Red blood cell survival was determined in patients with aortic valvular disease, postoperative patients with aortic valvular ball-valve prostheses and postoperative patients with multiple ball-valve prostheses. The red blood cell survival was reduced in the majority of patients in each group when compared with the red blood cell survival from a normal control group. A detailed analysis of the survival curves suggested that in many patients there was more than one population of red blood cells. The first population displayed rapid random destruction. This population was not present in normal persons in the control group. The second population showed the usual decline in radioactivity due to random destruction and loss of the red cell label due to elution. The shortened red blood cell survival in some patients was due to a large percentage of the first population of randomly destroyed red blood cells, in other patients to an accelerated rate of destruction of the usual single population of cells while others had a combination of the two mechanisms. A mechanism of mechanical hemolysis due to increased intracardiac turbulence was suggested as a cause for the shortened survival. When the turbulence was increased by a leak around the aortic or mitral valve prosthesis the red blood cell survival was found to be further decreased. In some cases this reduction in survival was enough to produce hemolytic anemia. The Coombs antiglobulin test was positive in three patients. The suggestion was made that the development of autoantibodies to red blood cells was secondary to increased destruction of red blood cells.
A 28-year-old man with a history of multiple emergency department presentations related to foreign body ingestion secondary to uncontrolled schizophrenia presents with a complaint of dysphagia for the past 2 weeks. The patient's vital signs were as follows: temperature, 101.6°F; heart rate, 131 bpm; blood pressure, 150/75 mm Hg, and RR, 18. Physical examination revealed a small -1- cm wound in the mid-sternum with overlying granulation tissue. Anteroposterior and lateral chest X-rays revealed a foreign body projecting through the mediastinum (Figure 2). Computed tomography angiography of the chest revealed an 8.7 cm metallic nail penetrating the sternum with a surrounding anterior mediastinal hematoma measuring 7.2 × 4.6 (Figures 1, 3A, red arrow). The distal nail is seen lying within a pseudo-aneurysm of the ascending aorta measuring 4.4 × 4.3 cm (Figure 3B, measurement shown with orange arrow pointing toward intimal flap). The distal nail is seen lying within a pseudo aneurysm of the ascending aorta (Figure 3A). The patient was emergently taken to the operating room where the nail was identified and extracted. Purulent drainage and large emboli were noted around the distal nail. A 1.5-inch diameter opening of the aortic wall was appreciated and was subsequently repaired with a Cormatrix patch. Further history obtained revealed that the patient used a nail gun to self-inflict this wound 2 weeks prior to presentation. Due to the proximity of the aorta to the esophagus, a variety of aortic abnormalities can cause dysphagia including aortic dissections and aortic aneurysms.1 Choosing to evaluate for a suspected benign etiology of dysphagia without considering this more sinister cause can lead to delays in diagnosis and increased morbidity and mortality when aortic injury is present.2 Additionally, chronicity of dysphagia cannot successfully rule out aortic abnormalities as this patient had been ambulatory for 2 weeks. Although rare, pathology of the aorta has been demonstrated to cause chronic dysphagia.3
Red cell survival times were measured in patients with mitral valvular disease, mitral ball-valve prostheses, and multiple valve prostheses. Red cell survival was shortened in patients with mitral valvular disease but not in patients who had insertion of a normally functioning mitral prosthesis or after mitral commissurotomy. Mean red cell survival was also reduced in patients who had normal mitral prostheses associated with aortic valvular disease and in patients with a leak around the mitral prosthesis. Mean red cell survival was the same in patients with multiple prostheses and in patients with a single aortic prosthesis. If a leak developed around the mitral prosthesis in patients with multiple prostheses, hemolytic anemia could develop. Renal excretion of iron and iron deficiency were demonstrated in two patients with traumatic hemolytic anemia. The urinary iron loss apparently exceeds the capacity for intestinal absorption, and parenteral iron would seem to be indicated for replacement.
A 47-year-old man with a long history of atrial fibrillation presented with a regular rhythm and absent P waves on the surface electrocardiogram. When this rhythm persisted after digitalis withdrawal His bundle electrocardiography demonstrated sinus rhythm. Recognition of concealed sinus rhythm prevents misdiagnosis of digitalis intoxication and inappropriate withdrawal of digitalis therapy.
