Atrial arrhythmias related to trauma to sinoatrial node

Atrial Arrhythmias Related to Trauma to Sinoatrial Node Saroja Bharati, Abraham Chervony, John Gruhn, Kenneth M. Rosen and Maurice Lev Chest 1972;61;331-335 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/61/4/331

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1972by 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

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1972, by the American College of Chest Physicians

Atrial

Related

Arrhythmias

Sinoatrial Saroja

M.D.;

M.

Abraham

Rosen,

Chervony,

and

M.D.;

M.D.;

Maurice

Lev,

This

atrial

arrhythmias

she

with

conduction

system

caused by fatly incident, there and

made.

Since

she

at

surgical

study

of a patient

infiltration about ensued hemorrhage

who

the

developed

sino-afrmal in the SA

sinus

(SA) node

node. which

collapse.

disability

had

this

no

time,

exertional

she

treatment.

completely

multiple

was

M.D.;

arrhythmias

patient who disease with Subsequent

developed

collapse,

and

atrial

traumatic

incident,

is a clinical

produced

to

Gruhn,

F.C.C.P.#{176}

probably a traumatic

mitral a

John

M.D.,

bradycardia Following

were able to study a young clinically had an obscure heart insufficiency, and bradycardia.

WTe

to

Node*

Bharati,

Kenneth

to Trauma

Since

well,

and

at

dyspnea

not given

was that

time

full

activity

and

any

she

no

real

medication

was up

or

subjectively

to

the

present

illness.

resuscitated,

On

June 30, 1970, she was in an automobile accident and admitted to Skokie Valley Community Hospital. She had lost consciousness during the accident for an unknown period of time. Upon entry, she had severe pain in the left side of the chest, left upper arm, neck and back. was

For

editorial

but

later

died

the

heart

in

specifically node the

suddenly.

fatty

see

and

the

partial

tissue

page

310

Comprehensive

general, revealed

by SA

comment,

and

studies

conduction

separation

an

of

extensive

of

system the

Family

SA

hemorrhage

35

in

history

years

over left

This

35-year-old

diac

disease

since

diagnosis 1968,

of

left

of

subaortic sure found. ventricle

hospital. hypertrophy

moderate

stenosis.

in the

age heart

catheterization in another

ventricular

petence

woman

the

rileumilatic

cardiac

performed of

white

left

Tile were

REVIEW was

of

21

disease

elevated.

in

At

was

made.

and

angit)cardiography

This

showed

severity.

ventricle

to

years.

with

There

was

elevation

have

that In

of

outer

pulmonary

wedge

pressure

tile

pulmonary

artery

and

of

cardiomyopathy

the

were

present

in the

left

The

heart

incom-

left of

was

sternal

fracture

the

and

skull

were

tory

right

negative,

#{176}From tile Congenital Heart Disease Research and Training Center, Hektoen Institute for Medical Research; the Departments of Pathology-Nortiswestern University Medical School; University of Chicago School of Medicine; The Chicago Medical School, University of Health Sciences; and Loyola University, Stritch School of Medicine; the Departments of Pathology and! Medicine of Abrahanl Lincoln School of Medicine, University of Illinois; Department of Adult Cardiology, Cook County Hospital, Chicago; and tile’ De.partment of Patilology of Skokie Valley Conlnlunity Hospital, Skokie, Illinois. This investigation was supported by Grants HE 07605-10 and NIH No. 71-2478, Myocardial Infarction Program, from the National Institutes of Health, National Heart and Lung Institute, Bethesda, Md. **Career Investigator and Educator, Chicago Heart Association, Reprint requests: Dr. Lee, Hektoen Institute, 62.9 South Wood Street, Chicago 60612

pain

in

tilat

day,

lapsed, an

opening

of the

left

clavicle

was

found

V dissociation below). antibiotics. sive

was

unit

improved on

of

SCPT

tory

found

this, for

a few dead

and

she

and

July

enlargement

Despite

and

9, 1970. of the LDH,

improved

days.

On

less

but

morning

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1972, by the American College of Chest Physicians

A-

(see

diphenylhyC (Cedilanid), from she

no

inten-

elevation

peripheral to he 28,

and the

progressively

progressive

of Jtmly

331

she

arrhythmias

clinically

in bed.

resus-

where

tachycardia,

Subsequently ascites,

minutes

was

unit

transferred with

On col-

five

she

hydrocortisone,

liver

great 1970.

suddenly

care

lanatoside

of

otherwise

5,

than

and

sufficiently the

July

of cardiac

was

nor Labora-

experienced

ventricular

with

ribs

was

she

coronary

rhonchi,

treated

developed SCOT,

the

heparin

She

care

to

the

460.

on

introduced

a multiplicity

(Dilantin),

but she

In

not

examination

of the

minutes

respiration.

but along

enlarged. LDH

days

20

was

diffuse

and

She

dantoin

or

brought

to have

few

not

sound

split

X-ray

gm, and

ambulatory for

tube

but

was

first

murmur

greatly

29,

first was

walking

was

the

pressure

was

snap.

10.5

SCPT

The

pulse

She

left

crepitant

The

systolic

was

Hh

56, She

withotit

citated.

heart

showed

endotracheal

the over

contu-

few

blood felt,

sound

soft

no

SCOT

while

of

tenderness

Multiple

were

was

second

Il/VI

The

hack.

line.

percussion;

but

Course: the

age

over

tenderness

There

heave The

spine.

with

and

body. to

a grade

examination Hospital

was

the

enlarged

border,

revealed

the

and and

axillary

ventricular

was

at

field.

loud.

There

died

clavicle

pain

posterior

over

moderately

loud.

the

had

swelling

left

exquisite

lung

A left

was

pres-

in

rales 120/60.

revealed

of the

was

hemithorax

degree

evidence

end-diastolic

There

a sister

cause.

aspect

sions

a

were

and

A diagnosis

time

mitral no

car-

January

a marked

associated

Significant

pressures

thought

that

unknown

examination

the

shoulder. CLINICAL

an

Physical

node.

revealed

from

1970,

edema. ambulashe

was

332

BHARATI

ET AL

A L::j:f4

FIGURE 1. Rhythm strips following cardiac arrest ( monitor leads). (A) Paroxysmal atrial tachycardia with varying I)lOCk. Tile atrial rate is 185 per minute with varying ventricular rate. (B) Strip recorded during sec-

.

B

ond arrest. and bizarre the ventricular per minute),

:

ELECTROCARDIOGRAPHIC Two sum

electrocardiograms were

patient right

on

January

16,

minute),

cific

ST

right

and

bradycardia wandering

ST

the

per

present

atrial

admis-

22,

the

left

and

sinus

bradycardia and

110

hi-atrial

taken

on

July

minute)

1, 1970

with sinus the sinus

from

enlargement,

per

revealed

cardiac

and

arrest

paroxysmal IA),

(probable these acute instability

the

sinus

normal

or

waves

with

an

(56 nonspe-

revealed

minute.

the

wave

changes

(C) Episode supraventricular 7/8 with sponto sinus brady-

frequient

premature

were sinus

arrest.

Two

short

atrial Heart

rates

episodes

were

taken

prior

Figure

2.

cardiac

also

arrest,

were to

the

sinus

arrhythmia node to the

nonspecific

on of

5,

T

prolonged

PR

retrograde

varying with

(Fig

of

beats

varied

from

paroxysmal

recorded

no

noted

(Fig

patient’s

on

45

supra-

July

significant 2).

death

PATHOLOGIC

and A-V

Aside nosis

wave

from was

with

intervals)

contour

to and

with

normal

8th

(Fig

QRS,

Multiple

ST

or

were

T

cardiograms

similar

to

those

in

tIAl

A-V PR

Gross

junction

findings

in

passive

cardiac

the

heart

hyperemia cirrhosis,

fractures

of the

of

the

pathologic

the

lungs,

bilateral

left

clavicle

diagliver,

and

hydrothorax and

fourth

and left

rib.

Examination

The

heart

hypertrophy

wandering

intervals)

and

EXAMINATION

QRS

Following marked

morphology

the

short

block

the

cllronic with

ascites,

strips

wide

1B). revealed

pacemaker

waves

rhythln

with

tachycardia) electrocardiograms (P

1970,

tachycardia

supraventricular node

July

tachycardia

episode

ventricular arrhythmia.s, of

the

atrial

and

of

tachycardia

spleen the

there

periods

cular tachycardia. of paroxysmal tachycardia on taneous reversion cardia.

changes.

cardiogram

Following

from

addition,

Despite

changes.

(Fig

short

QRS is widened appearance, and rate is rapid (200 suggesting ventri-

1C).

A cardiogram

enlargement,

In

and

ventricular

hypertrophy

changes.

2). to

1966,

minute),

ventricular

T wave revealed

left

(50 to 60 per of the pacemaker

junction,

January

left

and

1968,

and

T wave

Admission

On (74

and

and

to

rhythm

enlargement, voltage

prior

analysis.

sinus

both

taken per

for

normal

atrial

with

ANALYSIS

taken

available had

..

The in

and (P (Fig

especially

the

thickened.

At

mitral

leaflet

white

plaque-like

was

enlarged

and

enlargement

left. the close

and

weighed of

The

endocardium

junction

of

to

the

the

both of left

posterior

formation

470

giss.

atria

and

the

atrium 1.5

was

ventricles,

left

atrium

and

the

commissure,

measuring

There

there cm

in

was inferior was greatest

AV*I

:i: 1i:L

p

...

iOi

tui

-------

Ur44

____:

.

H

1IT

I

-

tEIE1I 11t

2.

FIGURE

ventricular lead 2.

Electrocardiogram pacemaker Multiple atrial

following with wandering premature heats

cardiac between are seen

arrest. There the sinus and (leads 1 and

is marked instability A-V junction. This V6). PR intervals

CHEST,

VOL.

of the suprais well seen in vary.

61,

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1972, by the American College of Chest Physicians

NO.

4,

APRIL,

1972

a

ATRIAL

ARRHYTHMIAS

RELATED

TO

TO

TRAUMA

SINOATRIAL

333

NODE

‘1

3A,

FIGURE

left. of

Enlargement dimension

(Fig

showed

a

diameter

and

mitral Tile

orifice

was

coronary The

was

along

enlarged,

tile but

anterior

left

circumflex

length

the

revealed

and

and

firm

measulring of

valve

on to

tile

no

cm

arteries

taken

for

change.

showed

and

no

witIl

Methods:

region

every

tions

Tile atriulnl

entire

mitral

and

ventricle

FIGURE

4.

isolation

SA

of

rim,

including

were

node.

the

portions

serially

by

the

sectioned

Hematoxylin-eosin

node

of

fat

tissue.

necrosis

in

stain

In

the

Fat

(A,

right)

left)

x

x

this

partially

39,

showing

showing

bundle

678 a

(Fig isolated

hemorrhage

hemorrhage,

4A). and

VOL.

61,

NO.

4,

APRIL,

were of

This

was

did

with pigment,

1972

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1972, by the American College of Chest Physicians

the

into

atria blocks sec-

Weigert-van exaniined. and

accompanied

completely

partial and

to and

hemorrhage cells

not

and up

Alternate and

mononuclear hut

of cult

block.

area

nodes

sectioned

were

sections

large

AV

branches

remainder

each

macr(iphages.

CHEST,

and

serially

ventricles

from

manner was

node

SA

and

hematoxylin-eosin

fibroblasts

tissue

130,

taken

The

The

of the

with

right) mass.

were

retained.

were

There

macrophages,

and

(B,

stains.

bundle band

was

stained

Node:

retained. AV

portions

sections

SA

base. (B, tumor-like

moderator

section

were

Gieson Examination

the

available

two

andi

tile

was the

of

20th the

at the to the

section

approaches,

the

The

section

20th

their

in The

atherosclerosis.

descendling

every

section

.4

plaque.

showed

moderate was

.3

valve.

\Iiroscopie

adjacent

plaque

formation

arteries

narrowing. mitral

This

extending

coronary

right

3).

tulmor-like

View of the mitral valve showing tumor-like formation the tumor mass with section through it. Arrow points

by

(Fig

4B).

separate

334

BHARATI pericarditis

was

present

moderate

infiltration

trophils.

An

Mitral

showedi

there

were

rounded

of

In

no

ana.plasia

other

bult

These

cells

with

areas

a inure

there were These

basophilic

them.

were

cells

These

in

no

The

localized!

lay

were

sur-

which

showed

mitotic

and

arranged

latter

adjacent

figin

with cells

cells

in turn

basophilic to

Multinucleated

acctimulated

basophilic

foreign

lay

masses masses

body

giant

cells

in areas.

Coronary left

cytoplasm.

spots

normal continuous

containing

turn

nuclei.

cells

were

as

In

arteriolosclero-

fusiforns

areas

5).

which with

occasional areas

grossly

( Fig

fibroblastic

in

a

neu-

degeneration.

picture tissue

present

some

appeared

concretions

were

did

to similar

containing

actlte

same

tile

degenwith

with

of what

connective

formation.

adijacent

cells

cm

calcified

hyalinized

atrium.

silowed!

1.5

or less

Inasses

sis.

palisade

entire

more

right

Inonontlclear vessel

Tile

by

ures.

the

vactmolar and eosinophilic with fibrosis was apparent

of

occasional

Rim:

ttlmor

in

over

Septum: Moderate of myocardial cells

Atrial .erati()n

ET AL

Arteries:

circumflex

Atherosclerosis

was

was

considerably

considerable.

narrowed

in the

The

beginning

of

course.

its

DISCUSSION

This

case

presents

a good

electrocardiographic findings. several anatomic node

SA

have

tissue.

node

5. “Ttinior-like” mass at toxylin-eosin stain. (A, upper) sisowing osteoid-Iike cells gradually A = atrial mtisculature. V = ventricular musculature. E = end!ocardium.

base

tile

nodle

cardium

from showed!

organizing The

in

been

change.

(SA

The

nodal

and!

moderate

of the

not

identified.

SA

Node:

eosinophilic

fatty

accompanied trophilic

the

to

cells.

showed

AV

Node:

showed

cavac

was focal

fibrosis

cells, was

nlononuclear

no

remarkable

There

was

and net!-

changes.

slight

to moderate

fibrosis. AV

Node:

ening

andi

The

AV

narrowing.

nodal

artery

There

was

showed

moderate

slight

thick-

fibroelastosis

of

the

Other

Parts

Ventricles: of

yotmng

was

noted.

was

present

cially Atria:

of In

the

some

fibrous

Conduction areas

System:

prominent Tile and

These

This

in the

followed

areas

was

accompanied These

changes

proliferation old and

fibrosis sclerosis

by

a

were

fine espe-

showed moderate

moderate fibrosis.

Chronic

degenerative organizing

by

literature.

the

hemorrhage

organizing

the

pericarditis in the interesting osteoid-like

of

mitral

the

absence chordae,

SA and

to the

node

is

been in

the

being in

nature

the

of

organizing

adjacent, evidence

of

the organi-

itself. of

reaction valve.

This

stress

this

in the is

of mitral

considered

changes which arteriolosclerotic

VOL.

61,

study

annulus

insufficiency.

of changes in the mitral the insufficiency is thought

CHEST,

block

have

documented

traumatic

by-product

to the myocardial arteriosclerotic and

heart

trauma

the

the

in likely

hemorrhage

appendage

hemorrhage

peculiar

secondary

the atrial

the

is most chest

is not of

to

hemorrhage

nonsurgical

support in

in

the

the

arrhythmias

In

thrombus

An

with

atrial

of

associated

complete of

knowledge

associated

the

showed

ventricle.

my(icardiumm to

other

degeneration

cells. left

a marked

In

arteriolar

mononuclear

slight

was

tissue.

throughout. of

there

connective

Considlerable

infiltration

changes

node

to

Although

our

atrial

of the factor.

subsequent

hemorrhage

wounds to

atrial

the

is probably

arrhythmias patient

This

origin.

with of

node

related

node. in

AV

of

bradycardia.

the

probably

reported,7’8

changes.

the

for an SA

septum

to the narrowing be a contributing

atrial of

atrial

fibrosis

in the

nonpenetrating

zation

node. insignificant

are

sino-atrial

SA

present and

accident

in

of

collapse

traumatic

focal

muscle

the

the

superioris

considerable

of of

cavity.

approaches ostii

There

infiltration

vessels

to the

Approaches

its

ramus

A slight

a fine

Tile

in

An

atrial

fibrosis

the

associated

moderate

superimposed

with

the system

or isolation

of as

The

importance

The

epi-

hemorrhage.

adjacent

degeneration

infiltration. by

and

part

was

and

in the

regi(in

initial

artery)

Approaches vacuolar

node

present

adjacent

infiltration

documented

slight

minimal The

between

conduction

infiltration

septrirn, probably related left circumflex artery, may The

inflammation

was

the

of mitral valve. Hema20. (B, lower) x 260, going on to calcification.

nlyocardium.

chronic

thrombus

vessels

no

adjacent

tile

x

Fatty

and

arrhythmias.6 FIGURE

the

The bradycardia that this patient had years before the accident probably has basis in the partial separation of the by fatty

the

correlation

and

NO.

Downloaded from chestjournal.chestpubs.org by guest on July 11, 2011 1972, by the American College of Chest Physicians

is

the

fibrosus to

be

In the

valve leaflets and to be secondary are a heart

4, APRIL,

part of disease.

1972

ATRIAL

ARRHYTHMIAS

ACKNOWLEDGMENT: Ralevich for his

RELATED We are assistance.

technical

TO

indebted

TRAUMA

to

Mr.

TO

SINOATRIAL 4

Mi!orad

Balsaver

tion

AM, of

defect. 5

REFERENCES 1 Lev

M,

Kinare

ti-icular

SC,

block

in

Pick

A:

coronary

The

pathogenesis

disease.

Circulation

of

6

Lewis

T:

heart-block.

AE,

A

description

syndrome,

incltiding

4:15-32, 3

Auricular

fibrillation (if

the

a

and

case

postmortem

of

WM:

in allied

Pathologic

changes

arrhythinias.

Arch

complete 7

Adams-Stokes’

examination.

in

Intern

aulricular Med

Forty

years

ago

could

hardly

ature

on

tity

fibrillation

and

43:808-834,

with

subject

his

The

general The

or

accidental were noted

tion

from

few

lobar

lobes.

ous

or of

uneven bizarre

clearing

days.

Many

clude

parasitic

several

CHEST,

of of

these scattered

of the

drugs,

VOL.

lung may

infestation, contrast

61,

involve

giant

be

may heavy,

lesion

medium,

4,

of

round,

effusion initiate

of

one numer-

cells.

may

ensue

this

disease.

ComThey

bacterial

smoke

APRIL,

few in-

infections,

inhalation

in

infiltra-

conduction

1967 sinus

node

in cor

pulmonale.

Atrial

and

arrhythmias

cardiac

interatrial

lipoma-

septum.

Amer

Complete

heart

block

following

with

contusion

perforated of

the

chest.

1956 Traumatic

heart

repeated Also, its

termination

JS:

block.

Brit

Heart

1989

Syndrome Rarely, person.

nodosa

has

been

horses

recorded.

is

may in

Ford

considered

et al suggested

be

fatal

observed

seen polyone

a

(Nature

hypersensitivity 184:1328,

1959)

of the blood might, be instrumental in Others believe that eosinophils pardisposal of the antigen-antibody complex. that extract of eosinophils from the blood

subjected

histaminic

properties.

roborative

information

to

Loeffler

is, Its

allergenic be sure,

a great

deal

is

for

clarification

To

the basic immunologic a corollary, mention with

occurrence

syndrome in about 300 patients with (Am Rev Resp Dis 93:797, 1966).

syndrome Pepys

carditis, that eosinophihia.

triangular within

Geddes

that precipitins its development. ticipate in the It is of interest

entity Pul-

homogene-

is infrequent.

IL:

case of Loeffler’s bronchial asthma

of

histiocytes,

occasional or

pre-

lesions

revealed

mycoses,

NO.

lung

lymphocytes,

fluffy Pleural

mild

of consolidain diameter, broncho-

examination

density,

be

the

J 52:940-943,

fire fighters. in the same arteritis

DL:

of

septum

BA,

disease.

victims

may

Fat

cardiac

1969

Page

Rubin

Sims

Loeffier’s

on

In

They

manifestations

agents

may

C, Heart

There find-

detected

be

FW:

of

1971

Amer

TUE

x-ray

subjects, areas

to 5 cm

fibers,

shape.

plete

may

leukocytes,

radiologic

and

pulmonary,

pneumonia.

collagenous

monary

eosinophilia).

examination.

Histologic

eosinophilic

fibroblasts,

or

enlistment

millimeters

or

more

ous

or

PIE

and

symptoms

disease

death of some in the form

pneumonia or

between

absent.

employment

with

en-

followed:

eosinophilia)

infiltration

former,

eponymic

acronyms

AM,

31:140-142,

pertinent

an

Jr

hypertrophy

Paulin

of Loeffler’s

reported

of

8

1929

79:368, 1932) he voluminous liter-

designation with

contrast

entirely

first

Related

name. lung

striking

ings.

or

infiltration

(transitory

or

Loeffler

z KIm d Tuberk the subsequent

anticipate the

(pulmonary is

when

(Beitr

cause

The

5:831-2,

interventricular

Heart

Complexities observations

Sci

Whitehouse a

19:281-265, AST:

HeartJ82:16-21,

1912-1913

Yater

J Med

Cardioi

Wee

MA,

Hutter tous

Cohn

J

Amer

as

atrioven-

42:409-425,

1970 2

AR,

Morales

myocardium

Thomas Israel

335

NODE

needed

sensitization the

has more

anticorof

mechanism of this syndrome. As should be made of another clinical as

its

eponym:

Loeffler’s

parietal fibroplastic endocarditis characteristic pathologic changes

endo-

with are:

pronounced thickening and fibrosis of the parietal endocardium of either or both ventricles, with occasional mitral or tricuspid insufficiency due to involvement of the papillary muscles and chordae tendineae (Loeffler, W: Schweiz med Wchnschr 66:8 17, 1936). Andrevv L. Banyai, M.D.

1972

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Atrial Arrhythmias Related to Trauma to Sinoatrial Node Saroja Bharati, Abraham Chervony, John Gruhn, Kenneth M. Rosen and Maurice Lev Chest 1972;61; 331-335 This information is current as of July 11, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/61/4/331 Cited Bys This article has been cited by 1 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/61/4/331#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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