Two acoustically different types of lung crackles, fine and coarse, occur in different pathophysiological conditions. To differentiate these crackles from objective characteristics of frequency information, crackles were recorded from 16 patients with pulmonary fibrosis judged clinically to have "fine" crackles and from 10 with chronic bronchitis who had mainly "coarse" crackles. Time expanded waveforms (1/4 cycle duration, initial deflection width, two cycle duration, and 9/4 cycle duration; duration of the first 1/4, 2/4, 8/4, and 9/4 cycles of crackle waveforms) were examined and fast Fourier transform analysis (peak and maximum frequencies) was performed. All waveform measurements for fine crackles were significantly smaller than those for coarse crackles. Peak and maximum frequencies for fine crackles were significantly higher than those for coarse crackles. Although there was some overlap in these values for individual crackles between the two groups when average values of these measurements were calculated for each patient, there was no overlap between fine and coarse crackles and the two groups could be clearly separated. Log peak frequency and log maximum frequency correlated better with 9/4 cycle duration (r = 085, 0 84) and two cycle duration (r = 0-87, 0 86) than with 1/4 cycle duration (r = 0-66, 0 77) or initial deflection width (r = 0-67, 0 79). Early and late segments of crackles have different characteristics, probably related to the origin of the sound and the resonance of the lung respectively. These results suggest that spectral and waveform characteristics may help to improve the accuracy of pulmonary auscultation and increase knowledge of how crackles are generated.

Chronic thromboembolism is a frequent cause of progressive hypertension and carries a poor prognosis. Medical treatment is not effective and surgery provides the only potential for a cure at present. We herein report a successful case of thromboendarterectomy treated via a median sternotomy with intermittent circulatory arrest. A 43-year-old man was admitted to our hospital complaining of progressive dyspnea, edema of the lower extremities, and a fever with an unknown origin. A subsequent definitive evaluation showed him to be suffering from surgically accessible chronic thromboembolic pulmonary hypertension with a thrombus in the right ventricle. He underwent a pulmonary thromboendarterectomy and thrombectomy via a median sternotomy with intermittent circulatory arrest on November 24, 1994. Postoperatively he showed a marked improvement in his hemodynamic status and blood gas analysis. He has also returned to work with no trouble. Deep vein thrombosis appeared to be the pathogenesis of this case, but we could not find the origin of his unknown fever. He is currently being controlled by treatment with methylprednisolone as before.

A 75-year-old woman presented with chest pain on exertion. Cardiac catheterization revealed double vessel coronary artery disease. Echocardiographic examination showed the presence of an abnormal mass in the interatrial septum without any flow velocity signal within the mass. She was scheduled for elective coronary artery bypass grafting. The lesion appeared as a homogeneous mass on CT scan, with an attenuation coefficient of -122 Hounsfield units, suggestive of lipoma. A T1-weighted MRI scan demonstrated that the signal intensity of the interatrial mass corresponded to that of fatty tissue. On surgery with cardiopulmonary bypass a large mass was found to involve the right atrial wall, the interatrial sulcus and the interatrial septum. The mass could not be resected completely, because it adhered strongly to the septal myocardium. On histological examination, the tumor was composed of mature fatty tissues, was not encapsulated and was diagnosed as infiltrating lipoma. The postoperative course was uneventful. CT, MR imaging and color Doppler ultrasonography were very useful in making a tissue-specific diagnosis. Jpn.

The patient was an 18-year-old man with congenital cerebral palsy who had undergone a tracheotomy at the age of 12. He underwent 2 emergency operations for massive endotracheal bleeding due to a tracheoinnominate artery fistula. At the first operation, the tracheal and tracheoinnominate artery fistulas were each closed directly, with median sternotomy. The second operation was due to recurrence of bleeding on the 20th postoperative day. The innominate artery was transected to avoid recurrence of bleeding. We only used an autologous pericardium but no artificial materials other than sutures, because of operative field contamination. Although a subcutaneous abscess developed at the operative wound 2 years after the operation, it was cured by incisional drainage and administration of antibiotics. In the case of tracheoinnominate artery fistula, it is impossible to save life without surgical treatment. However, the surgery involves a risk of repeated hemorrhaging and infections, resulting in a very poor prognosis. In our case, transection should have been performed at the first operation to avoid a recurrence of bleeding. The surgical method, using an autologous pericardium but no artificial materials, appeared to be effective in preventing infections. The surgical method should be selected with careful consideration to prevent repeated hemorrhaging and infection.

We report here a surgical case of sinus of Valsalva and right atrium fistula associated with acute infective endocarditis (AIE) without perivalvular abscess cavity or aneurysm of the sinus of Valsalva (ASV).A 51-year-old man, who had been given a diagnosis of rheumatic aortic stenosis and regurgitation (AsR) and mitral stenosis and regurgitation (MsR) and tricuspid regurgitation (TR) by echocardiography, had a high fever 2 months after removal of teeth and AIE was diagnosed. He was referred to our hospital because sinus of Valsalva and right atrium fistula were detected by echocardiography and congestive heart failure (CHF) deteriorated during medical treatment.Perivalvular abscess cavity and ASV were not detected by preoperative echocardiography.Medical treatment was continued after admission, and operation was done after amelioration of the CHF and infection were recognized. The aortic valve was removed together with vegetation, two areas of the aortic wall in which the tissue was fragile were cauterized by electrocautery, patch closure at the sinus of Valsalva was performed using a partial of e-PTFE graft and aortic valve replacement (AVR) and mitral valve replacement (MVR) were done. Though residual aortic-right atrium shunt was detected after the operation, the postoperative course was good with no CHF or signs of infection.