veno-RV ECMO had been established in three dogs, a two-ring thoracic tracheal segment was resected and the tracheal ends were anastomosed by video-assisted thoracic surgery without ventilation.In the acute study, when the veno-RV ECMO flow was maintained at 100 mL/kg/min, all six dogs remained hemodynamically stable and the arterial oxygen saturation was maintained at more than 98%, despite total lung collapse. In the survival study, all three dogs made an uneventful postoperative recovery.Video-assisted tracheal surgery can be performed without conventional respiratory support. Veno-RV ECMO as total lung support may become an alternative respiratory management device for thoracic surgery.

To describe four patients having total anomalous pulmonary venous connection with an intrapulmonary vertical vein, rendering difficulty in diagnosis and surgery.a tertiary referral center.By reviewing medical records, 4 of 25 patients with right atrial isomerism and total anomalous pulmonary venous connection were identified to have an intrapulmonary vertical vein. All four patients underwent echocardiography, catheterization, and angiography. One underwent MRI. Two underwent open-heart surgery and one received a modified Blalock-Taussig shunt.Right atrial isomerism was present in all four patients. On chest x-ray films, an abnormal shadow resembling scimitar syndrome was seen in two patients. Imaging the vertical vein was unsuccessful with an echocardiogram in all four patients. The intrapulmonary course of the vertical vein was depicted with a pulmonary venogram in two patients and with magnetic resonance in one patient. The intrapulmonary segment remained undetected until autopsy in one patient. All four patients died. At autopsy, the pulmonary venous confluence was hypoplastic in all four hearts. The vertical vein was buried in pulmonary parenchyma and drained to superior vena cava with significant obstruction.In the presence of right atrial isomerism and total anomalous pulmonary venous connection, there may be an intrapulmonary pulmonary venous connection that may be obstructed. Anastomosing the pulmonary venous confluence to the atrium may be difficult because of hypoplasia of the pulmonary venous confluence.

We describe the first reported patient with a persistent left superior vena cava that communicates directly with the left atrium as an isolated congenital defect. She developed mitral stenosis and physiologic conditions that favored left-to-right shunting--a modified Lutembacher's syndrome. Noninvasive cardiac imaging completely elucidated her cardiac anatomy and physiology.

Central venous catheter migration to the arterial system occurred due to the surgical procedure during total cavopulmonary shunt. The catheter seems to have crept into the portion of the vena cava that had been designated for clamping, because of the position for the surgery and the anatomic characteristics of the patient. The catheter migrated in the right popliteal artery and was removed immediately; however, it could enter the pulmonary arterial system and the other systemic arterial branches.

We describe a patient with an acute inferior wall myocardial infarction who underwent percutaneous coronary angioplasty. He subsequently had a cardiac arrest and developed progressive severe hypoxia. Although findings from pulmonary angiography were nondiagnostic, transesophageal echocardiography demonstrated a nonocclusive, right pulmonary artery thrombus. Therapy was changed, and the patient recovered. Transesophageal echocardiography was also used to monitor anticoagulation therapy.

A 26-year-old woman presented with fever, chills, and back pain 6 weeks postpartum. An infused CT scan of the abdomen and pelvis with IV contrast confirmed septic pelvic vein thrombophlebitis as the diagnosis. To the best of our knowledge, this is the first case report describing such a massive thrombophlebitis extending from the superior vena cava to the femoral vein inferiorly responsive to conventional anticoagulation therapy. This exceptional case reminds us to entertain septic pelvic thrombophlebitis in the differential of any patient who presents with fever and back pain of unknown etiology.

The purpose of this study was to evaluate the pathophysiologic role of atrial natriuretic peptide (ANP) as a pulmonary artery vasodilator in patients with acute respiratory failure receiving artificial ventilation. Twenty-one consecutive patients were studied, 12 without and 9 with preexisting cardiopulmonary disease. Pulmonary artery plasma ANP levels were significantly higher than the levels obtained in the superior vena cava and radial artery. Plasma ANP levels correlated significantly with the plasma levels of its second messenger, guanosine 3',5'-cyclic monophosphate (cGMP). In the 12 patients without prior cardiopulmonary disease, plasma ANP levels correlated significantly with mean pulmonary arterial pressure (MPAP). This correlation was not found in the nine patients with preexisting cardiopulmonary disease. The cGMP/ANP ratio, indicating the biologic effect of ANP, was also higher in the patients without preexisting cardiopulmonary disease. These results are compatible with clearance and vasodilator activity of ANP in the pulmonary vascular bed, but only in patients without preexisting cardiopulmonary disease.

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.

Percutaneous transvenous biopsy of an isolated obstructing mass of superior vena cava (SVC) is reported. Basilic vein access and King's endomyocardial bioptome have been successfully used. Metastatic cancer of SVC has been diagnosed and radiochemotherapy instituted, avoiding an undesirable thoracotomy.

Monitoring of the central venous pressure is a simple, relatively inexpensive method of assessing a patient's cardiac status, circulating blood volume, and vasomotor tone. Although it is a measure of considerable value in patients with cardiac, vascular pulmonary, renal, or other acute problems, for regulation of fluid or blood administration, it is essential that the physicians and nurses be fully aware and take into consideration some of the inherent fallacies and inadequacies of the information derived. Inaccurate measurements are often obtained by the aberrant lodgment of the venous pressure catheter tip, in addition to the other well-known complications. Radiographic identification of the catheter tip is essential to eliminate these problems.

Electrocardiograms and large film biplane angiocardiograms were reviewed in 14 cases of anatomically proved common atrium. All were associated with persistent atrioventricular canal. Electrocardiograms (available in 12 cases) revealed frontal plane QRS loops consistent with persistent atrioventricular canal. Horizontally or superiorly oriented abnormal P vectors were observed in 7 of 12 (58 percent) cases, only one of which was associated with persistent left superior vena cava. None of the cases with a persistent left superior vena cava had a coronary sinus. Abnormal atrioventricular conduction was encountered in two thirds of the cases. In all eight cases in which left ventriculograms were reviewed, typical goose-neck deformity diagnostic of persistent atrioventricular canal was observed. In the five cases in which atrial structure was studied either after the injection of contrast material into the right ventricle or directly into the atrium, a single large globular atrial structure was demonstrated. Although clinical examination and hemodynamic study often cannot distinguish common atrium from the more frequently encountered secundum and primum types of atrial septal defects with large intra-atrial communication, diagnosis of common atrium can be made if the following findings are present: an abnormal frontal plane P axis in conjunction with a frontal QRS loop consistent with persistent atrioventricular canal in the electrocardiograms, and the demonstration of a single atrial structure by large film biplane angiocardiograms after rapid injection of contrast material into the right ventricle, into the main pulmonary artery, or directly into the atrium.

A patient with superior vena cava syndrome due to an infected benign mediastinal bronchogenic cyst is reported. Although bronchogenic cyst is a rare cause of the superior vena cava syndrome, it should be considered because it is a potentially treatable lesion. Patients with bronchogenic cysts should have elective surgery before major complications develop.

We have reviewed four reported cases of aneurysmal dilatation of the superior vena cava and added a fifth case report. We wish to emphasize: (1) inclusion of mis rare lesion in the differential diagnosis of superior mediastinal mass; (2) the value of venous angiography in delineating the true nature of this lesion; and (3) the benign nature of this congenital malformation, which does not require specific therapy.

Three patients under two years of age are described with unusual fistulas involving the brachiocephalic arteries and the innominate vein or the superior vena cava. Two patients were asymptomatic, and one newborn was cyanotic and in congestive failure. This unusual presentation has only rarely been reported in thoracic arteriovenous malformations. Two of the three patients underwent successful surgical repair. Two-dimensional echocardiography aids in the evaluation of these patients, but cardiac catheterization and angiography are indispensable diagnostic techniques for documenting the extent and location of these lesions and thus guiding proper therapy.

Various congenital systemic arteriovenous fistulas have been described. An unusual case of congenital systemic arteriovenous fistula arising from the descending aorta and draining separately into the superior vena cava, the azygos vein, and the innominate vein is reported. Clinically, this case simulated a patent ductus arteriosus. To our knowledge, this particular anomaly has not been described before.

We have documented a unique instance of the development of the Eisenmenger syndrome 17 years after rupture of the infarcted ventricular septum. Our patient represents the longest reported survivor of a postinfarction VSD and the only one known to have reversed the shunt as a result of a striking increase in pulmonary vascular resistance.

CHEST, VOL. 57, NO. 4, APRIL 1970 that the platelet count might fall further with iron therapy.11 This was not observed (Fig 1). Thrombocytopenia has apparently not been reported in this situation. In the seven previously reported patients with sideroblastic anemia associated with similar antituberculous drugs, the platelet counts were normal2’3 or not mentioned.1 In these patients, the anemia was less severe and the duration of therapy with the suspect drug shorter than in our patient. Folate deficiency is frequent both in patients with tuberculosis (whether on antituberculous therapy or not)7 and in patients with sideroblastic anemia.12 It is possible that a concomitant folate deficiency contributed to or was responsible for the thrombocytopenia. However, the thrombocytopenia disappeared on PZA withdrawal alone while a hospital diet was continued without folate supplementation.

Widening of the vascular pedicle on the chest roentgenogram is a recently identified sign of increased circulating blood volume. To determine whether vascular pedicle enlargement can be detected during the initial day of burn resuscitation and whether this change correlates with the early development of pulmonary edema, we reviewed the serial chest roentgenograms of 42 patients with cutaneous burns and risk factors for inhalation injury. Although no patient had pulmonary edema at the time of vascular pedicle measurements, 18 (42.9 percent) developed this complication during the 3.3 +/- 1.5 days after injury. These patients were significantly older (p less than 0.025) and had received more resuscitative fluid (P less than 0.005) than those without pulmonary edema. Initial vascular pedicle width was similar in both groups (5.9 +/- 0.9 vs 6.0 +/- 1.0 cm) and did not change in patients without pulmonary edema (5.8 +/- 0.7 cm). Vascular pedicle width increased (6.9 +/- 1.2 cm, p less than 0.01) in patients who subsequently developed pulmonary edema, and 12 of the 13 patients who had changes exceeding +1.0 cm had this problem. Enlargement of the vascular pedicle is associated with early burn-related pulmonary edema and might provide a clinically useful predictor of this cardiopulmonary complication.

When superior vena caval obstruction complicates cancer of the lung; the prognosis is grave; 1 percent of such patients survive for one year. Improved palliation is reported from many radiation therapy centers using higher initial dose fractions and tumoricidal doses. We now report the findings in three patients with histologically confirmed bronchogenic carcinoma who had superior vena caval obstruction and who survived for nine years (two patients) and seven years (one patient). Aggressive therapy with irradiation seems to provide better palliation and may occasionally be associated with remarkably long survivals in this normally highly lethal disease.

The purpose of this study was to characterize the type and prevalence of abnormalities associated with right heart catheterization. We performed detailed post-mortem examinations of 32 consecutive patients brought to autopsy with a right heart catheter in the pulmonary artery. Thrombosis (17 patients, 53 percent), hemorrhagic lesions (25 patients, 78 percent), and intimal fibrin deposition (21 patients, 66 percent) were found at sites along the entire path of the catheter. Twenty-nine patients (91 percent) had either thrombosis, hemorrhage or both. While the superior vena cava was the most common site for all lesions, seven patients had thrombosis involving the chambers and valves of the heart and four had thrombosis involving the pulmonary artery. The incidence of thrombosis was significantly higher after 36 hours of catheterization (p less than 0.05). All five patients with thromboemboli in the more proximal pulmonary arteries had catheter-related thrombosis. We conclude that there is a high prevalence of thrombotic and hemorrhagic lesions in patients dying with pulmonary catheters in place; that the risk of thrombotic complications increases with duration of catheterization; and that patients with catheter-related thrombosis are at increased risk of thromboemboli to the proximal pulmonary arteries.

The development of dilatation of the left superior intercostal vein ("aortic nipple") on chest radiographic studies can be used as a clue to impending superior vena caval syndrome. Two cases are described in which detection of an "aortic nipple" on chest roentgenograms predated the clinical syndrome by seven to ten weeks. Since superior vena caval syndrome is a medical emergency, recognition of signs such as this which may significantly predate the "full-blown" syndrome have far-reaching implications in the care of patients.

A 48-year-old man developed symptoms of progressive angina pectoris leading to myocardial infarction 12 years after two large doses of radiation for treatment of superior vena caval syndrome. Angiographic studies showed an isolated critical stenosis in the left anterior descending coronary artery, for which a successful surgical procedure for saphenous vein bypass graft was was performed. Coronary arterial stenosis following radiation therapy has been reported rarely, but this case supports the thesis that such lesion can be treated surgically.

A 37-year-old parturient woman with presumed mediastinal fibrosis survived an antepartum pulmonary embolism, antepartum circulatory collapse with loss of consciousness and postpartum pneumonia. Her infant is developing normally 18 months after delivery.

A case of an inferior vena caval drainage anomaly presented as a right hilar density on plain chest roentgenogram. The benign nature of this shadow was established by angiography. Clues to its presence are reviewed and appropriate diagnostic steps are illustrated.

A patient was found to have a large mobile right atrial mass by two-dimensional echocardiography after developing sepsis due to prolonged central hyperalimentation. Contrast echocardiography was helpful in localizing the origin of the mass. A large infected thrombus emanating from the superior vena cava was removed at operation. The discussion includes a review of the literature on the echocardiography of right atrial masses.