severe mitral regurgitation successfully underwent surgery, one mitral replacement, one valvuloplasty. One of the patients described by Criscitiello and associates6 died four days after aortic valve replacement from hemorrhagic complications. Postoperative bleeding problems also complicated our case and both patients reported by Wood et al, 11 in spite of normal preoperative coagulation studies. Varying degrees of both platelet dysfunction and capillary fragility have been described in osteogenesis imperfecta.7 It is uncertain whether or not these patients should be given anticoagulants after valve replacement; tissue valves not requiring anticoagulation would be preferable. Dehiscence of the prosthetic valve due to the connective tissue abnormality is a theoretical complication but has not yet been reported. We conclude that valve replacement for severe aortic or mitral regurgitation is feasible with osteogenesis imperfecta. Postoperative hemorrhage may occur even when routine coagulation studies reveal no abnormality. ACKNOWLEDGMENT: We would like to thanJc Dr. William B. Fackler for referring this patient for study.
1 McKusiclc VA : Heritable Disorders of Connective Tissue ( ed 4 ), St. Louis, CV Mosby, 1972, pp 390-454 2 McKusiclc VA: Heritable Disorders of Connective Tisme (ed. 2), St. Louis, CV Mosby, 1960, p 197 3 Heppner RL, Babitt HI, Bianchine JW, et al: Aortic
regurgitation and aneurysm of the sinus of Valsalva associated with osteogenesis imperfecta. Am J Cardiol 31 :654-
657, 1973 4 Galton BB, Wayne NJ: reported by McKusiclc VA, in reference 1, p 413
(Laerdal), which displays the position of the dp of the exploring fteuble broncboscope. This helps the student to approximate bis distance and gauge movement and deftecdon from bronchial orifice to orifice. Simultaneously, be can also learn bow to centrally posidon the tip of the instrument in the lumen, which Is essential In brushing biopsy, and bow to prevent mucosal Injury. Instrucdon In open broncboscopic examination bas also been used successfully In this teaching modeL for the physician with little or no experience Guidance in bronchoscopic technique may be greatly facilitated by an integrated electronic display board with a model of the tracheobronchial tree (Zavala) attached to a manikin ( Laerdal) for adult intubation. The manikin has been modified for this specific purpose. Modification has been accomplished by removing the lung, the plastic main bronchi, and the trachea just below the vocal cords in the manikin. A model of the tracheobronchial tree (Zavala) was then fitted and glued with epoxy into the tube just below the vocal cords of the manikin for intubation. This model allows for a realistic use of the head and neck either through a transnasal or transoral approach to the manikin. A nasopharyngeal, oropharyngeal, or endotracheal tube may realistically be placed in the manikin for practice with the bronchoscope. This model has been most helpful to physicians in the early stages of the practice of procedures for insertion and for identification of the segmental orifices. Upon entering the trachea, a red light is immediately triggered on the electronic display board, which is synchronized with the model of the lung. The same
5 Wood SJ, Thomas J, Brambridge MV: Mitra! valve disease and open heart surgery in osteogenesis imperfecta tarda. Br Heart J 35:103-106, 1973 6 Criscitiello MG, Roman JA, Besterman EMM, et al: Cardiovascular abnormalities in osteogenesis imperfecta. Circulation 31 : 255-262, 1965 7 Siegel BM, Friedman IA, Schwartz SO: Hemorrhagic disease in osteogenesis imperfecta; study of platelet function defect. Am J Med 22: 315-321, 1957
Integrated Electronic Display Model for Teaching Bronchoscopy * Oscar S. Cunanan, M.D., F.C.C.P., 00 and John E. Mazzat
The integrated electronic display model for teaching broncboscopic technique bas been most helpful In guiding the student-broncboscoplst. especiaDy In the early stages of reorientadon In both the procedure for Insertion and the pracdce of ldentificadon of the Individual segmental orifice. The display board Is electronlcaDy integrated with the lung model (Zavala) In the manikin °From the Heart Center, St. Francis Hospital, Roslyn, NY. Supported in part by the American Lung Association, Nassau-Suffolk, NY. 00 Director, Department of Continuing Medical Education. tTechnical Assistant in Electronics.
364 CUNANAN, MAZZA
F1cURE 1. Integrated electronic display model for teaching bronchoscopy.
CHEST, 72: 3, SEPTEMBER, 1977
process of identification occurs when one approaches the right or left main bronchus. All segments on the display board are represented by a red and green light aligned side by side in each respective segment. .As soon as the tip of the bronchoscope approaches within 2 mm of the sensor in the model of the lung, it will activate the electronically integrated circuitry, in turn activating the two lights on the display board. This indicates that the tip of the bronchoscope is wedged into the distal end of the segmental orifice. As the bronchoscope is withdrawn from that particular segment, the memory information on the display board will continue to register a red light but at the same time will turn off the green light. This signi6es that the student has already explored the area. The system of sequential memory retention operates throughout the entire tracheobronchial tree. The model may be used for instruction with either an open bronchoscope or a flexible 6beroptic bronchoscope. It is necessary to thoroughly lubricate the bronchoscope with silicone spray to facilitate better maneuverability of the bronchoscope and to prevent damage to the deflecting mechanisms. The practice of bronchoscopic technique becomes particularly rewarding for the student if two individuals participate at the same time. One may operate the bronchoscope while the other notes the score on the electronic integrated board.
Echophonocardiographic Diagnosis of Le~ Ventricular Pseudoaneurysm* PeterG. Mills, B.M.; 00 John D. Rose, M.D.;t Bruce R. Brodie, M.D.;t David]. Delany, M.B., B.Ch.§ and Ernest Craige, M.D.11
seudoaneurysms occur following rupture of the mycr Pcardium due to infarction, surgery, or trauma, 1-3
4
5
when the resulting hematoma is contained within a circumscribe4 area of the pericardial space. While true aneurysms arise from the ventricular wall and are composed of myocardial scar tissue, the walls of pseudoaneurysms are not formed from myocardium and are composed of fibrous tissue only; consequently, they carry a high risk of sudden rupture. t-S Now that surgical treatment is available for this condition, 5-7 the recognition of pseudoaneurysms has become increasingly important. The present report describes the unusual features of a systolic murmur in a patient with a traumatic pseudoaneurysm. Recognition of these features may be useful when considering this diagnosis. CASE REPoRT
A 20-year-old man was admitted to the hospital with a twoweek history of intermittent sharp substernal chest pains. Six years previously, he had been attacked by six men and severely kicked in the head and chest. There were no immediate sequelae, but six months later, the patient experienced a two-week illness charactem.ed by fever and retrostemal chest pain. At that time, no murmur or rubs were heard, but cardiomegaly was noted on the chest x-ray film. The patient subsequently remained free of symptoms until the present illness. Physical examination on admission showed a healthy black man in no acute distress. A sustained systolic precordial impulse was palpable from the right parasternal area to the left anterior axillary line. There was an apical systolic thrill. The first and second heart sounds were normal. No third or fourth heart sounds were heard. There was a grade 4/6 early to midsystolic murmur heard loudest at the mitral area,
We report the presence of an unusual systolic murmur associated with a traumatic left ventricular pseudoaneurysm. Echophonocardiographic studies showed the murmur to begin at the first heart sound, but end well before the second heart sound. It seems likely that the murmur is caused by the systolic flow of blood from the left ventricle into the relatively noncompliaot pseudoaneurysm. The echocardiographic scan of the left ventricle demonstrated a relatively echo-free space posterior to the left ventricular wall, supporting the diagnosis of pseudoaneurysm, which was confirmed with angiographic studies and at surgery. These findings indicate that a combination of noninvasive techniques is useful in establishing this diagnosis. °From the Deparbnent of Medicine, University of North Carolina School of Medicine and the C. V. Richardson Laboratory of North Carolina Memorial Hospi•~' Chapel Hill. ....., Supported by Public Health Service grant HL 5727. 00 Assistant Visiting Professor of Medicine. tFellow in Cardiology. !Associate Professor of Medicine. §Associate Professor of Radiology. I!Professor of Medicine. Reprint requests: Dr. Craige, University of North Carolina, Room 338, Clinical Sciences, Chapel Hill 27514
CHEST, 72: 3, SEPTEMBER, 1977
FlcURE 1. Part of chest x-ray film taken in right anterior oblique projection showing thin rim of calcification at apex of heart. A"ows indicate gap in calcification, through which left ventricular cavity was shown by angiogram to communicate with pseudoaneurysm.
ECHOPHONOCARDIOGRAPHIC DIAGNOSIS OF LEFT VENTRICULAR PSEUDOANEURYSM 365
1 McKusiclc VA : Heritable Disorders of Connective Tissue ( ed 4 ), St. Louis, CV Mosby, 1972, pp 390-454 2 McKusiclc VA: Heritable Disorders of Connective Tisme (ed. 2), St. Louis, CV Mosby, 1960, p 197 3 Heppner RL, Babitt HI, Bianchine JW, et al: Aortic
regurgitation and aneurysm of the sinus of Valsalva associated with osteogenesis imperfecta. Am J Cardiol 31 :654-
657, 1973 4 Galton BB, Wayne NJ: reported by McKusiclc VA, in reference 1, p 413
(Laerdal), which displays the position of the dp of the exploring fteuble broncboscope. This helps the student to approximate bis distance and gauge movement and deftecdon from bronchial orifice to orifice. Simultaneously, be can also learn bow to centrally posidon the tip of the instrument in the lumen, which Is essential In brushing biopsy, and bow to prevent mucosal Injury. Instrucdon In open broncboscopic examination bas also been used successfully In this teaching modeL for the physician with little or no experience Guidance in bronchoscopic technique may be greatly facilitated by an integrated electronic display board with a model of the tracheobronchial tree (Zavala) attached to a manikin ( Laerdal) for adult intubation. The manikin has been modified for this specific purpose. Modification has been accomplished by removing the lung, the plastic main bronchi, and the trachea just below the vocal cords in the manikin. A model of the tracheobronchial tree (Zavala) was then fitted and glued with epoxy into the tube just below the vocal cords of the manikin for intubation. This model allows for a realistic use of the head and neck either through a transnasal or transoral approach to the manikin. A nasopharyngeal, oropharyngeal, or endotracheal tube may realistically be placed in the manikin for practice with the bronchoscope. This model has been most helpful to physicians in the early stages of the practice of procedures for insertion and for identification of the segmental orifices. Upon entering the trachea, a red light is immediately triggered on the electronic display board, which is synchronized with the model of the lung. The same
5 Wood SJ, Thomas J, Brambridge MV: Mitra! valve disease and open heart surgery in osteogenesis imperfecta tarda. Br Heart J 35:103-106, 1973 6 Criscitiello MG, Roman JA, Besterman EMM, et al: Cardiovascular abnormalities in osteogenesis imperfecta. Circulation 31 : 255-262, 1965 7 Siegel BM, Friedman IA, Schwartz SO: Hemorrhagic disease in osteogenesis imperfecta; study of platelet function defect. Am J Med 22: 315-321, 1957
Integrated Electronic Display Model for Teaching Bronchoscopy * Oscar S. Cunanan, M.D., F.C.C.P., 00 and John E. Mazzat
The integrated electronic display model for teaching broncboscopic technique bas been most helpful In guiding the student-broncboscoplst. especiaDy In the early stages of reorientadon In both the procedure for Insertion and the pracdce of ldentificadon of the Individual segmental orifice. The display board Is electronlcaDy integrated with the lung model (Zavala) In the manikin °From the Heart Center, St. Francis Hospital, Roslyn, NY. Supported in part by the American Lung Association, Nassau-Suffolk, NY. 00 Director, Department of Continuing Medical Education. tTechnical Assistant in Electronics.
364 CUNANAN, MAZZA
F1cURE 1. Integrated electronic display model for teaching bronchoscopy.
CHEST, 72: 3, SEPTEMBER, 1977
process of identification occurs when one approaches the right or left main bronchus. All segments on the display board are represented by a red and green light aligned side by side in each respective segment. .As soon as the tip of the bronchoscope approaches within 2 mm of the sensor in the model of the lung, it will activate the electronically integrated circuitry, in turn activating the two lights on the display board. This indicates that the tip of the bronchoscope is wedged into the distal end of the segmental orifice. As the bronchoscope is withdrawn from that particular segment, the memory information on the display board will continue to register a red light but at the same time will turn off the green light. This signi6es that the student has already explored the area. The system of sequential memory retention operates throughout the entire tracheobronchial tree. The model may be used for instruction with either an open bronchoscope or a flexible 6beroptic bronchoscope. It is necessary to thoroughly lubricate the bronchoscope with silicone spray to facilitate better maneuverability of the bronchoscope and to prevent damage to the deflecting mechanisms. The practice of bronchoscopic technique becomes particularly rewarding for the student if two individuals participate at the same time. One may operate the bronchoscope while the other notes the score on the electronic integrated board.
Echophonocardiographic Diagnosis of Le~ Ventricular Pseudoaneurysm* PeterG. Mills, B.M.; 00 John D. Rose, M.D.;t Bruce R. Brodie, M.D.;t David]. Delany, M.B., B.Ch.§ and Ernest Craige, M.D.11
seudoaneurysms occur following rupture of the mycr Pcardium due to infarction, surgery, or trauma, 1-3
4
5
when the resulting hematoma is contained within a circumscribe4 area of the pericardial space. While true aneurysms arise from the ventricular wall and are composed of myocardial scar tissue, the walls of pseudoaneurysms are not formed from myocardium and are composed of fibrous tissue only; consequently, they carry a high risk of sudden rupture. t-S Now that surgical treatment is available for this condition, 5-7 the recognition of pseudoaneurysms has become increasingly important. The present report describes the unusual features of a systolic murmur in a patient with a traumatic pseudoaneurysm. Recognition of these features may be useful when considering this diagnosis. CASE REPoRT
A 20-year-old man was admitted to the hospital with a twoweek history of intermittent sharp substernal chest pains. Six years previously, he had been attacked by six men and severely kicked in the head and chest. There were no immediate sequelae, but six months later, the patient experienced a two-week illness charactem.ed by fever and retrostemal chest pain. At that time, no murmur or rubs were heard, but cardiomegaly was noted on the chest x-ray film. The patient subsequently remained free of symptoms until the present illness. Physical examination on admission showed a healthy black man in no acute distress. A sustained systolic precordial impulse was palpable from the right parasternal area to the left anterior axillary line. There was an apical systolic thrill. The first and second heart sounds were normal. No third or fourth heart sounds were heard. There was a grade 4/6 early to midsystolic murmur heard loudest at the mitral area,
We report the presence of an unusual systolic murmur associated with a traumatic left ventricular pseudoaneurysm. Echophonocardiographic studies showed the murmur to begin at the first heart sound, but end well before the second heart sound. It seems likely that the murmur is caused by the systolic flow of blood from the left ventricle into the relatively noncompliaot pseudoaneurysm. The echocardiographic scan of the left ventricle demonstrated a relatively echo-free space posterior to the left ventricular wall, supporting the diagnosis of pseudoaneurysm, which was confirmed with angiographic studies and at surgery. These findings indicate that a combination of noninvasive techniques is useful in establishing this diagnosis. °From the Deparbnent of Medicine, University of North Carolina School of Medicine and the C. V. Richardson Laboratory of North Carolina Memorial Hospi•~' Chapel Hill. ....., Supported by Public Health Service grant HL 5727. 00 Assistant Visiting Professor of Medicine. tFellow in Cardiology. !Associate Professor of Medicine. §Associate Professor of Radiology. I!Professor of Medicine. Reprint requests: Dr. Craige, University of North Carolina, Room 338, Clinical Sciences, Chapel Hill 27514
CHEST, 72: 3, SEPTEMBER, 1977
FlcURE 1. Part of chest x-ray film taken in right anterior oblique projection showing thin rim of calcification at apex of heart. A"ows indicate gap in calcification, through which left ventricular cavity was shown by angiogram to communicate with pseudoaneurysm.
ECHOPHONOCARDIOGRAPHIC DIAGNOSIS OF LEFT VENTRICULAR PSEUDOANEURYSM 365
