each case.

Among the many possibilities, the presence of Pneumocystis organisms should always be suspected and searched for, since it is not uncommon in these types of patients.

or tarnponade.l.2 In this report a patient with massive pericardial e h i o n and total electrical alternans demonstrated gross pendular motion of the heart during cardiac catheterization and pericardiotomy.

1 Forrest JV: Radiographic findings in Pneumocystis carinii pneumonia. Radiology 103:539-544, 1972 2 Rarnirez-Ronda CH: Infections in the immunosuppressed host. Continuing Education 124-28, ( Nov ) 1974. 3 Steigbigel RT, Cross AS: Pneumocystis c d n i i pneumonia presenting as localized nodular densities. N Engl J Med 291 :831-832, 1974 4 Finley R: Bronchial brushing in the diagnosis of pulmonary diseases in patients at risk for opportunistic infection. Am Rev Respir Dis 109:379-387, 1974 5 Rosen P, Armstrong D, Ramos C: Pneumocystis catinii pneumonia: A clinicopathological study of 12 patients with neoplastic disease. Am J Med 43:428-436, 1972 6 Walzer PD, Per1 DP, -stad DJ, et al: Pneumocystis catinii pneumonia in the United States: Epidemiologic, diagnostic and clinical features. Ann Intern Med 80:83-93, 1974

Cardiac Motion in Total Electrical AIternans*

John J . Rozanski, M.D.,OOand Morris Neinfeld, M.D.t

Gross pendalar motion of the heart at half the heart rate was observed during cardiac catheterization and perk cardiotomy in a patient with massive pericardial e W o n and electrical alternarm in the electrocardiogram. These observations support the hypothesis that total electrical altein pericardial effusion is a result of alternate change in cardiac position.
lectrical alternans, that is, alternate change in the P, or T waves of the electrocardiogram, has been reported most often in patients with pericardial effusion

A 41-year-old Puerto Rican woman was admitted to the hospital because of shortness of breath after one week of dry cough and fever. Her blood pressure was 110/68 mm Hg, and her pulse was 60 beats per minute, with 23 respirations per minute and a temperature of 38.0C ( 100.4OF). There was marked distention of the veins in the neck, hepatomegaly, and distant heart sounds. The ECG showed normal sinus rhythm and total electrical alternans ( Fig 1) . The chest x-ray f i l m and echocardiogram were compatible with massive pericardial effusion. The white blood cell count was 8UX)/cu mm, with 18 percent lymphocytes. The findings from antish-eptolysin 0 titer, antinuclear antibody, latex fixation test, lupus erythematosus preparation, and skin test with purified protein derivative of tuberculin were negative. There was no rise in antibody titer to Coxsackie B type 1-6 viruses, tomplasmosis, or cytomegalovirus. The findings from pleural, liver, and bone biopsies were normal. The patient's condition deteriorated despite treatment with salicylates and digoxin. During cardiac catheterization, the heart was observed to move in a pendular anteroposterior direction at a rate one-half of the heart rate. Each extreme of the wing correlated with total electrical alternans in the ECC. Thoracotomy for pericardial-window formation was performed, during which exaggerated cardiac motion at half the pulse rate was noted. After 1,500 ml of serosanguinous fluid was removed, both the electrical alternans and the exaggerated motion ceased. Microscopically the pericardium showed only acute inflammation. Pericardial fluid failed to grow bacteria, L-forms, acid-fast organisms, or fungi. Cytologic findings were normal. The patient improved rapidly and at ten months after surgery remained clinically well with normal heart size on the x-ray film and normal ECG.

E QRS,

e ent of Medicine, *From Bellevue Hospital and the D G New York City. New York University School of M **Presently Medical Resident, Department of Medicine, Mount Sinai School of Medicine, New York City. +Attending Physici Maimonides Medical Center, and Medicine, State University of New Clinical Professor York, Downstate Medical Center, Brook1 NY. Reprint requests: Dr. Roranski, 309 South P % Street, Elizabeth, New Jersey 07206

In 1955, McGregor and Baskind1 proposed that electrical alternans might be caused by alternate change in cardiac position. This hypothesis received support in 1966 when Feigenbaum and associates3 demonstrated, by means of echocardiography, gross anteroposterior cardiac motion a t half the heart rate in two patients with pericardial effusion and electrical alternans. Several additional case reports have c o n h n e d such motion using

FIGURE 1. Total electrical alternans.

ROUWSKI, KLEINRLD

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echocardiography.4*5 In the present case, visual observation during thoracotomy and cineangiogram taken during catheterization showed antemposterior swinging of the heart within the fluid-Wed p e r i d mvity at one-half of the heart rate. M o v h e n t was in a pendular fashion from the root of the greae vessels, and there was significant torsional movement as well. After removal of 1,500 rnl of pericardial fluid, both the electrical altemans and the cardiac motion stopped. These observations lend additional support to the anatomic motion hypothesis of electrical altemans in conditions which allow gross cardiac motion, such as pericardial effusion and tamponade. Not all electrocardiographic alternating phenomena are associated with cardiac motion, as evidenced by the many different cardiac disorders in which some type of altemans has been reported6 and by experiments demonstrating dtemans of components of the action potent i a l in single myocardial d s . 7 . 8

constrictive pericarditis the characteristic hemodynamic abnormalities are a consequence of restricted ventricular filling. Rarely, it is ventricular ejection that is impaired by fibrous tissue located at the base of the heart. In the few such cases that have been documented, the diagnosis has been fairly obvious, because the condition followed inadequate pericardiectomy, and annular calcification was evident radiologically. .Inthe case reported here, the typical clinical, radiologic, and electrocardiographic features of constrictive pericarditis were masked in a patient who presented in right ventricular failure consequent upon fibrous extrinsic subpuhnonic stenosis without prior pericardiectomy or perioardial calcification.

In

1 McGregor M, Baskind E: Electrical altemans in pericardial effusions.Circulation 1 1:837-&43,1955 2 Spodick DH: Electrical alternation of the heart. Am J Cardiol 10:155-165,1962 3 Feigenbaum H, Zakey A, Grabhorn L I : Cardiac motion in patients with p&icardial effusion. Circulation 34:611619, 1968 4 Gabor GE, Winsberg F, Bloom HS: Electrical and mechanical alternation in p e r i d efhsion. Chest 59: 341*,1971 5 Usher BW, Popp RL: Electrical altemans: Mechanism in p e r i d effusion. Am Heart J 83:459-463,1972 6 Kleinfeld M, Stein E, Kossman CE: Electrical alternans with emphasis on recent observations made by means of single-cell electrode recording. Am Heart J 65:495;500, 1963 7 Kleinfeld M, Stein E, Magin J: Electrical altemw in single ventricular fibers of the frog heart. Am J Physiol 187:139-142,1956 8 Kleinfeld M, Stein E: Electrical altarnans of components of action potential. Am Heart J 75:5e&530,1968

T h i s 14-year-old African girl had been ill for two years with progressive dyspnea and swelling of the feet and abdomen. At the time of admission, she was acyanotic, and there was no edema. The jugular venous pressure was raised t o the angle of the jaw at 45 degrees, but there was no specific wave form. The blood pressure was 130/80 mm Hg, and pulsus paradoxus was not present. The liver was palpable 3 an below the right costal margin. Palpation of the premdium elicited a left pamternal thrust compatible with right ventricular hypertrophy. Auscultation at the lower left sternal border disclosed a grade 3 pansystolic murmur of tricuspid insuEiciency, and at the second left interspace, there was a long systolio ejection murmur; the pulmonary component of the second heart sound was inaudible. The elecbxardiogram showed sinus rhythm, a mean QRS axis of +We, and severe right ventricular hypertrophy. The chest x-ray film showed a cardiothoracic ratio of 60 percent and normal lung fields ( Fig 1) . A clinical diagnosis of infundibular pulmonic stenosis was made, and the patient was submitted to cardiac catheterization; the findings are detailed in Table 1. The pulmonary artery could not be traversed; intracardiac shunts were excluded by oximetric studies and indicator-dye dilution curves. Noteworthy features were ( 1) a mean right atrial pressure of

Subpulmonic Stenosis as a Result of Noncalcific Constrictive pericarditis*

Elliott Chesler, M.D.; Abdul S . Mitha, M.B., Ch.B.; Rodney E. Matkonn, M.B., Ch.B.; and Michael N . A. Rogers, M.B., Ch.B.
1

The clinical, electrocardiographic, and radiologic features in a patient with a pericardial band which prodneed an unusual form of infondibolar pulmonary stenoeis are pre sented. The findings are nniqne in that the band was not calcified and, therefore, not viwalized roentgenographi d l y and developed witho~~t a previous history of pericardftis or periuudial sorgery. The diagnostic valne of cineangiography is stresged and i h s h & d
*From the Cardiac U n i t , Wentworth Hospital and the University of Natal, Durban, South Africa. Supported by a grant from the Medical Research Council of South Africa.
FIGURE 1.Frontal chest roentgenogram showing cardiomegaly

r a c t . and inconspicuous pulmonary outllow t

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