The electrocardiographic changes in pneumothorax in which the heart has been rotated: The similarity of some of these changes to those indicating myocardial involvement

The electrocardiograms of seven cases of pneumothorax, five spontaneous and two artificial, are described. In three, and possibly in six of the cases, the changes were significant enough to suggest the presence of myocardial involvement, and yet three of these definitely had good heart muscle. A prominent S-wave in Lead I was present seven times—in 100 per cent of the cases; a right axis deviation of the QRS group occurred in five cases, small amplitude of the QRS group four times, and small T-waves three times. Unusually high or low voltage of the S-T segments was present three times; finally, tachycardia was noted three times. All of the right pneumothorax cases showed a right axis deviation of the QRS group.In pneumothorax, particularly right pneumothorax, a rotation of the heart occurs and probably accounts for the findings described. Another way of stating the same fact might be to say that the right ventricle comes closer to the frontal leads than ordinarily.Follow-up procedures on two patients, whose pneumothorax had disappeared, showed a return to a normal electrocardiogram, with a disappearance of the characteristic changes observed in pneumothorax.The most marked electrocardiographic changes occurred with displacement of the mediastinum.It is suggested that the S-T changes noted in acute coronary closures. i.e., the high take-off of the S-T transition period from the QRS group may be due, at least in a measure, to a rotation of the heart which may occur when a portion of the heart muscle dies.The low voltage of the QRS group and the T-waves is probably to be accounted for either by the rotation of the heart or by the fact that air in the chest is a poor conductor for the heart current.     

Tako-tsubo cardiomyopathy after automobile accident

A 53-year-old woman was involved in a traffic accident while driving her car. She had chest oppressive sensation 6 h after the accident, and was admitted to our hospital. On admission, she had no external injury. She was fully conscious, and felt anxiety about the accident. Twelve-lead electrocardiogram showed mild ST-segment elevation in leads II, III, aVF and V2-5. Chest X-ray did not show pneumothorax, rib fracture or pulmonary congestion. Emergency coronary angiography showed no significant coronary artery disease. However, left ventriculography showed akinesia of the mid-to-distal portion of the left ventricular chamber and hyperkinesia of the basal portion (ejection fraction=45%). She was diagnosed as having tako-tsubo cardiomyopathy. Follow-up left ventriculography 11 days later showed normal wall motion of the left ventricular chamber (ejection fraction=62%). Clinicians should recognize that tako-tsubo cardiomyopathy is one of etiologies of chest symptom after automobile accident. It can occur due to emotional stress even if patients have no external injury.     

Spontaneous pneumothorax after chemotherapy for sarcoma with lung metastases: Case report and consideration of pathogenesis

Spontaneous pneumothorax is a rare complication of chemotherapy for lung neoplasm. Herein, we report a case of right spontaneous pneumothorax occurring in a patient in whom lung metastases from synovial cell sarcoma were treated with combination chemotherapy. Chest tube alone was unable to attempt the resolution of air leaks. Thus, it was connected to gentle suction set at minus 15 cm of water which achieved complete re-expansion of the lung with reduction of air leaks. In closure, chemical pleurodesis was attempted using 5 gram of talc diluted in 50 ml normal saline solution instilled into the right pleural cavity via chest tube. The connecting tube was suspended at 30 cm above the level of the patient's chest for one hour and the patient's position was changed at 15 minutes intervals to ensure uniform distribution. At three months of follow-up, the patient had no-recurrence of pneumothorax.     

Traumatic rupture of the pericardium

Isolated pericardial rupture due to nonpenetrating chest injury was diagnosed in a 21 year old man with multiple traffic injuries. Radiologic examination showed displacement of the heart to the left and therefore gave rise to a suspicion of pericardial rupture. The diagnosis was proved by establishing left-sided pneumothorax when the air passed into the pericardial cavity. The patient had no cardiac symptoms. His electrocardiogram, cardiac volume and hemodynamics at rest and during exercise were entirely normal. The physiologic and clinical implications of pericardial defects are briefly discussed.     

平板运动试验阳性对冠状动脉造影正常患者的评价

为评价平板运动试验阳性而冠状动脉造影正常的胸痛患者的临床意义，对３６例平板运动试验阳性而造影阴性的患才与３６例运动试验和造影阳性的患者进行临床资料及平板运动试验参数的对照分析。     

Unusual electrocardiographic changes during acute pancreatitis

A 46-year-old man suffered from mild upper abdominal pain radiating to the back and nausea; after a week he began to complain also of chest discomfort radiating to the neck and presented to the emergency room. A 12 leads electrocardiogram showed large peaked T waves in leads II-III-AVF and giant T waves inversion in AVL, V₁ through V₆; half an hour later the chest discomfort and the electrocardiographic changes resolved. Serum biochemistry results showed elevated serum pancreatic enzymes; electrolytes, creatinine kinase and troponin T serum values remained normal. Coronary angiography showed normal coronary arteries. The patient was conservatively managed.Electrocardiographic abnormalities were reported in patients with acute pancreatitis but broad, tall and peaked T waves, as found in our patient electrocardiogram, have not been yet reported.     

Pneumothorax after diagnostic laparoscopy

Here we want to call laparoscopist's attention to pneumothorax after diagnostic laparoscopy. Diagnostic laparoscopy has less complications, compared with laparoscopic surgery. In our experience, only one case (0.04%) developed pneumothorax during routine diagnostic laparoscopic procedure. This complication is presented in a 50-year-old female. She complained of dyspnea just after the decrease of intraabdominal pressure and deflation of intraperitoneal gas. The chest roentgenogram showed a right pneumothorax, and a right chest tube was inserted with immediate relief of tension. Pneumothorax during diagnostic laparoscopy is relatively rare but a major complication; Medline literature research showed six reported cases of pneumothorax after diagnostic laparoscopy from 1983 to 1998 including our case. The etiology was idiopathy in 5 and diaphragmatic injury in 1. Hypotension, elevation of inspiratory pressure, dyspnea, a decrease in systemic oxygen saturation, and loss of breath sounds suggest tension pneumothorax. The clinical condition of the patients improved rapidly because of the easy diffusion of the gas used in laparoscopy. Diagnostic laparoscopists should be aware of this complication and treat ventilatory problems.     

An early stage case of pulmonary lymphangiomyomatosis

A 35-year-old unmarried woman was admitted to our hospital because of right pneumothorax. Pulmonary lymphangiomyomatosis was suspected from CT and transbronchial lung biopsy findings. The diagnosis was confirmed histologically by open lung biopsy. As her biopsy specimen showed positive findings for both estrogen and progesterone receptor, tamoxifen administration was started. The CT revealed multiple cystic lesions (5-10 mm in diameter) but otherwise normal vascular structures and normal lung density. The plain chest radiograph showed no abnormalities. CT is very useful for the early detection of pulmonary lymphangiomyomatosis.     

Recurrence of catamenial pneumothorax after surgical treatment]

We reported a case of catamenial pneumothorax that was recurrent after surgical treatment. A 43-year-old woman had sudden chest pain and dyspnea during menstruation. Right pneumothorax and pleural effusion were pointed out on chest X-ray films. When the patient was 31 years old, she received a diagnosis of catamenial pneumothorax and underwent thoracotomy for resection of diaphragmatic endometriosis. However, after surgery she experienced recurrence of right pneumothorax, and was accordingly treated with danazol. The patient decided to terminate medication by herself because her symptoms had disappeared. Several years after the cessation of medication, she experienced chest pain frequently during menstruation, but did not seek a medical check-up. She visited our department because of persistent chest pain in 1997. After the patient was hospitalized, pneumothorax was diagnosed and continuous drainage was performed. Although pneumothorax was alleviated by drainage, it recurred during the patient's next menstrual period. Open lung surgery was performed. Diaphragmatic endometriosis with a small hole and inflammatory thickened lesions on the visceral pleura of the lower lobe (S 6) were found and excised. Microscopic examination of the excised specimens showed endometriosis. Visceral pleural endometriosis has been histologically demonstrated in very few cases. After surgery, hormonal therapy was started. The patient has been well for 12 months without recurrence of pneumothorax. Both surgical and hormonal treatment were considered necessary for the treatment of catamenial pneumothorax in this case.     

肺萎陷与气胸鉴别方法初探

目的探讨鉴别肺萎陷与气胸的方法。方法5名肺癌患者,其中合并气胸3例。合并右胸腔积液1例,合并以积液为主右液气胸1例。合并胸腔积液患者先行闭式胸腔引流术加负压抽完胸液后,影像学检查尚见气胸,进行闭式胸腔引流抽气却未见气体抽出,合并气胸者进行闭式胸腔引流抽气亦未见气体抽出。所有患者在CT引导下,将含有10ml气体的注射器穿刺进入胸腔,见气体吸人胸腔。结果考虑5例患者存在肺萎陷。结论肺萎陷与气胸的鉴别方法：胸部影像学示气胸,行闭式胸腔引流术抽气未见气体抽出,可在CT引导下将含有10ml气体的注射器穿刺进入胸腔,见气体吸入胸腔者,考虑存在肺萎陷。     

Magnetocardiograms and their variation over the chest in normal subjects

Magnetocardiograms of 6 normal male subjects are presented. For each subject magnetocardiograms were taken at about 32 positions on the chest; the positions were the junctions of a 2 by 2 inch grid. The electrocardiograms of each subject are also presented, for comparison. The magnetocardiograms are recordings of that component of the magnetic field vector which is normal to the chest. They were taken in a magnetically shielded chamber with a newly developed superconducting magnetometer, and are as clear as the conventional electrocardiogram. They contain the same general features as the electrocardiogram such as QRS, T, P and U waves, but with different ratios. New information about the heart, unavailable to the electrocardiogram, is believed to be contained in the variation of the magnetocardiogram across the chest. It is not yet known how to extract this information.     

Comparison of clinical utility between digital and analog drainage systems in patients with spontaneous pneumothorax

BackgroundDigital drainage systems can continuously and numerically monitor air leakage, which may lead to a shorter duration of drainage and hospitalization; however, the usefulness of digital drainage systems compared to that of analog drainage systems for patients with primary or secondary spontaneous pneumothorax remains unclear.MethodsThis retrospective study included 108 patients with spontaneous pneumothorax who were successfully treated with chest drainage alone at our institution. We compared the clinical efficacy of digital and analog chest drainage systems.ResultsFrom the study population, 68 patients were diagnosed with primary and the other 40 with secondary spontaneous pneumothorax. The analog drainage system was used in 44 patients, and the digital drainage system in 64 patients. Among patients with primary spontaneous pneumothorax, the digital group had a significantly shorter duration of chest drainage than the analog group (median 2 vs. 4 days; p = 0.001), but there was no significant difference in those with secondary spontaneous pneumothorax. Additionally, the length and cost of hospitalization in the digital group were significantly lower than those in the analog group for both patients with primary and secondary spontaneous pneumothorax. There was no significant difference in recurrence within 1 week after chest tube removal between the two groups, neither among patients with primary nor among those with secondary pneumothorax.ConclusionsDigital drainage system may be better than analog drainage system for patients with primary spontaneous pneumothorax who need chest drainage, but further research is needed on drainage system selection for those with secondary disease.     

Spontaneous resolution of an accidental total coronary occlusion

In December 2007, a woman was involved in a traffic accident. At first, her vital signs were normal, but electrocardiogram showed ST-segment elevation in the inferior leads. She was diagnosed as a blunt chest trauma-induced myocardial infarction. Her right coronary angiography showed total occlusion. She underwent an emergency coronary artery bypass surgery; 64-multi-detector-row computed tomography (64-MDCT) demonstrated an intravascular protruding lesion, which suggested subintimal hematoma. One month later, repeat coronary angiogram showed spontaneous recanalization, and 64-MDCT showed no discontinuous vessel wall. Coronary artery occlusion secondary to blunt chest trauma is rare, and it's even rarer to have spontaneous recanalization.     

Severe re-expansion pulmonary edema after chest tube insertion for the treatment of spontaneous pneumothorax: A case report

Rationale:Re-expansion pulmonary edema (REPE) is a rare complication after chest tube insertion for the treatment of spontaneous pneumothorax. However, this complication can be life threatening when it occurs. Therefore, it is necessary to recognize REPE early and treat it appropriately. In the present study, we report a severe REPE case occurring after chest tube insertion in a patient with spontaneous pneumothorax.Patient concerns:A 27-year-old male patient visited out hospital with chest pain on the left, which had started a week ago. After diagnosed with pneumothorax and having chest tube insertion, the patient complained of sudden shortness of breath, persistent cough, foamy sputum, and vomiting.Diagnosis:Based on the symptoms and imaging findings, the patient was diagnosed as REPE.Interventions:After the condition of the patient deteriorated rapidly, he was transferred to intensive care unit and then mechanical ventilation and conservative treatment were performed after endotracheal intubation.Outcomes:After mechanical ventilation and conservative treatment in the intensive care unit, the symptoms and radiological findings improved, and then mechanical ventilation was weaned and the chest tube was removed from the patient. However, due to recurrent pneumothorax after removal of the chest tube, video assisted thoracoscopic surgery (VATS) wedge resection was performed. At 6 months post-operative follow up, he was well with normal radiological findings.Lessons:REPE occurs rarely, but once it does, it causes a serious condition that can be life-threatening. Therefore, patients with the risk factors related to it should receive a closed observation after chest tube insertion. Moreover, if REPE occurs, appropriate treatments should be carried out by recognizing it early.     

Transient midventricular ballooning syndrome. an atypical presentation of takotsubo cardiomyopathy

A 72-year-old woman without cardiovascular history presented with acute substernal chest pain and dyspnoea. The electrocardiogram was normal, but the blood test analyses showed an elevated troponin T level. Emergency coronary angiography revealed normal epicardial coronary arteries, but the left ventriculogram demonstrated midventricular dilatation and akinesis with well-preserved contractility of the apex and base. The patient was diagnosed as having an atypical presentation of takotsubo cardiomyopathy. She was treated with a beta blocker and an ACE inhibitor and recovered well. A follow-up echocardiogram at 2 months showed normalization of the wall motion abnormality.     

Simultaneous bilateral pneumothorax complicating Pneumocystis carinii pneumonia in a homeless man with AIDS]

Although pneumothorax is a well-known complication of AIDS related Pneumocystis carinii pneumonia, simultaneous bilateral pneumothorax has not been reported in Japan. A 54-year-old homeless man was admitted with emaciation and dyspnea. Chest X-ray showed diffuse ground glass opacity. Computed tomography of the chest demonstrated ground glass opacity and cyst-like lesions in both upper lobes of the lung. The patient was HIV positive. Grocott's stain of a bronchial lavage specimen demonstrated Pneumocystis carinii microorganisms. Intravenous trimethoprim-sulfamethoxazol and steroid administration was started. Seven days later, the patient developed tension pneumothorax of the right lung. Immediately after the thoracostomy, contralateral pneumothorax developed. Another chest tube was inserted. Subsequently, the patient died from bilateral pneumothorax. The endemicity of HIV infections among the homeless population is already a significant problem in Western countries. We should be aware that HIV infection may become a problem among the Japanese homeless as well.     

Positional ventricular tachycardia from a fractured mediport catheter with right ventricular migration--a case report

The totally implantable catheter system has gained popularity as venous access when prolonged treatment is needed. Despite its frequent use, intravascular fracture and embolization of catheter fragments from implantable venous port-catheter systems present a rare but potentially life-threatening complication. Any implanted catheters should therefore be removed after completion of the treatment or the system's integrity should be monitored on a regular basis. This report illustrates such a case, which presented with ventricular tachycardia triggered by changes in body position from a fractured Mediport catheter with cardiac migration. A 34-year-old woman had a venous port catheter (Mediport) implanted into the right subclavian vein for neoadjuvant radio-chemotherapy for Hodgkin's lymphoma. Owing to the patient's difficult venous access the catheter was left in situ after treatment. Three years after insertion of the Mediport she presented with shortness of breath and palpitations when lying in the left lateral position. Physical examination revealed no abnormalities. An electrocardiogram was within normal rhythm. An outpatient Holter monitor revealed multiple episodes of nonsustained and sustained ventricular tachycardia triggered by lying in the left lateral position. A chest radiograph showed a normal location of the port-system, but the distal fragment of the catheter had embolized into the right ventricle. The embolized fragment was extracted with a gooseneck snare technique and the reservoir of the system was removed under local anesthesia without any complications. The patient was free of symptoms at 7 seven months follow-up.     

Efficient utilization of echocardiography for the assessment of left ventricular systolic function

BACKGROUND: We hypothesized that patients could be selected for echocardiographic evaluation of left ventricular (LV) systolic function on the basis of historic, clinical, radiographic, and electrocardiographic criteria. METHODS AND RESULTS: We prospectively evaluated 300 consecutive inpatients referred for the echocardiographic assessment of LV function, of whom 124 (41%) had LV systolic dysfunction (LVSD) (LV ejection fraction <0.45). Among the historic variables, male sex was the only predictor of LVSD, whereas of the abnormal physical and radiographic findings, cardiomegaly on chest radiography was the only predictor. Among the electrocardiographic findings, the presence of left bundle branch block was positively correlated with the presence of LVSD, whereas a normal electrocardiogram was negatively correlated with this finding. Only 2 patients with LVSD had a normal electrocardiogram. The addition of significant predictors on physical examination and chest radiography doubled the predictive value of the historic variables for determining LVSD. The addition of electrocardiographic findings further doubled the predictive value of the model. Almost 45% of the predictive power of the final multivariate model (chi-square of 48 of the total chi-square of 108) was based on the absence of normal electrocardiogram in patients with LVSD. When chest radiographic findings were excluded from the model, the overall predictive power of the model did not change, with the normal electrocardiogram gaining greater prominence: Full 56% of the predictive power of the model (chi-square of 60 of the total chi-square of 108) resided in the ability of a normal electrocardiogram to discriminate between patients with and those without LVSD. CONCLUSIONS: Historic, chest radiographic, and electrocardiographic variables can be used to predict low likelihood of LVSD on echocardiography. In particular, when the electrocardiogram is normal, it is extremely unlikely to have LVSD. It can be argued that such patients should not be referred for echocardiography.     

U wave inversion in unstable angina due to left main coronary artery stenosis

A 50-year-old male was admitted to hospital for repeated episodes of chest pain due to unstable angina. Serial electrocardiograms were all normal except for one electrocardiogram, recorded during chest pain, which showed isolated U wave inversion in leads I, V4 and V5. Subsequently, selective coronary arteriography showed isolated 99% stenosis of his left main coronary artery.     

Exercise stress testing in patients with chest pain and normal coronary arteriography: with review of the literature.

Eighty of 654 patients studied because of chest pain were found to have normal coronary arteriography. Fifty of these completed submaximal treadmill exercise studies. The purpose of this study was to determine whether treadmill electrocardiography could obviate the need for coronary arteriography in the evaluation of patients with undiagnosed chest pain. Of patients studied, 22% had typical angina pectoris, while 78% had atypical chest pain. The resting electrocardiogram was normal in 58% of patients, while 42% showed repolarization abnormalities. Submaximal treadmill testing was normal in 64%, incomplete in 12%, and demonstrated classic ischemic S-T depression in 24%. Our findings of 24% positive studies in patients with normal vessels and 12% incomplete tests suggest that stress electrocardiography may be of limited value in predicting the morphologic state of the coronary arteries in patients with undiagnosed chest pain.