Friday, December 07, 2007

The Ultimate Double Bubble

This is the CXR of my toughest single chamber pacemaker cases, ever. (Used with patient permission).

It demonstrates massive right and left atrial enlargement from severe, longstanding mitral and tricuspid insufficiency. It also nicely demonstrates the "double-bubble" sign, with the right atrium outlined but the pacemaker lead descending down the margin of the right atrium from the superior vena cava, and the left atrial free wall nearly touching her right chest wall.

The patient was nearly 96 years old and collapsed while in her bathroom, striking her head and causing an asymptomatic subarachnoid hemorrhage while on coumadin for long-standing atrial fibrillation. She was found to have a regular junctional escape rhythm at 35-40 and was on no rate-slowing medications. Her lead dislodged six times during the case as it was forcefully ejected from the right ventricle. Fortunately, this morning she was doing well with great pacing thresholds.

Massive left atrial enlargement was also described by Ortner in the setting of mitral stenosis where the left atrium was so large that it compressed the recurrent laryngeal nerve as it passed beneath the tracheal bifurcation, giving rise to Ortner's Syndrome.

Ah, just another day at the office...


1 comment:

The Happy Hospitalist said...

pretty neat chest xray.

I can't wait to see what neato device we can implant in her at age 106. What technology will bring her.

By then, It might give her another 10 years of good solid livin'

Maybe a bionic eye?

I can't wait to pay for that.

(all tongue in cheek of course)

I look at a 96 year old lady with that CXR and the first thing that pops in my mind is, wow, it looks like she is trying to die on me.

I guess she can live forever with today's technology, payed for with the the courtesy of the Medicare National Bank.