aneurysm. mycotic aorta in long axis: diagnosis of a ...

Ultrasonic visualization of the posterior thoracic aorta in long axis: diagnosis of a saccular mycotic aneurysm. P C Come, B Sacks, H Vine, C McArdle, S Koretsky and R Weintraub Chest 1981;79;470-472 DOI 10.1378/chest.79.4.470 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/79/4/470

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1981by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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lung

complex

is a separate

tion

generally

does

more

commonly

trachea

the

anomalous

lung

There

arterial

aorta,

the right lung. is typically

than

normally.

systemic

the descending

involve

left

branches

Pulmonary sequestraan entire lung. It affects

entity.

not

supply,

often

The an

arising

from

the sequestered pulmorarely, if ever, encounin which the main stem bron-

supplying features are

nary tissue. These tered in esophageal lung chus originates from the esophagus comes from the pulmonary artery.

the blood

and

supply

shift

of the

not shift

heart

completely to this

deviation

tethered

to the

of the

to the

side

may

may

hemithorax, since

lung.

However,

rightward

occur.

A barium

esophago-

affected

esophagus

right

be absent,

it is

gram showing contrast filling of the bronchus is diagnostic. Cardiac catheterization and angiocardiography are necessary to evaluate the blood supply of the anomalous lung and to establish the presence or absence of associated

cardiac

defects.

ACKNOWLEDGMENT: The authors wish to thank Rene A. Arcilla, M.D., for his help in the preparation of this manuscript. REFERENCES

1 Klebs

E. Mlssbildungen

spondenzblatt 2 Bates

M.

Thorax

3 Thomson

tration

Aerzt]iches

pulmonary

unilateral

Corre-

13:111-23

sequestration.

EA.

Broncho-esophageal

of the

right

lung.

fistula

Ann Surg

with

1964;

total

seques-

159:4:599-603

FS, McGraw CT, Peterson HG, Cleland BW. Lung ectopla and ageneals with heart trorotatlon. Ani J Chil 1961; 101:514-18

ES,

Meyer

J. Pediatric x-ray Medical PublIshers,

diagnosis,

ed 2. ChIcago;

of the new born and & WilkIns, 1973:94-96

11 Genie ED, Jaretzkl

A, Ashley

CA, Benne

broncho-pulmonary

foregut

malformation:

sequestration

communicating

tract.

Med

1968;

dex-

Year

1972:590-91

10 Swischulc LE. Radiology Infant. Baltimore: William

N EnglJ

in

Long

Diagnosis of a Saccular Mycofic Aneurysm Patricia C. Come, Hugh Vine, M.D.;

Barry Sacks, M.D.; McArdle, M.D.; and Ronald Weintraub,

M.D.;

Cohn

KoretsJcy,

M.D.;

M.D.

A saccular aneurysm arising from the descending thoracic aorta was Ideatified ultrasonically In a 60-year-old man with a subsequent pathologic diagnosis Listeria monocytogenes mycotic aneurysm. A cross-sectional scanning technique, which permitted visualization of the descending thoracic aorta In long axis, demonstrated a 3 X 5 cm relatively echo-free mass between the heart and the aorta. A communication between the mass and the aorta established the diagnosis of an aneurysm.

ofa

U ltrasonic

recognition of the descending thoracic aorta has been technically difficult due to the presence of adjacent air-filled lung which interferes with transmission of sound waves through the chest. We report below a cross-sectional scanning technique which allows

visualization

long ning

of the

descending

thoracic

axis. In the patient presented, permitted the diagnosis of

from the anterior

wall

aorta

in

such long a saccular of the descending

aorta. This aortography

diagnosis was subsequently and by the pathologic diagnosis terla monocyto genes mycotic aneurysm.

with 278:1413-19

the

CASE

axis scananeurysm thoracic confirmed by

of a Lie-

young

AS. Congenital pulmonary

gastrointestinal

REPORT

A 80-year-old sion

8 Warner

Book

Aorta

23:311-15

5 Nlkaldoh H, Swenson 0. The ectopic origin of the right main bronchus from the esophagus. J Thorac Cardiol Surg 1971; 62:1:151-60 6 Keeley J, Schairer AE. The anomalous origin of the right main bronchus from the esophagus. Ann Surg 1960; 152:871-74 7 Mukal S, Kikuchi H, Akiyaina H, Mono M. Management of anaesthesia In an Infant with an anomalous lung arising from the esophagus. Br J Anaesth 1977; 49:379-82

9 Caffey

Thoracic

NB. Aqulno T. Anomalous origin of the right bronchus. Ped Surg 1964; 51:668-76

mainstem 4 Hanna

Total

1968;

1874;

the

of

Axis*

arising

der Lunge.

fur Bohinen

Visualization

Posterior

Sidney

Clinical recognition of esophageal lung complex is possible. It should be suspected whenever the chest roentgenograms of a newborn infant reveal persistent, total opacification of the right hemithorax. Despite the tracheal

Ultrasonic

was

history

man with diabetes mellitus and hypertenthe emergency room with a five-week of progressive dull left precordial chest pain, a 5.4 seen

kg weight loss, and a one-week

in

three

episodes

of drenching night sweats, and dysphagia. On physical examination, he had a heart rate of 90 beats per minute, a blood pressure of 160/105 mm Hg, and a rectal temperature of 38.3#{176}C.Cardiac examination was remarkable for an accentuated aortlc second sound and for a diffuse systolic precordial lift. There were no signs of congestive heart failure or of endocarditis. The hematocnit value was 45 percent, and the white blood cell count was 9,500/cu mm. Five blood cultures showed no growth. Chest x-ray film revealed a normal cardiac silhouette and calcification of the descending thoracic aorta. An overpenetrated chest x-ray film raised the question of a retrocardlac mass, and

history

of hoarseness

ultrasound

examinations were An M-mode echocardlogram

(Fig 1) was obtained using The mitral and aortIc valves normal, without evident vegetations to suggest bacterial endocarditls. There was a relatively

an ultrasonoscope appeared underlying ‘From

graphic Surgery, Boston.

performed.

and

recorder.

Thorndike Laboratory, Combined EchocardioService, Departments of Medicine, Radiology, and Beth Israel Hospital and Harvard Medical School,

the

470 COME El AL

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Ficunz 1. M-mode echocardiographic scan from aortic free space (mass), measuring 2.7 to 3.0 cm in diameter far left side of picture, left atrial diameter appears greatly MV, mitral valve; LV, left ventricle; SEP. septum; and

echo-free mass behind the left atrium, measuring 2.7 to 3.0 cm in diameter. The superior portion of the left atrium appeared to be markedly compressed between the aortic root and the posterior mass. A cross-sectional echocardiographic scan was obtained using a phased array sector scanner with an 80#{176} sector arc. To visualize the retrocardiac descending thoracic aorta in long axis, the transducer was positioned several centimeters to the left of the sternum in the fourth intercostal space.

root to left ventricle. Relatively echois seen behind left atrium (LA). At diminished. AV indicates aortic valve; PW, posterior wall.

The plane of the sweep was directed superiorly and Infeniorly and was then rotated medially on its longitudinal axis in order to visualize the descending aorta. The latter was recognized as a pulsating elongated structure with parallel walls, measuring 2.0 cm In diameter and lying In the posterior part of the chest (Fig 2). However, In addition, there was a 3 x 5 cm relatively echo-free mass Interposed between the heart and the aorta. With slight changes In the direction of the ultrasound plane, there appeared to be a communication posteriorly between the mass and the aorta. A diagnosis of a saccular aneurysm arising from the descending thoracic aorta was made. Thoracic aortography (Fig 3) confirmed the presence of an aneurysm measuring 3 x 4 cm and extending anteriorly and to the left from the anterior aspect of the descending thoracic aorta. A nonopacifled additional soft tissue density suggested either thickening of the aneurysm wall or thrombus within the aneurysm Itself. At surgery, the saccular aneurysm was resected. The aneurysm wall showed evidence for recent dissection with the media split into two equal portions by intramural clot. Gram-positive bacilli were demonstrated on Gram stain of the aneurysm wall and confirmed by culture to be Llsterla monocytogenes.

DiscussioN The value of ultrasound examination in the evaluation of the abdominal aorta, including the recognition of aneurysmal dilatation and even dissection, has been well established.1,2 It has even been suggested that ultrasound may be a more accurate technique than aortography in defining the actual diameter of the ab2. Cross-sectional ultrasound examination, performed according to method described, demonstrates a 3 x 5 cm, relatively echo-free, mass interposed between descending FIGUBz

thoracic munication diagnosis

descending were

LV,

aorta (A) and left-sided cardiac chambers. Combetween aorta and mass is visualized, permitting of saccular aortic aneurysm (AN) arising from

aorta.

better seen left ventricle;

Parallel

walls

of descending

thoracic

in other views. LA indicates left M, mitral valve anterior leaflet;

septum.

CHEST, 79: 4, APRIL, 1981

aorta atrium; and

S,

dominal identify

aorta in such patients.2 Because ultrasound can the wall thickness as well as the intraluminal diameter, mural thrombus, which may not be apparent on aortography,2.8 can be recognized ultrasonically. Echocardiographic recognition of most of the thoracic aorta has been more difficult since the adjacent aircontaining lung interferes with penetration of the ultrasound beam through the chest Nevertheless, recognition of various parts of the thoracic aorta has been

ULTRASONIC

VISUALIZATION OF POSTERIOR THORACIC

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AORTA 471

the

descending

mal

ascending

cles.

aorta

to

of the

entire

of the

suprasternal,

sternal

such

ably

the

papillary

posterior

not

described

however,

have aorta,

mus-

descending in that

pa-

reported

vis-

including

aorta,

using

subxiphoid,

and

two

echocardiographic able to visualize

long

a combination different

studies,

the

para-

above. scanning

aneurysm arising thoracic aorta. While

showed and

produced

a relatively suggested

by the

have

demonstrated

from the

the

a

retrocardiac

M-mode

echo-free left

we

retrocardiac desection using the In the case pre-

in longitudinal detailed

cross-sectional

aortic

cardiogram to the heart

of

the

in proxi-

positions.

routine been

saccular descending

level

thoracic

scending thoracic aorta cross-sectional method sented,

of the

descending

transducer

During frequently

visualized

level

were

Tajik,9

and

be

the

of

however,

Seward

ualization axis views

the

views

aorta,

per.’2

could from

aorta section

Longitudinal

thoracic

of

thoracic

or oblique

transverse

space

echoposterior

atrial

compression,

prob-

the

abnormalities

were

aneurysm,

nondiagnostic. In contrast, cross-sectional long axis study, which allowed recognition of intrathoracic structures relative to one another, clarified anatomic relationships and permitted not only the diagnosis of an aneurysm, but also an assessment of its shape, size, and location relative to the heart and aorta. Although mycotic aneurysms are uncommon and only

3. Contrast injection into demonstrates a saccular aneurysm FIGURE

descending

thoracic

accomplished

in the

second

sternal

border,

descending

(arrow)

thoracic aorta (AO indicates

aorta).

by ultrasound. to fourth the aortic

With

the transducer

intercostal root, both

space

at

placed the

left

at and above the level of the aortic valve leaflets, can be identified,4 allowing recognition of proximal aortic root dilatation,4’5 dissection,4 and supravalvular aortic stenosis.6’T With the transducer placed in the suprasternal notch, the aortic arch, pulmonary artery, and left atrium can be visualized.8’9 In addition, cross-sectional scanning permits visualization of the upper descending thoracic aorta,9’1#{176}an Important area for study when coarctation is suspected. Early attempts to visualize the descending thoracic aorta more distally involved placement of the transducer on the posterior thorax, just to the left of the vertebral column.8,11 The aortic diameter could be visualized in occasional patients, all of whom had dilatation of the descending aorta which may have caused lateral displacement of the lungs.8.il Recently, Mintz et ails have reported M-mode and cross-sectional echocardlographic recognition of the descending thoracic aorta using the standard transducer position for M-mode and cross-sectional long axis views of the heart. The descending thoracic aorta was seen on M-mode examination as an echo-free structure posterior to the left atrium, to the atrioventricular groove, or to the left ventricular

posterior

472

ET AL

COME

wall.

On cross-sectional

scanning,

rarely

affect

the

descending

thoracic

aorta,

other

abnormalities of the aorta, especially dissection, commonly involve this area. A painless, noninvasive technique, capable of rapidly and accurately imaging the descending thoracic aorta in longitudinal as well as transverse views could, as demonstrated in this report, provide important diagnostic information. Further study of this technique, including correlation of ultrasound measurements with those obtained at aortography and surgery, is suggested. REFERENCES 1Hertzer

NB.,

and elective

Beven EG. Ultrasound aortlc measurement aneurysmectomy. JAMA 1978; 240:1966-68

2 Wheeler WE, Beachley MC, Rannlger K. Anglography and ultrasonography, a comparative study of abdominal aortlc aneurysms. Am J. Roentgenol 1916; 126:95-100 3 Goldberg BB, Ostrum BJ, Isard HJ. Ultrasonic aortography. JAMA 1966; 198:353-58 4 Nanda NC. Echocardlography of the aortlo root Am J Med 1977; 62:836-42 5 Brown OR, DeMots H, Kioster FE, Roberts A, Menashe VD, Beals RK. Aortlc root dilatation and mitral valve prolapse in Marfan’s syndrome. CIrculation 1975; 52:

651-57

6 Bolen JL, Popp RL, French tures

of supravalvular

JW.

Echocardlographlc

aortlc

stenosis.

RL,

Hurwltz

Circulation

fea1975;

52:817-22 7

Weyman

AE,

sectional

echocardlographic

obstructIon: hypoplasla. 8 Goldberg

Caidwell

BA, et al. Crossof aortlc stenosis and aortlc

characterization

1. Supravalvular aortlc 1978; 57:491-97 ultrasonography.

CIrculation BB. Suprasternal

JAMA

1971;

215:245-50 9 Seward

JB,

TajIk

AJ. Noninvaslve

visualization

of the

CHEST, 79: 4, APRIL, 1981 Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011 © 1981 American College of Chest Physicians

thoracic aorta: a new application of wide-angle two-dimensional sector echocardiographic technique (abstract). Am J Cardiol 1979; 43:387 10 Weyman AE, Caldwell RC, Hurwitz BA, et al. Crosssectional echocardiographic detection of aortic obstruction: 2. Coarctation of the aorta. Circulation 1978; 57: 498-502 11 Goldberg BB, Lehman JS. Aortosonography: ultrasound measurement of the abdominal and thoracic aorta. Arch Surgery 1970; 100:652-55

Table1-Hemodynamic

entire

12

Mintz

CS,

sional

echocardiographic

thoracic

Kotler

aorta.

MN,

Segal

BL,

Parry

WR.

recognition

Am

J Cardiol

of

1979;

Two-dimendescending

the

44:232-38.

Cardiac

Findings

Data Cardiac Stroke

output, index,

Pressure,

L/min ml/beat/sq

Origin

Coronary

Artery

Angographk

and

Scinfigraphic

Correlafes

Melvin

W.

We

studied

artery

angiographic

mques.

I. Hamby,

Myocardial

confirmed the defect in anterior

of thallium

and

imaging significance

in the

radioactive

perfusion

of resting coupled

pulmonary

outflow

A nomalous hemodynamically sions.’

Despite

ature

on

this

myocardial ported report

Q

waves,

and

the

with the presence tract during exerof the ischemic

left

coronary artery from most common of the significant congenital coronary lea number of review articles in the literis the

subject,25

only with

recently

was

radioactive

the

use

zoithalliusri

of re-

to be of diagnostic aid.#{176}’The purpose of this is to present the findings in an adult patient with

studied

origin by

‘0’thallium ture

the

artery

imaging

anomalous

sults

of

origin

pulmonary

F.C.C.P.;

left coronary by using conimaging tech201thallium

myocardial with

cise underscored the dynamic nature response to exercise in this syndrome.

the

M.D.,

a patient with an anomalous from the pulmonary artery

arising

ventional

Robert

PerFusion

of

of

both

which

left

standard

imaging

of this

the

shed

coronary

invasive

at

rest

further

and light

artery

techniques with on

who and

exercise, the

ischemic

4.6

3.3 ±0.8

35

m

1 28/3 22/9:13 9

Left

97/7

ventricle

92/60:74

nil/sq ml/sq

m m

41 ± 15

90 25 0.71