Posteroanterior Chest Roentgenograms Research Articles

Cardiothoracic ratio may be misleading in the assessment of right- and left-ventricular size in patients with repaired tetralogy of Fallot

To assess the relationship between cardiothoracic ratio (CTR) and ventricular and atrial volumes in patients with repaired tetralogy of Fallot (TOF). Patients with repaired TOF undergoing cardiac magnetic resonance (CMR) and chest radiography within 1 day were included (n=82; median age: 24.7 years, interquartile range: 21.5-35.9). The CTR was obtained from upright posteroanterior chest roentgenograms. Analyses of CMR images and radiographs were performed in a blinded fashion. There were 35.1% (13/37) of patients with normal CTR (<0.5) who had severe right ventricular (RV) dilatation. There were six patients (13.3%, 6/45) with high CTR with both normal RV and left-ventricular (LV) volumes. CTR did not correlate with either RV or LV volumes but showed a weak correlation with right- and left-atrial volumes (r=0.43, p=0.0001; r=0.27, p=0.01, respectively). CTR ≥0.5 showed poor ability in the identification of severe RV dilatation (sensitivity: 61.8%, specificity: 50%). The combination of CTR and signs of RV enlargement on lateral radiographs did not improve the diagnostic accuracy of any of those parameters alone. CTR in patients with repaired TOF reflected atrial rather than ventricular dilatation. The use of CTR or lateral radiographs in patients with repaired TOF may lead to false conclusions concerning ventricular size.

Fechamento primário do pericárdio em cirurgia cardíaca: uma opção segura?

Primary pericardium closure may reduce the risk of cardiac injury during chest re opening, especially the right ventricle, aorta and coronary bypass grafts. Nevertheless, concern about adverse hemodynamic effects prevents most heart surgeons of closuring the pericardium. We evaluated 48 patients undergoing open heart surgery consecutively which the pericardium was closed in 30 patients (group A) and 18 patients, as a control group (group B) in which the pericardium was left open. All patients underwent posteroanterior and lateral chest roentgenograms before surgery and one week postoperatively. Postoperative evaluation also included echocardiograms, ECG and postoperative enzyme analysis. There were no deaths or any complications in both groups (acute myocardial infarction, stroke, bleeding or cardiac tamponate). It was observed statistically differences between both groups especially in echocardiogram parameters and cardiothoracic ratio without clinical impact. Pericardium closure is a simple method to facilitate resternotomy during subsequent re operative procedures. However, cardiac surgeons should be aware of the transient deterioration in hemodynamics associated with it, even thought there was no clinical significance in this study.

Left atrial emptying fraction correlation with vascular pedicle width in patients with normal systolic function.

To determine the correlation and diagnostic utility of impaired left atrial emptying fraction, an indicator of diastolic dysfunction, with raised intravascular volume determined by vascular pedicle width on upright postero-anterior chest roentgenogram. Cohort study. Department of Medicine, King Abdulaziz National Guard Hospital, Alhasa, Saudi Arabia from October till December 2002. Thirty-two out of 56 patients with normal systolic function (ejection fraction >50%) on echocardiogram were included in the study. Left atrial dimensions were measured at the end of left ventricular diastole (LADed) and systole (LADes) on M-mode tracing. Left atrial emptying fraction (LAEF) was calculated by dividing LADed by LADes. Ratio of peak early diastolic velocity (E/A) to peak late diastolic velocity, isovolemic relaxation time (IVRT) and deceleration time of E-wave (DT) were also recorded on transmitral Doppler signal. Postero-anterior views of chest X-rays done within 48 hours of echocardiogram were studied for the measurement of vascular pedicle width (VPW) and cardiothoracic ratio (CTR). Univariate and multiple regression analysis were performed to identify possible predictors of VPW. Receiver operator curves were constructed to see diagnostic utility of impaired LAEF for raised intravascular volume measured by VPW. Mean age for the patients was 58.56 +/- 17 years. There were 15 females (46.9%) and 17 males (54.1%). LADes, LADed, LAEF and DT were 2.89 +/- 0.63 cm, 3.81 +/- 0.53 cm, 0.75 +/- 0.10 and 202 +/- 49.9 msec respectively. VPW and CTR were 55.81 +/- 10.2 mm and 0.54 +/- 0.08. Significant independent predictors of VPW on univariate regression analysis were entered into multiple regression models, which revealed LAEF and DT as the only predictors of VPW. The final regression equation was VPW = 15.43 + 35.7 (LAEF) + 0.06 (DT), R2 = 0.35, p = 0.0008. LAEF > 0.75 had a sensitivity of 74% and specificity of 94% for diagnosing raised intravascular volume defined as VPW > 53 mm. LAEF > 0.75 is a reliable indicator of intravascular volume expansion in patients with normal systolic function signifying diastolic dysfunction and activation of salt and water retaining mechanisms.

How to Find the Limit Between Station 2 and Station 4 During Mediastinoscopy?

During mediastinoscopy, the definition of the limit between station 2 and station 4 is arbitrary. We describe a simple technique based on computed tomographic scan evaluation to precisely define it. The technique is based on calculating the distance between the sternal notch and the upper aortic arch on computed tomographic scan (radiological station 2 lower limit), and subtracting a constant factor (at our institution, 20 mm) to compensate for modifications of mediastinal structures due to neck hyperextension during mediastinoscopy. This corrected distance (surgical station 2 lower limit) is labeled on the mediastinoscope. When the mediastinoscope is inserted to this distance with a lateral deviation of about 45 degrees, the point of contact with the mediastinum of the biopsy forceps is the limit between station 2 and station 4. We applied this technique in 15 consecutive patients submitted to video-assisted mediastinoscopy for lung cancer. The R2 lower limit was identified by positioning 2 surgical clips during mediastinoscopy. The position of the clips, verified by a chest roentgenogram, was excellent (on the upper aortic arch line) in 7 patients, good (at less than 5 mm from the line) in 6 patients, and acceptable (at 7 mm from the line) in 1 patient. In one case clips were not visible. The proposed technique is simple and precise. Due to the possible differences in patient positioning during mediastinoscopy in other institutions, this correcting factor (-20 mm) should be verified before using this technique to define the lower limit of station 2.

Chest Roentgenography After Outpatient Thoracentesis

To evaluate the clinical utility of posteroanterior chest roentgenograms after thoracentesis in the outpatient setting. We undertook a retrospective study of clinical records of outpatient thoracentesis performed between January and December 1996 by the Division of Pulmonary and Critical Care Medicine at Mayo Clinical Rochester. The medical records of 54 men and 39 women who underwent 123 outpatient thoracentesis were reviewed. Exclusion criteria were the need for pleural biopsy at time of thoracentesis or the need for ultrasound-guided assistance for completion of the procedure. Indications for thoracentesis and postthoracentesis chest roentgenography were analyzed. Of 123 thoracentesis performed in the outpatient setting during the specified study period, 104 met the inclusion criteria. Of these 104 thoracentesis, 54 (52%) were followed by chest roentgenography. Pneumothorax occurred in only 5 of these 104 procedures (5%), in 5 separate patients. Three of these patients were asymptomatic and did not require therapeutic intervention; the two symptomatic patients required hospitalization and chest tube drainage. Of the two pneumothoraces in patients with symptoms, one was detected on the same day as the thoracentesis, and the other was diagnosed 2 days later. The patients who did not undergo postthoracentesis chest roentgenography had no reported complications. Of the 54 chest roentgenograms, 52 were obtained in asymptomatic patients, with no suspicion of pneumothorax. These x-ray studies led to a total cost of $4,862 and detection of three pneumothoraces that did not require therapy. Routine performance of chest roentgenography after outpatient thoracentesis can incur substantial cost. A more selective approach to this practice is needed, both to optimize patient care and to manage limited medical resources efficiently. Postthoracentesis chest roentgenograms should be limited to patients with symptoms indicative of thoracentesis-induced pneumothorax.

Effect of digital edge-enhancement on the visibility of normal parenchymal lung markings

Digital ‘conventional-like’ (C-L) and edge-enhanced (E-E) posteroanterior chest roentgenograms of 42 healthy individuals were ranked twice (interval of at least 5 days) in the order of increasing lung parenchymal markings (a total of four rankings). This was done by three radiologists, two residents, one medical student and one radiographer. There was a good general consistency of rankings for both the C-L and E-E images. The correlation coefficients were best (median 0.600) ( P < 0.05) between the consequent rankings of C-L images compared to the subsequent rankings of E-E images (median 0.440) and to the various combinations between the rankings of both kinds of images. Subtle differences in normal lung parenchyma could, therefore, generally (five of the seven observers) best be demonstrated in C-L images, but two observers managed best with the E-E images.

Radiographic and hemodynamic changes during recovery from high-altitude pulmonary edema.

It has been suggested that accentuated pulmonary hypertension is a contributing factor in the development of high-altitude pulmonary edema (HAPE). The purpose of this study was to evaluate the chest radiographic features associated with pulmonary hemodynamic changes in HAPE. We studied 16 patients with HAPE using posteroanterior chest roentgenograms taken in the standing position both on admission and following recovery. The cardiothoracic ratio (CTR) as well as the area and volume of the main pulmonary artery were measured. During HAPE, we found slight enlargement of the CTR, especially the right ventricle, and prominence of the main pulmonary artery. These abnormalities significantly improved in the recovery state. The changes in area and volume of the main pulmonary artery were closely correlated with a decrease in CTR during recovery from HAPE, and correlated with the pulmonary hemodynamic changes observed by right heart catheterization (n = 4). Radiographic changes reflect the alterations in pulmonary hemodynamics in patients with HAPE.

Bronchial Carcinoid Tumors

Bronchial carcinoid tumors, termed (incorrectly) "bronchial adenomas" in the past, are uncommon pulmonary neoplasms. These tumors are currently classified as neuroendocrine in origin because of their potential to form and sometimes secrete a variety of chemical substances. Overall, approximately 75% of bronchial carcinoid tumors arise in the lobar bronchi, 10% occur in the main-stem bronchi, and 15% originate in the periphery of the lung. Well-differentiated carcinoid tumors constitute almost 90% of all bronchial carcinoids. Atypical carcinoid tumors have a higher malignant potential than do typical bronchial carcinoids. The carcinoid syndrome is rarely, if ever, associated with carcinoids limited to the tracheobronchial tree. Occasionally, Cushing's syndrome due to ectopic hormone production is caused by bronchial carcinoid tumors. More than 75% of bronchial carcinoids are detected on conventional posteroanterior chest roentgenograms. Computed tomography may help disclose small neoplasms that are occult on conventional roentgenography, particularly in the assessment of patients who have Cushing's syndrome due to ectopic hormone production. Pulmonary resection is the treatment of choice for bronchial carcinoids. The prognosis is related to the pathologic grade and stage of the tumor.

Posterior mediastinal masses

Solid mediastinal masses in infancy and childhood occur most frequently in the posterior mediastinum. From 1972 to 1989, 63 patients presented with a posterior mediastinal mass. The median age at diagnosis was 6 years (range, 1 day to 26 years). Thirty patients were female. Forty-five percent of the patients presented with respiratory symptoms or chest pain; 13% had neurologic symptoms, one half of which were related to spinal cord compression; and 5% had a palpable mass. In 32% of patients the mass was an incidental finding. The tumors were of neurogenic origin in 89% of patients, of which neuroblastoma was the most common. Of all patients with posterior mediastinal masses, 60% had malignant tumors. Median follow-up for 62 of 63 evaluable patients was 45 months (range, 1 to 289 months). One patient was lost to follow-up. Of the 62 patients followed, 84% are alive and free of disease. All but 4 of the 32 patients with neuroblastoma are alive and free of disease with a median follow-up of 73 months (range, 7 to 289 months). Patients with neuroblastoma who were diagnosed in the first year of life had a significantly better survival pattern than those presenting after the first year. There were seven deaths in the series: four from neuroblastoma, two from primitive neuroectodermal tumor, and one from malignant schwannoma. Preoperative diagnostic evaluation of a posterior mediastinal mass should include posteroanterior and lateral chest roentgenograms, and either CT or MRI of the chest and abdomen to assess the extent of the mass.(ABSTRACT TRUNCATED AT 250 WORDS)

Fleksibl Fiberoptik Bronkoskopla Bilateral ve Periferik Yerleşimli Metalik Yabancı Cisim Çıkarılması

Nowadays and especially in our country, it is stili thought that rigid bronchoscope must be used for the removal of all kinds of aspirated foreign bodies in adults or children even if this process has a high risk of complications and it usually needs to be done under general anesthesia. Islamic faith requires women to cover their hair with a head scarf. This practice is more popular especially among young women. They use some kind of pins to attach this scarf. This pin has a coloured plastic little ball on the top and it is longer than the normal pins. in recent years, aspiration of this pin has been very frequent causing severe medical problems. A young wornen applied to our clinic with the same problem. On the postero-anterior chest roentgenogram of this patient, bilaterally placed two metallic foreign bodies were seen in the traceobronchial tree. Contrary to the comrnon beliPf, flexible fiberoptic bronchoscope was used for the removal of these foreign bodies. On the bronchoschopic examination revealed the head scarf pins in the medial segment of the right middle lobe and in the inferior lingula segment of left lung. Tips of the pins were located on the proximale and stuck to the bronchial wall. At first, the stuck tips of the pins were released from the wall of the bronchia with the help of dassic biopsy forceps. Then they were held diagonally by their tips using the forceps which pulled the pin up to the internal channel of bronchoscope. Then the bronchoscope was taken out gradually along with the forceps and the pin. This case report shows that bilateral and peripheric foreign bodies in the tracheabronchial tree can be removed by using flexible fiberoptic bronchoscope under the local anesthesia without any complications.

Transvenous pacemakers in children: Relation of lead length to anticipated growth

Although transvenous pacing is feasible in infants and children, uncertainty remains as to how to allow for future growth at the time of lead insertion. Accordingly, we retrospectively reviewed the relation between age and transvenous lead length. Standard posteroanterior chest roentgenograms were reviewed for 26 patients with transvenous pacemakers inserted at Babies Hospital and Presbyterian Hospital between 1985 and 1989. Sixteen of these were children (age range, 0.75 to 15 years) and 10 were adults (age range, 27 to 90 years). The intravascular length of right ventricular pacing leads was measured as projected on the roentgenogram. In 10 children, the presence of lead loops in the right atrium required the lead length that would have resulted from conventional placement to be estimated. Results for right ventricular pacing lead lengths were correlated with age using linear regression analysis. Average uncorrected lead length measured on the roentgenogram was 345 ± 35 mm (standard deviation) in adults and 222 ± 51 mm in children. The use of right atrial loops increased implanted lead length by an estimated 79 mm, from 188 ± 26 to 267 ± 43 mm. The difference between lead length in children and adults was analyzed. Approximately 190 mm of additional right ventricular pacing lead in infants and 100 mm in 10-year-old children was needed for growth to adult size. We conclude that an 80-mm right atrial lead loop will allow 6 to 12 years (mean, 8 years) of growth in infants and children without the need for reoperation to adjust lead length.

Isolated pulmonary valvular regurgitation: Current perspectives

IPVR is a rare clinical entity that was first diagnosed during life in 1955. In the past 35 years, only 69 patients have been reported. With increasing clinical awareness, as well as use of PDE, the confirmation of its clinical diagnosis has become easier and more accurate without having to take recourse to invasive cardiac studies as in the past. For this reason, it is becoming increasingly apparent that IPVR is not so rare as has been suggested in the past. IPVR is more common in men than in women, in whites than blacks, and in the young than the elderly. The mean age of IPVR patients is 27 years (range, 4 to 85). The majority of the patients are asymptomatic and the diagnosis is usually suspected upon the discovery of a crescendo-decrescendo, low-pitched, early to mid diastolic murmur in the second and third left intercostal space, which increases during inspiration, particularly in the presence of a hyperdynamic right ventricle and in the absence of peripheral circulatory phenomenon of aortic regurgitation. The ECG often shows right axis deviation, incomplete right bundle branch block, and rarely, right ventricular hypertrophy and strain. However, a normal ECG does not preclude its diagnosis. Approximately 30% of the IPVR patients have normal 12-lead ECGs. The diagnosis may be further suggested by the posteroanterior chest roentgenogram when dilated and large central pulmonary arteries are noted to pulsate vigorously (hilar dance) on chest fluoroscopy. In the past, the diagnosis of IPVR could only be confirmed at cardiac catheterization by demonstrating equalization of late diastolic pressures in the right ventricle and pulmonary artery, and with selective angiocardiography by demonstrating reflux of contrast material from the main pulmonary artery into the right ventricle. However, the diagnosis now can be accurately confirmed by noninvasive PDE, and more recently by CDFM, particularly when the regurgitation jet is detected 1 to 2 cm or more below the pulmonic valve and it occupies 75% or greater of the entire duration of diastole. Because the majority of the patients with IPVR are asymptomatic, they need not be subjected to invasive studies; however, these should be considered before any active surgical intervention. Besides periodic follow-up and infective endocarditis prophylaxis, no other intervention is needed in most cases of IPVR. However, with the first indication of right ventricular failure, surgical intervention should be actively considered, either in the form of prosthetic valve replacement when IPVR is solely due to valvular abnormality or a composite graft when IPVR is due to both valvular dysfunction, as well as pulmonary artery dilatation. The long-term prognosis of IPVR appears excellent, particularly in those who are young and have a congenital variety of IPVR. However, the ultimate prognosis remains uncertain, particularly in those with acquired IPVR. Even this lesion is well tolerated in middle-age and elderly individuals; however, rarely right heart failure may ensue, particularly in those who have severe regurgitation to the degree that compromises the capcity of the right ventricle to tolerate it. Until the results of a large long-term cooperative study of several patients with IPVR becomes available, it will be difficult to be certain about the prognosis in any given patient.

Changes in Total Lung Capacity during Acute Spontaneous Asthma

An increased TLC has been reported during exacerbations of asthma, but the methods used (helium, dilution, plethysmography) have been subsequently found unreliable in the assessment of lung volumes in patients with obstructive lung disease. To address this problem, we measured TLC (TLC-XR) from posteroanterior and lateral chest roentgenograms obtained during exacerbations (E) of asthma and after recovery (R) using planimetry in 12 asthmatic subjects. At recovery, TLC was also measured by plethysmography or by helium dilution for comparison with the radiographic measurement. The plethysmographic measurements were made with a panting frequency less than 1 Hz to allow for airway obstruction. A chest radiologist also used independent radiologic measurements of hyperinflation (lung height, diaphragmatic arc height, rib counts) to assess lung volumes. Mean FEV1 during E was 1.43 +/- 0.38 L, and significant improvement occurred at R (FEV1 = 2.81 +/- 0.58 L, p less than 0.05). Of the independent radiologic variables measured, only an increase in lung height distinguished the two sets of radiographs. Mean TLC-XR (E) (6.01 +/- 1.62 L) was significantly greater than mean TLC-XR (R) (5.44 +/- 1.17 L, p less than 0.05). TLC measured radiographically at recovery was strongly correlated (r = 0.94) with TLC measured by plethysmography or helium dilution. We conclude that acute reversible increases in TLC do occur during exacerbations of asthma and that these changes are only readily detected by formal planimetry.

Complications associated with thoracentesis. A prospective, randomized study comparing three different methods

To determine what role the technique plays in complications associated with thoracentesis performed by physicians in training, we undertook a prospective study of thoracentesis in the medical service at our institution in which the sampling method was randomized among needle, needle with catheter, and needle with direct sonographic guidance. Fifty-two spontaneously breathing, cooperative patients with free-flowing effusions obliterating more than half of the hemidiaphragm on an upright, posteroanterior chest roentgenogram were randomized. When we analyzed those complications that were potentially life-threatening (eg, pneumothorax) and/or placed patients at increased risk for further morbidity (eg, pneumothorax, dry tap, inadequate tap), the sonography-guided method was associated with significantly fewer serious complications (0 of 19) than the needle-catheter (9 of 18) or needle-only methods (5 of 15). The sonography-guided method was associated with fewer pneumothoraces (0 of 19) than the needle-catheter (7 of 18) or needle-only methods (3 of 15). The difference between needle-catheter and needle-only methods was not significant. From our results, we conclude that the method by which thoracentesis was performed significantly influenced the spectrum and frequency of complications, and the sonography-guided method was the safest.

The Correlation of Subcarinal Density Visualized on Plain Chest Roentgenograms with Computed Tomographic Scans

A prospective evaluation of 212 paired chest roentgenograms and computed tomographic (CT) scans was performed to determine the predictive value of detecting subcarinal adenopathy by finding increased subcarinal density on routine roentgenograms. Based on CT criteria for subcarinal lymphadenopathy, 37 true-positive and 124 true-negative cases of subcarinal adenopathy were found in 161 patients. Evaluation of density in the subcarinal area on the routine posteroanterior (PA) chest roentgenograms in these patients demonstrated a sensitivity of 72 percent and specificity of 96 percent for the detection of adenopathy when compared with established CT criteria. False-positive and false-negative appraisals of central mediastinal density on routine roentgenograms appear to be due to the super-imposition of other masses, bullae, or lack of appropriate roentgenographic contrast. The accuracy of predicting the presence or absence of subcarinal adenopathy from routine chest roentgenograms suggests that this observation is clinically useful and should be routinely evaluated.

Patterns of pulmonary perfusion scans in normal subjects. IV. The prevalence of abnormal scans in smokers 30 to 49 years of age.

The usefulness of ventilation-perfusion scans in the diagnosis of pulmonary embolism is limited by the wide range of pulmonary diseases that are associated with abnormal scans, and by the largely undetermined prevalence of abnormal scans in persons without cardiopulmonary disease. In prior studies, we found perfusion defects to be rarely present in young persons and in older nonsmokers. To determine if normal older smokers have a higher prevalence of abnormal ventilation and perfusion scans, we performed six-view 99mTc perfusion (Q) scans and 133Xe ventilation (V) scans in 40 subjects 30 to 49 yr of age who had no known cardiopulmonary disease. Each subject had undergone a history, physical examination, electrocardiogram, spirometry, and posteroanterior chest roentgenogram prior to scanning. All V and Q scans were interpreted blindly and independently by two experienced readers. No subject demonstrated a lobar or segmental defect on two views. One subject had a matched subsegmental defect, and one subject had delayed washout from a subsegmental area of the right upper lobe during V scanning, with a normal Q scan. We conclude that abnormal V and Q scans are uncommon among normal smokers 30 to 49 yr of age.

Familial occurrence of right ventricular dysplasia: A study involving nine families

Right ventricular pathologic involvement, with autopsy evidence of fibrous and fatty infiltration of the right ventricle, was investigated in numbers of families in which cases of juvenile sudden death had occurred. Seventy-two subjects from nine families were studied. Sixteen died at a young age and 56 are living. Postmortem investigation in 11 cases (mean age at death 24 years) revealed massive replacement of the right ventricular free wall by fat or fibrous tissue. In the 56 living patients clinical examination included an electrocardiogram (ECG) at rest, ambulatory ECG recording, posteroanterior and lateral chest roentgenograms, M-mode and two-dimensional echocardiograms and exercise stress tests. In 14 patients, hemodynamic, angiographic and electrophysiologic studies were also carried out; right ventricular endomyocardial biopsy was performed in four.Structural and dynamic right ventricular impairment was detected in 30 living patients (mean age 25 years), and concomitant mild left ventricular abnormalities were present in 4. In eight of the nine families studied at least two members were affected. Ventricular arrhythmias (Lown grade ≥4a) were recorded in more than half of the cases.The data reveal that right ventricular dysplasia shows a familial clustering and causes electrical instability that may place affected subjects at risk of sudden death. The mean age of these subjects suggests that the disease is manifested at a young age with a polymorphic clinical and arrhythmic profile. Finally, because this disease is a primary disorder of the ventricular myocardium, it should be included among the cardiomyopathies.

MRI findings in pulmonary sarcoidosis

Postero-anterior radiographs and magnetic resonance imaging (MRI) of the chest were performed in nine biopsy proven cases of sarcoidosis. MRI was more sensitive than a postero-anterior chest roentgenogram in detecting hilar and mediastinal adenopathy but less informative in detecting pleural and parenchymal disease.

Lack of Association of Pleural Effusion with Chronic Pulmonary Arterial and Right Atrial Hypertension

Right atrial hypertension has been considered to have a major physiologic influence on the formation of transudative pleural effusions. Since pleural fluid is thought to be cleared primarily by the parietal pleural lymphatic vessels that empty into the systemic veins, systemic venous hypertension secondary to right atrial hypertension should decrease the lymphatic drainage of the pleural space. We retrospectively studied nine patients and prospectively studied 18 patients with long-term right atrial or pulmonary arterial hypertension (or both). All patients had stable respiratory symptoms, and none had a significantly elevated pulmonary arterial wedge pressure. Our purpose was to determine the relationship of right atrial and pulmonary arterial hypertension to the development of transudative pleural effusions. Posteroanterior and bilateral decubitus chest roentgenograms and ultrasound were used to detect pleural effusions. Pleural effusions were not identified in any of the 27 patients, even in four patients with right atrial pressures greater than 20 mm Hg. We conclude that chronic elevation of right atrial pressure or pulmonary arterial pressure (or both) alone is not a cause of pleural effusion. In contrast, elevation of left atrial and pulmonary arterial wedge pressures is associated with the formation of transudative pleural effusions in man. Thus, if pleural effusions are detected in patients who have cor pulmonale, a search should be made for coexisting left heart failure or a primary cause of pleural inflammation, such as pulmonary emboli or infection.

Standard Biplane Roentgenography Is Highly Sensitive in Documenting Mediastinal Masses

The records of 30 patients with mediastinal masses were reviewed to evaluate the signs, symptoms, and preoperative tests that were most useful in diagnosing and localizing the masses. Sixteen (53%) of the tumors were benign, and 14 (47%) were malignant. Twenty patients were seen with symptoms. The most common symptoms suggesting malignancy were pain, weight loss, fever, and cough. Four of the 5 patients who were truly asymptomatic had benign lesions. All 4 patients with palpable adenopathy had malignant tumors. Posteroanterior and lateral chest roentgenograms detected the mediastinal mass in 29 (97%) of the 30 patients. All patients were operated on for tissue diagnosis or resection (13, median sternotomy; 8, right thoracotomy; 3, left thoracotomy; 2, low anterior cervical approach). Eight patients underwent mediastinoscopy, which was diagnostic in 6 and obviated the need for operation in 4. It was of particular value for patients with lymphoma, who can be managed without resection.