lying organisms in six cases initially misdiagnosed as negative by the referring hospital. Most errors in diagnoses resulted from poor staining methods and lack of familiarity with the appearance of the organisms. The authors then emphasized the need for simultaneous controls in methenamine-silver staining for P carinil. However, they failed to explicitly state the need for the control to be P carinii. Following this case, we conducted a telephone survey of 15 hospitals in the greater Boston area. All hospitals employed the methenamine-silver stain for the identification of suspected P carlnU. However, only three hospitals were using a positive P carinfi specimen as a control at the time of our patient's hospitalization. Subsequently, our own and one other hospital have adopted the practice of routinely using P carlnfi controls. Pneumocystia carinii bas become a frequent cause of pneumonia as the population of immunocompromised hosts has increased. Pneumocystia carinfi pneumonia also has been reported to occur in otherwise healthy adults 5 •8 and has been reported to be a frequent cause of infection in premature infants in Europe. 7 Cases can now be expected to be seen outside of academic centers. Careful attention to the proper histologic preparation and staining of specimens is required if the diagnosis of P carinii is to be made. On the basis of our case, we conclude that fungal controls do not guarantee adequate staining of P carinii and that controls during methenamine-silver staining should be of P carlnfi itself. An additional advantage to the implementation of this procedure will be the greater familiarity pathologists will acquire for the morphologic details of P carinil organisms.
1 Doppman JL, Geelhoed GW and DeVita VT: Atypical radiographic features' in PneumocystiB carinU pneumonia. Radiology 114:39-44, 1975 2 Hughes W: Pfi8UmOC!Jiti8 carinH pneumonia. N Engl J Med 297:1381-1383, 1977 3 Walzer PD, Perl DP, Krogstad, DJ, et al: Pneumocyltil carlnii pneumonia in the United States. Ann Intem Med 80:83-93, 1974 . 4 Grocott RG: A stain in tissue sections and smears using Gomori's methenamine-silver nitrate technic. Am J Clin Pathol25:975-979, 1955 5 Lyons HA, Vinijchaikul K, Hennigar GR: PneumocystiB carlnii pneumonia unassociated with other disease. Arch lntem Med 108:929-936, 1961 6 Watanbe JM, Chincbinian H. Weitz C: Pneumocylti8 C.. lrUi pneumonia in a family. JAMA 193:685-686, 1965 7 lvady G, Paldy L, Koltay M, et al: Pneumocyltil carinU pneumonia. Lancet:616-617, 1967
380 CASAROnO ET AL
Surgical Removal of a Left Atrial Myxoma During Pregnancy* Dino Ct~~arotto, M.D.; Ubedo Bortolottl, M.D.; Rosario Russo, M.D.; DarlO Betti, M.D.; Luciano SchWaz.appa, M.D.; and Gaetano Thiefle, M.D.
Saeeessfol removal of a left atrial mymma In a prepant woman bas not been previously reported. The patient postoperatively bad an 11DC011lplleated prepaney, deBvering at term a normal, healthy baby. first case reported by Leyse and colleagues, Afterheartthesurgery, with the aid of cardiopulmonary 1
bypass ( CPB), can currently be accomplished during pregnancy with minimal hazards both for the mother and the fetus. We describe the first successful removal of a left atrial myxoma in a pregnant woman.
A 39-year-old woman, who previously had had two wcomplicated pregnancies, experienced easy fatigability, weight loss, and occasional palpitation two years prior to admission. Recently, some episodes of noctumal dyspnea occurred, and signs of congestive heart failure appeared. She was referred to our department for further evaluation. On admission, May 5, 1977, she was in the 21st week of pregnancy, the uterine enlargement being compatible with the gestational age. Blood pressure was 120/80 mm Hg. Pulse rate was 120 beats per minute and regular, and fetal heart rate was 140 beats per minute. The intensity of the first sound was increased; a protodiastolic sound, interpreted as an opening snap of the mitral valve, and a grade 3/6 diastolic-presystolic murmur at the apex were noted; the auscultatory 6ndings were apparently not related to positional changes. Bilateral pulmonary rales were present, and the liver was not enlarged. Pertinent laboratory findings revealed a moderate hypochromic anemia and a high erythrocyte sedimentation rate. The ECG showed sinus tachycardia and the chest x-ray film, pulmonary venous congestion and a moderate enlargement of the left atrium. · Since her condition progressively deteriorated despite medical treatment, a right cardiac catheterization was accomplished on May 12. The capillary pulmonary wedge pressure was markedly increased (average 28 mm Hg), and moderate pulmonary hypertension was present. During the levophase, an angiopneumocardiogram disclosed a roundshaped 6lling defect in the left atrial cavity which moved during the cardiac cycle from the atrium into the ventricle (Fig 1). The diagnosis of a floating left atrial mass was made and emergency surgery was performed on the same day. From the Departments of Cardiovascular Surgery, CardiolOIY,. and Patliology, University of Padova Medical School, Paaova, Italy. Reprint reqt.IB8t8: Dr. Ct~~arotto, Clmica ChitVrgica Genertils, Centro di Canliochifvgia, Via GiulejnitJni 2, 35100, Padooti, Italy 0
CHEST, 75: 3, MARCH, 1979
1. Angiopneumocardiogram (right anterior oblique projection). A round-shaped filling defect (arrows) appears in left atrium (A), ( left) during the levophase and moves through atrioventricular orifice into left ventricle (B), ( right) along with the cardiac cycle.
FIGURE
Anesthesia
Anesthesia was induced with 6 mg of pancuronium bromide and 30 mg of alphaxolone ( Althesin); the patient was then intubated and mechanically ventilated. Anesthesia was maintained with nitrous oxide and oxygen in a ratio of 50:50 and with 0.15 mg of fentanyl in repeated doses to a total of 1.75 mg. Blood pressure, pulse rate of mother and fetus, and body temperature were monitored. Arterial blood samples were frequently taken to measure blood gases and electrolyte balance. The Pa02 was maintained around 150 mm Hg and Pco 2 between 30 and 35 mm Hg during the whole procedure. Cardiopulmonary Bypass
Heparin, 3 mg/kg body weight, was administered before the insertion of aortic and right atrial cannulas; a normothermic CPB with total hemodilution was then started utilizing a bubble oxygenator ( Temptrol Q 200). The flow of the pump was determined to achieve a mean blood pressure of 80 mm Hg. During the bypass, a total of 3 units of fresh homologous blood plus 2,500 ml of Normosol-R pH 7.4 was administered. After the removal of aortic cross clamp, cardiac
FIGt111E 2.
Surgical specimen.
CHEST, 75: 3, MARCH, 1979
activity started again SPOntaneously, and· after decannulation, protamine suHate was given to neutralize heparin in a rate of 1 to 1.5. Total CPB time was 25 minutes, while aortic cross clamping lasted 14 minutes. Operative Findings and Surgical Technique
After the heart had been exposed through a median sternotomy, and the left atrium widely opened, a pedunculated gelatinous mass, inserted on the interatrial septum just above the mitral annulus, was noted. The mass, which was carefully removed together with its sta1k by simple excision, measured approximately 45 X 55 mm and weighed 24 gm (Fig 2) . The patient was automatically ventilated for 18 hours postoperatively, and sedation was achieved with small doses of morphine. No vaginal bleeding, no abnormal uterine contractions, and no alteration of the fetal cardiac rate were noted. On the 12th postoperative day, she was discharged. Four months later, the patient delivered, at term and without complications, a normal healthy baby. Histologic appearance of the excised mass was consistent with the diagnosis of a cardiac myxoma (Fig 3) .
FIGURE 3. Histologic section shows myxoma cells with glandlike arrangement and pseudovascular configuration. ( Alcian PAS stain, original magnification X 375).
REMOVAL OF LEfT ATRIAL MYXOMA DURING PREGNANCY 391
DJSCUSSION
The surgical excision of a left abial myxoma using total CPB was first performed by Crafoord in 1955; 2 we are not aware of any previous report concerning the removal of a left abial myxoma during pregnancy with the aid of extracorporeal circulation. The current techniques of CPB, which allow an adequate oxygen saturation of placental blood and a uniform perfusion pressure, together with the employment of analgesic and anesthetic agents which do not interfere with the organogenesis, presently make open heart surgery feasible with minimal hazards both for the mother andfetus. 3 The increase in cardiac output, blood volume, and oxygen consumption, and the hypercoagulability state occurring in pregnancy, render the patient with left abial outflow obstruction more vulnerable to congestive heart failure and exposed, by elevated clotting activity, to a higher risk of thromboembolism. 8 •4 Systemic embolization, which can be disabling or fatal to the mother, may also result in placental injuries leading to fetal distress or miscarriage. The open surgical approach with CPB is the best method to achieve total excision of the myxoma, and surgery must be always performed as soon as the diagnosis is made. G,8 The mass must be carefully removed, as it is usually friable, in order to avoid the partial detachment of emboli. 8 - 8 In the surgical management of abial myxomas, we prefer to remove a portion of the adjacent interabial septum to avoid possible recurrences; considering the rarity of this complication,9 in this very peculiar case, a simple excision of the tumor was performed to shorten the CPB time. Cardiac myxomas occur most frequently in women.10 No previous reports are available on the behavior of atrial myxomas in pregnancy. Therefore, it is quite impossible to establish if deteriorating symptoms in our patient should be related to gestational hemodynamic changes, to an increased growth of the tumor during pregnancy, or both. REFERENCES
1 Leyse R, Ofstun M, Dillard DH, et al: Congenital aortic stenosis in pregnancy corrected by extracorporeal circulation, offering a viable male infant at term, but with anomalies eventuating in his death at four months of age: Report of a case. JAMA 176:1009, 1961 .2 Crafoord C, in discussion, Glover RP: The technique of mitral commissurotomy in cardiovascular surgery. In: International Symposium at Henry Ford Hospital. Philadelphia, WB Saunders Co, 1955, pp 202 3 Estafanous FG, Buckley S: Management of anesthesia for open heart surgery during pregnancy. Clev Clin Quart 43:1.21, 1976 4 Hytten FE, Leitch 1: The Physiology of Human Pregnancy. Oxford, England, Blackwell Scientific Publications, 1971 5 Miller Jl, Mankin HT, Broadbent JC, et al: Primary cardiac tumors: Surgical considerations and results of operation. Circulation 45-46( suppl I) : 134, 197.2
392 ZAJKOWSKI, KRAYATH
6 Thomas KE, Winchell CP, Varco RL: Diagnostic and surgical aspects of left atrial tumors. J Thorac Cardiovasc Surg 53:535, 1967 7 Brewin TB: Myxoma of the heart: Report of a case in which death occurred as a result of detachment of the tumor from its pedicle. Guy's Hosp Rep 100:278, 1951 8 May lA, Kimball KG, Goldman PW, et al: Left atrial myxoma: Diagnosis and pre and postoperative physiological studies. J Thorac Cardiovasc Surg 53:805, 1967 9 Sasaki S, Lin TY, Redington JV, et al: Primary intracavitary cardiac tumors: A review of 11 surgical cases. J Cardiovasc Surg 18:15, 1977 10 Pritchard RW: Tumors of the heart. Arch Pathol51:98, 1951
Bilateral Diaphragmatic Paralysis in the Newborn Infant* Treatment With Nasal Continuous Positive Airway Pressure Edwtml ]. Zaikowaki, M.D., •• tmd Richard E. Krtmath, M.D.t
A ·newborn infant with aevere respiratory dlstresa from bilateral diaphraamatle panlysls eansed by birth lnjnry was sneeessfnlly treated with nllllll eontlanous positive airway pressnre (CPAP). Improvement padually occurred, and CPAP was disc:ontlaued after he 23 days of age. This therapy has advantaps over alternative methods.
w•
B
ilateral diaphragmatic paralysis is an extremely rare cause of respiratory distress. 1 •2 Even unilateral paralysis may be lethal but varies considerably in severity.t-8 The usual management of diaphragmatic paralysis has included administration of oxygen, tracheal intubation with assisted ventilation, and surgical plication of the affected hemidiaphragm. Two reports on the use of continuous positive airway pressure (CPAP) have appeared. 2,s This report documents the successful use of CPAP administered by nasal cannulae in bilateral diaphragmatic paralysis.
CASE REPoRT A 3.6 kg boy was hom at term at a community hospital. During delivery, fetal tachycardia and meconium-stained
amniotic fluid was noted. When prolapse of the umbilical cord occurred, the infant was delivered rapidly by high midforceps. Respirations were noted to be shallow and rapid and his cry was weak. The upper extremities showed flaccid paralysis. He developed apnea and cyanotic episodes unresponsive to
•From the Department of Pediatrics, Monteflore Hospital and Medical Cen~1 and The Albert Einstein College of Medicine, Bronx. N 1. • • Assistant Professor of Pediatrics. tAssociate Professor of Pediatrics. .Reprint requem: Dfo. Krtmath, DeptJfimlmt of P~ Montefiore Hospitol tmd Medical Center, lll Ecut !Uum StreB~, Bton2: 10467
CHEST, 75: 3, MARCH, 1979
1 Doppman JL, Geelhoed GW and DeVita VT: Atypical radiographic features' in PneumocystiB carinU pneumonia. Radiology 114:39-44, 1975 2 Hughes W: Pfi8UmOC!Jiti8 carinH pneumonia. N Engl J Med 297:1381-1383, 1977 3 Walzer PD, Perl DP, Krogstad, DJ, et al: Pneumocyltil carlnii pneumonia in the United States. Ann Intem Med 80:83-93, 1974 . 4 Grocott RG: A stain in tissue sections and smears using Gomori's methenamine-silver nitrate technic. Am J Clin Pathol25:975-979, 1955 5 Lyons HA, Vinijchaikul K, Hennigar GR: PneumocystiB carlnii pneumonia unassociated with other disease. Arch lntem Med 108:929-936, 1961 6 Watanbe JM, Chincbinian H. Weitz C: Pneumocylti8 C.. lrUi pneumonia in a family. JAMA 193:685-686, 1965 7 lvady G, Paldy L, Koltay M, et al: Pneumocyltil carinU pneumonia. Lancet:616-617, 1967
380 CASAROnO ET AL
Surgical Removal of a Left Atrial Myxoma During Pregnancy* Dino Ct~~arotto, M.D.; Ubedo Bortolottl, M.D.; Rosario Russo, M.D.; DarlO Betti, M.D.; Luciano SchWaz.appa, M.D.; and Gaetano Thiefle, M.D.
Saeeessfol removal of a left atrial mymma In a prepant woman bas not been previously reported. The patient postoperatively bad an 11DC011lplleated prepaney, deBvering at term a normal, healthy baby. first case reported by Leyse and colleagues, Afterheartthesurgery, with the aid of cardiopulmonary 1
bypass ( CPB), can currently be accomplished during pregnancy with minimal hazards both for the mother and the fetus. We describe the first successful removal of a left atrial myxoma in a pregnant woman.
A 39-year-old woman, who previously had had two wcomplicated pregnancies, experienced easy fatigability, weight loss, and occasional palpitation two years prior to admission. Recently, some episodes of noctumal dyspnea occurred, and signs of congestive heart failure appeared. She was referred to our department for further evaluation. On admission, May 5, 1977, she was in the 21st week of pregnancy, the uterine enlargement being compatible with the gestational age. Blood pressure was 120/80 mm Hg. Pulse rate was 120 beats per minute and regular, and fetal heart rate was 140 beats per minute. The intensity of the first sound was increased; a protodiastolic sound, interpreted as an opening snap of the mitral valve, and a grade 3/6 diastolic-presystolic murmur at the apex were noted; the auscultatory 6ndings were apparently not related to positional changes. Bilateral pulmonary rales were present, and the liver was not enlarged. Pertinent laboratory findings revealed a moderate hypochromic anemia and a high erythrocyte sedimentation rate. The ECG showed sinus tachycardia and the chest x-ray film, pulmonary venous congestion and a moderate enlargement of the left atrium. · Since her condition progressively deteriorated despite medical treatment, a right cardiac catheterization was accomplished on May 12. The capillary pulmonary wedge pressure was markedly increased (average 28 mm Hg), and moderate pulmonary hypertension was present. During the levophase, an angiopneumocardiogram disclosed a roundshaped 6lling defect in the left atrial cavity which moved during the cardiac cycle from the atrium into the ventricle (Fig 1). The diagnosis of a floating left atrial mass was made and emergency surgery was performed on the same day. From the Departments of Cardiovascular Surgery, CardiolOIY,. and Patliology, University of Padova Medical School, Paaova, Italy. Reprint reqt.IB8t8: Dr. Ct~~arotto, Clmica ChitVrgica Genertils, Centro di Canliochifvgia, Via GiulejnitJni 2, 35100, Padooti, Italy 0
CHEST, 75: 3, MARCH, 1979
1. Angiopneumocardiogram (right anterior oblique projection). A round-shaped filling defect (arrows) appears in left atrium (A), ( left) during the levophase and moves through atrioventricular orifice into left ventricle (B), ( right) along with the cardiac cycle.
FIGURE
Anesthesia
Anesthesia was induced with 6 mg of pancuronium bromide and 30 mg of alphaxolone ( Althesin); the patient was then intubated and mechanically ventilated. Anesthesia was maintained with nitrous oxide and oxygen in a ratio of 50:50 and with 0.15 mg of fentanyl in repeated doses to a total of 1.75 mg. Blood pressure, pulse rate of mother and fetus, and body temperature were monitored. Arterial blood samples were frequently taken to measure blood gases and electrolyte balance. The Pa02 was maintained around 150 mm Hg and Pco 2 between 30 and 35 mm Hg during the whole procedure. Cardiopulmonary Bypass
Heparin, 3 mg/kg body weight, was administered before the insertion of aortic and right atrial cannulas; a normothermic CPB with total hemodilution was then started utilizing a bubble oxygenator ( Temptrol Q 200). The flow of the pump was determined to achieve a mean blood pressure of 80 mm Hg. During the bypass, a total of 3 units of fresh homologous blood plus 2,500 ml of Normosol-R pH 7.4 was administered. After the removal of aortic cross clamp, cardiac
FIGt111E 2.
Surgical specimen.
CHEST, 75: 3, MARCH, 1979
activity started again SPOntaneously, and· after decannulation, protamine suHate was given to neutralize heparin in a rate of 1 to 1.5. Total CPB time was 25 minutes, while aortic cross clamping lasted 14 minutes. Operative Findings and Surgical Technique
After the heart had been exposed through a median sternotomy, and the left atrium widely opened, a pedunculated gelatinous mass, inserted on the interatrial septum just above the mitral annulus, was noted. The mass, which was carefully removed together with its sta1k by simple excision, measured approximately 45 X 55 mm and weighed 24 gm (Fig 2) . The patient was automatically ventilated for 18 hours postoperatively, and sedation was achieved with small doses of morphine. No vaginal bleeding, no abnormal uterine contractions, and no alteration of the fetal cardiac rate were noted. On the 12th postoperative day, she was discharged. Four months later, the patient delivered, at term and without complications, a normal healthy baby. Histologic appearance of the excised mass was consistent with the diagnosis of a cardiac myxoma (Fig 3) .
FIGURE 3. Histologic section shows myxoma cells with glandlike arrangement and pseudovascular configuration. ( Alcian PAS stain, original magnification X 375).
REMOVAL OF LEfT ATRIAL MYXOMA DURING PREGNANCY 391
DJSCUSSION
The surgical excision of a left abial myxoma using total CPB was first performed by Crafoord in 1955; 2 we are not aware of any previous report concerning the removal of a left abial myxoma during pregnancy with the aid of extracorporeal circulation. The current techniques of CPB, which allow an adequate oxygen saturation of placental blood and a uniform perfusion pressure, together with the employment of analgesic and anesthetic agents which do not interfere with the organogenesis, presently make open heart surgery feasible with minimal hazards both for the mother andfetus. 3 The increase in cardiac output, blood volume, and oxygen consumption, and the hypercoagulability state occurring in pregnancy, render the patient with left abial outflow obstruction more vulnerable to congestive heart failure and exposed, by elevated clotting activity, to a higher risk of thromboembolism. 8 •4 Systemic embolization, which can be disabling or fatal to the mother, may also result in placental injuries leading to fetal distress or miscarriage. The open surgical approach with CPB is the best method to achieve total excision of the myxoma, and surgery must be always performed as soon as the diagnosis is made. G,8 The mass must be carefully removed, as it is usually friable, in order to avoid the partial detachment of emboli. 8 - 8 In the surgical management of abial myxomas, we prefer to remove a portion of the adjacent interabial septum to avoid possible recurrences; considering the rarity of this complication,9 in this very peculiar case, a simple excision of the tumor was performed to shorten the CPB time. Cardiac myxomas occur most frequently in women.10 No previous reports are available on the behavior of atrial myxomas in pregnancy. Therefore, it is quite impossible to establish if deteriorating symptoms in our patient should be related to gestational hemodynamic changes, to an increased growth of the tumor during pregnancy, or both. REFERENCES
1 Leyse R, Ofstun M, Dillard DH, et al: Congenital aortic stenosis in pregnancy corrected by extracorporeal circulation, offering a viable male infant at term, but with anomalies eventuating in his death at four months of age: Report of a case. JAMA 176:1009, 1961 .2 Crafoord C, in discussion, Glover RP: The technique of mitral commissurotomy in cardiovascular surgery. In: International Symposium at Henry Ford Hospital. Philadelphia, WB Saunders Co, 1955, pp 202 3 Estafanous FG, Buckley S: Management of anesthesia for open heart surgery during pregnancy. Clev Clin Quart 43:1.21, 1976 4 Hytten FE, Leitch 1: The Physiology of Human Pregnancy. Oxford, England, Blackwell Scientific Publications, 1971 5 Miller Jl, Mankin HT, Broadbent JC, et al: Primary cardiac tumors: Surgical considerations and results of operation. Circulation 45-46( suppl I) : 134, 197.2
392 ZAJKOWSKI, KRAYATH
6 Thomas KE, Winchell CP, Varco RL: Diagnostic and surgical aspects of left atrial tumors. J Thorac Cardiovasc Surg 53:535, 1967 7 Brewin TB: Myxoma of the heart: Report of a case in which death occurred as a result of detachment of the tumor from its pedicle. Guy's Hosp Rep 100:278, 1951 8 May lA, Kimball KG, Goldman PW, et al: Left atrial myxoma: Diagnosis and pre and postoperative physiological studies. J Thorac Cardiovasc Surg 53:805, 1967 9 Sasaki S, Lin TY, Redington JV, et al: Primary intracavitary cardiac tumors: A review of 11 surgical cases. J Cardiovasc Surg 18:15, 1977 10 Pritchard RW: Tumors of the heart. Arch Pathol51:98, 1951
Bilateral Diaphragmatic Paralysis in the Newborn Infant* Treatment With Nasal Continuous Positive Airway Pressure Edwtml ]. Zaikowaki, M.D., •• tmd Richard E. Krtmath, M.D.t
A ·newborn infant with aevere respiratory dlstresa from bilateral diaphraamatle panlysls eansed by birth lnjnry was sneeessfnlly treated with nllllll eontlanous positive airway pressnre (CPAP). Improvement padually occurred, and CPAP was disc:ontlaued after he 23 days of age. This therapy has advantaps over alternative methods.
w•
B
ilateral diaphragmatic paralysis is an extremely rare cause of respiratory distress. 1 •2 Even unilateral paralysis may be lethal but varies considerably in severity.t-8 The usual management of diaphragmatic paralysis has included administration of oxygen, tracheal intubation with assisted ventilation, and surgical plication of the affected hemidiaphragm. Two reports on the use of continuous positive airway pressure (CPAP) have appeared. 2,s This report documents the successful use of CPAP administered by nasal cannulae in bilateral diaphragmatic paralysis.
CASE REPoRT A 3.6 kg boy was hom at term at a community hospital. During delivery, fetal tachycardia and meconium-stained
amniotic fluid was noted. When prolapse of the umbilical cord occurred, the infant was delivered rapidly by high midforceps. Respirations were noted to be shallow and rapid and his cry was weak. The upper extremities showed flaccid paralysis. He developed apnea and cyanotic episodes unresponsive to
•From the Department of Pediatrics, Monteflore Hospital and Medical Cen~1 and The Albert Einstein College of Medicine, Bronx. N 1. • • Assistant Professor of Pediatrics. tAssociate Professor of Pediatrics. .Reprint requem: Dfo. Krtmath, DeptJfimlmt of P~ Montefiore Hospitol tmd Medical Center, lll Ecut !Uum StreB~, Bton2: 10467
CHEST, 75: 3, MARCH, 1979
