Annotations
to emphasize that the use of an inflated balloon-tipped catheter for blind passage through the right ventricle might not prevent this complication. The catheter tip may not be the cause of mechanical damage to the right bundle branch. Trauma co the bundle might result as well from a rigid catheter loop fixed both at the site of venous introduction and at the site of pulmonary arterial occlusion. The occurrence of RBBB with Swan-Ganz catheterization should not be considered evidence for pulmonary thrombosis caused by distal migration of the catheter. In our patients the transient RBBB was of no clinical significance. However. the danger of induction of RBBB must be considered in the bedside catheterization of patients with pre-existing left bundle branch block or with acute anteroseptal myocardial infarction.
Jerry C. Luck, M.D. Resident in Medicine Department of Medicine Toby R. Engel, M.D. Assistant Professor of Medicine Director, Medical Intensive-Care Unit Department of Medicine Division of Cardiology The Medical College of Pennsylvania 3300 Henry Ave. Philadelphia, Pa, 19129
REFERENCES
1. 2.
3.
4.
5. 6. 7.
Foote. G. A.. Schabel, S. I., and Hodges, M.: Pulmonary complications of the flow-directed balloon-tipped catheter, N. Engl. J. Med. 290:927. 1974. Golden, M. S.. Pinder, T.. Jr.. Anderson. W. T.. and Cheitlin, M. D.: Fatal pulmonary hemorrhage complicating use of a flow-directed balloon-tipped catheter in a patient receiving anticoagulant therapy, Am. J. Cardiol. 32:865. 1973. Swan. H. J. C., and Ganz. W.: The use of balloon-tipped. flow-directed catheters in monitoring patients with acute myocardial infarction, in Corday E.. and Swan H. J. C., editors: Myocardial Infarction. Daltimo~e. 1973. The Williams & Wilkins Company. Swan. H. J. C.. Ganz. W.. Forrester. J.. Marcus. H.. Diamond G.. and Chonette. D.: Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter, N. Engl. J. Med. 283:447. 1970. Voukydis. P. C., and Cohen, S. I.: Catheter-induced arrhythmias, AM. HEART J. 88"588. 1974. Meister, S. G.. Banka. V. S.. and Helfant. R. H.: Transfemoral pacing with balloon-tipped catheters. J. A. M. A. 225:712. 1973. Mendel. D.: A practice of cardiac catheterization. Oxford, 1975. Blackwell Scientific Publications.
Of the heart-to-chest ratio
It has been the practice over many years for radiologists and cardiologists to determine cardiac enlargement from the ratio of the maximal transverse diameter of the heart to the maximal transverse internal diameter of the chest obtained from the teleoroentgenogram. When this ratio exceeds 50 per cent (actually 57 per cent}, the heart is considered to be large. ~/et, adequate consideration is not always gNen to patients whose chest size shrinks with age. The "senile chest"' is associated with shrinkage and change in shape with age. For example, Fig. 1 shows the teleoroentgenogram of the chest of a 78-year-old lady. Is her heart really enlarged, producing an abnormally great ratio of heart-to-chest diameter, or is this ratio abnormal because the chest has shrunk in size and changed shape with age without enlargement of the heart, or have both changes ~occurred to some extent? The heart shadow appears to be normal in size for the lady of 5 ft. 4 in. in height weighing 132 pounds. Should the heart be expected to shrink with age and, if so, at what rate and degree? After all, the heart exercises all the time so that its muscle mass is "used" constantly. The heart muscle is not at "disuse." If there is no atrophy of disuse there may be atrophy of less use. Finally, can the heart normally enlarge a little and the chest cage shrink some with age? If so, what are the standards? With degeneration of some myocytes with age, there may be
264
Fig. 1. Teleoroentgenogram of a 78-year-old female patient apparently showing an abnormally great ratio of heart-tochest diameter (see text).
August, 1976, Vol. 92, No. 2
Annotations
"work" h y p e r t r o p h y of t h e r e m a i n i n g m y o c y t e s w h i c h m u s t p e r f o r m t h e n e c e s s a r y cardiac work.
REFERENCE
1.
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
Burch, G. E.: I n t e r e s t i n g a s p e c t s of geriatric cardiology, AM. HEART J. 89:99, 1975.
Specialization--Another tiger by the tail
W h a t is a cardiologist? T h e definition was formerly s t r a i g h t forward a n d simple. A cardiologist was a physician with special knowledge of t h e h e a r t a n d its diseases ~from t h e Greek kardia for h e a r t + logia, t h e s t u d y of}. W i t h i n this medical specialty, however, a rapid expansion of knowledge t o g e t h e r with an increasing f r a g m e n t a t i o n of i n t e r e s t s h a v e occurred over t h e last 20 years. P r e s e n t - d a y t e c h n o l o g y p e r m i t s one to delve into a n d probe all orifices, internal organs, secretions. a n d cells of t h e body with a vast a r r a y of e q u i p m e n t , f u r t h e r p e r p e t u a t i n g this cycle of increasing subspecialization. Startm g with a cardiologist "'generalist." Fig. 1 m i g h t be considered as r e p r e s e n t i n g h o w this area of medicine h a s b e c o m e f u r t h e r f r a c t i o n a t e d into subspecialties a n d subinterests. T h i s progressive i n v o l v e m e n t with m o r e complex b u t n a r r o w e r a r e a s of interest creates a greater dependence u p o n appropriately t r a i n e d physicians, skilled t e c h n i c a l a s s i s t a n t s , increasingly sophisticated e q u i p m e n t , a n d suitable a n d a d e q u a t e p a t i e n t referral. I n so doing, it gives rise to n u m e r o u s q u e s t i o n s a n d problems, s u c h as: (1) W h e r e is t h e s u p p o r t (particularly financial) to come from. b o t h for e q u i p m e n t a n d personnel? (2) Is the t r a i n e d technical a s s i s t a n c e available? ~3 ) W h a t size c o m m u n i t y c a n s u p p o r t which procedures? H o w
lS this ro be decided? (4) W h a t d e t e r m i n e s t h e v o l u m e of p a t i e n t s t h a t is desirable so t h a t proficiency in a n y p a r t i c u l a r area c a n be acquired a n d m a i n t a i n e d ? H o w is t h e quality of p e r f o r m a n c e ro be m o n i t o r e d ? (5) If available resources are limited, h o w are t h e y to be distributed? Is this to be by chance, d e p e n d e n t only upon t h e interest or financial capability of a hospital or c o m m u n i t y ? Or are t h e r e o t h e r w a y s of determ i m n g this? In a n effort to apply knowledge a n d t e c h n o l o g y to beneficial use in a rational, realistic, a d v a n t a g e o u s , and n o n w a s t e f u l fashion, it is h o p e d t h a t t h e medical, academic, a n d governm e n t a l worlds c a n combine their wisdom a n d expemence to arrive a t workable solutions to t h e s e a n d like questions. It is also to be h o p e d t h a t this increasing subspecialization a n d its a t t e n d a n t desirable features will n e t be at t h e expense of direct a n d p e r s o n a l c o m m u n i c a t i o n between phys]cian a n d patient, especially in t h e area of h e a r t disease where this relationship is so vital a n d i m p o r t a n t m m a n a g e m e n t a n d therapy.
Martin Duke, M.D. Chief of Cardiology and Director of Medical Education Manchester Memorial Hospital Manchester, Conn. 06040
Supported in part by a grant from the Gertrude H. Rogers Fund.
Director of coronarycare. unit Surgical cardiologist (care of cardiac surgical patients) Card=ac patholog ist
f Research ~--"
~~'l Cardi~176
Animal Electrophysiolocjic Basic (i.e., cellular, metabolici Clinical
(Cardiac "generalist") // \\
// Pediatric--invamve (catheterization)
\
\\
//
/
\, Adult--invaslve (catheterization)
Nonmvasive I
Echocardiographer
I
I
Stress Phonocardiographer Electro-ano tester vectorcardiographer
I
Other techniques
Fig. 1. F r a c t i o n a t i o n of cardiology.
American
Heart
Journal
265
to emphasize that the use of an inflated balloon-tipped catheter for blind passage through the right ventricle might not prevent this complication. The catheter tip may not be the cause of mechanical damage to the right bundle branch. Trauma co the bundle might result as well from a rigid catheter loop fixed both at the site of venous introduction and at the site of pulmonary arterial occlusion. The occurrence of RBBB with Swan-Ganz catheterization should not be considered evidence for pulmonary thrombosis caused by distal migration of the catheter. In our patients the transient RBBB was of no clinical significance. However. the danger of induction of RBBB must be considered in the bedside catheterization of patients with pre-existing left bundle branch block or with acute anteroseptal myocardial infarction.
Jerry C. Luck, M.D. Resident in Medicine Department of Medicine Toby R. Engel, M.D. Assistant Professor of Medicine Director, Medical Intensive-Care Unit Department of Medicine Division of Cardiology The Medical College of Pennsylvania 3300 Henry Ave. Philadelphia, Pa, 19129
REFERENCES
1. 2.
3.
4.
5. 6. 7.
Foote. G. A.. Schabel, S. I., and Hodges, M.: Pulmonary complications of the flow-directed balloon-tipped catheter, N. Engl. J. Med. 290:927. 1974. Golden, M. S.. Pinder, T.. Jr.. Anderson. W. T.. and Cheitlin, M. D.: Fatal pulmonary hemorrhage complicating use of a flow-directed balloon-tipped catheter in a patient receiving anticoagulant therapy, Am. J. Cardiol. 32:865. 1973. Swan. H. J. C., and Ganz. W.: The use of balloon-tipped. flow-directed catheters in monitoring patients with acute myocardial infarction, in Corday E.. and Swan H. J. C., editors: Myocardial Infarction. Daltimo~e. 1973. The Williams & Wilkins Company. Swan. H. J. C.. Ganz. W.. Forrester. J.. Marcus. H.. Diamond G.. and Chonette. D.: Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter, N. Engl. J. Med. 283:447. 1970. Voukydis. P. C., and Cohen, S. I.: Catheter-induced arrhythmias, AM. HEART J. 88"588. 1974. Meister, S. G.. Banka. V. S.. and Helfant. R. H.: Transfemoral pacing with balloon-tipped catheters. J. A. M. A. 225:712. 1973. Mendel. D.: A practice of cardiac catheterization. Oxford, 1975. Blackwell Scientific Publications.
Of the heart-to-chest ratio
It has been the practice over many years for radiologists and cardiologists to determine cardiac enlargement from the ratio of the maximal transverse diameter of the heart to the maximal transverse internal diameter of the chest obtained from the teleoroentgenogram. When this ratio exceeds 50 per cent (actually 57 per cent}, the heart is considered to be large. ~/et, adequate consideration is not always gNen to patients whose chest size shrinks with age. The "senile chest"' is associated with shrinkage and change in shape with age. For example, Fig. 1 shows the teleoroentgenogram of the chest of a 78-year-old lady. Is her heart really enlarged, producing an abnormally great ratio of heart-to-chest diameter, or is this ratio abnormal because the chest has shrunk in size and changed shape with age without enlargement of the heart, or have both changes ~occurred to some extent? The heart shadow appears to be normal in size for the lady of 5 ft. 4 in. in height weighing 132 pounds. Should the heart be expected to shrink with age and, if so, at what rate and degree? After all, the heart exercises all the time so that its muscle mass is "used" constantly. The heart muscle is not at "disuse." If there is no atrophy of disuse there may be atrophy of less use. Finally, can the heart normally enlarge a little and the chest cage shrink some with age? If so, what are the standards? With degeneration of some myocytes with age, there may be
264
Fig. 1. Teleoroentgenogram of a 78-year-old female patient apparently showing an abnormally great ratio of heart-tochest diameter (see text).
August, 1976, Vol. 92, No. 2
Annotations
"work" h y p e r t r o p h y of t h e r e m a i n i n g m y o c y t e s w h i c h m u s t p e r f o r m t h e n e c e s s a r y cardiac work.
REFERENCE
1.
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
Burch, G. E.: I n t e r e s t i n g a s p e c t s of geriatric cardiology, AM. HEART J. 89:99, 1975.
Specialization--Another tiger by the tail
W h a t is a cardiologist? T h e definition was formerly s t r a i g h t forward a n d simple. A cardiologist was a physician with special knowledge of t h e h e a r t a n d its diseases ~from t h e Greek kardia for h e a r t + logia, t h e s t u d y of}. W i t h i n this medical specialty, however, a rapid expansion of knowledge t o g e t h e r with an increasing f r a g m e n t a t i o n of i n t e r e s t s h a v e occurred over t h e last 20 years. P r e s e n t - d a y t e c h n o l o g y p e r m i t s one to delve into a n d probe all orifices, internal organs, secretions. a n d cells of t h e body with a vast a r r a y of e q u i p m e n t , f u r t h e r p e r p e t u a t i n g this cycle of increasing subspecialization. Startm g with a cardiologist "'generalist." Fig. 1 m i g h t be considered as r e p r e s e n t i n g h o w this area of medicine h a s b e c o m e f u r t h e r f r a c t i o n a t e d into subspecialties a n d subinterests. T h i s progressive i n v o l v e m e n t with m o r e complex b u t n a r r o w e r a r e a s of interest creates a greater dependence u p o n appropriately t r a i n e d physicians, skilled t e c h n i c a l a s s i s t a n t s , increasingly sophisticated e q u i p m e n t , a n d suitable a n d a d e q u a t e p a t i e n t referral. I n so doing, it gives rise to n u m e r o u s q u e s t i o n s a n d problems, s u c h as: (1) W h e r e is t h e s u p p o r t (particularly financial) to come from. b o t h for e q u i p m e n t a n d personnel? (2) Is the t r a i n e d technical a s s i s t a n c e available? ~3 ) W h a t size c o m m u n i t y c a n s u p p o r t which procedures? H o w
lS this ro be decided? (4) W h a t d e t e r m i n e s t h e v o l u m e of p a t i e n t s t h a t is desirable so t h a t proficiency in a n y p a r t i c u l a r area c a n be acquired a n d m a i n t a i n e d ? H o w is t h e quality of p e r f o r m a n c e ro be m o n i t o r e d ? (5) If available resources are limited, h o w are t h e y to be distributed? Is this to be by chance, d e p e n d e n t only upon t h e interest or financial capability of a hospital or c o m m u n i t y ? Or are t h e r e o t h e r w a y s of determ i m n g this? In a n effort to apply knowledge a n d t e c h n o l o g y to beneficial use in a rational, realistic, a d v a n t a g e o u s , and n o n w a s t e f u l fashion, it is h o p e d t h a t t h e medical, academic, a n d governm e n t a l worlds c a n combine their wisdom a n d expemence to arrive a t workable solutions to t h e s e a n d like questions. It is also to be h o p e d t h a t this increasing subspecialization a n d its a t t e n d a n t desirable features will n e t be at t h e expense of direct a n d p e r s o n a l c o m m u n i c a t i o n between phys]cian a n d patient, especially in t h e area of h e a r t disease where this relationship is so vital a n d i m p o r t a n t m m a n a g e m e n t a n d therapy.
Martin Duke, M.D. Chief of Cardiology and Director of Medical Education Manchester Memorial Hospital Manchester, Conn. 06040
Supported in part by a grant from the Gertrude H. Rogers Fund.
Director of coronarycare. unit Surgical cardiologist (care of cardiac surgical patients) Card=ac patholog ist
f Research ~--"
~~'l Cardi~176
Animal Electrophysiolocjic Basic (i.e., cellular, metabolici Clinical
(Cardiac "generalist") // \\
// Pediatric--invamve (catheterization)
\
\\
//
/
\, Adult--invaslve (catheterization)
Nonmvasive I
Echocardiographer
I
I
Stress Phonocardiographer Electro-ano tester vectorcardiographer
I
Other techniques
Fig. 1. F r a c t i o n a t i o n of cardiology.
American
Heart
Journal
265
