4th Intercostal Space Research Articles

PO-01-014 IMPACT OF GENDER ON P- AND R-WAVE AMPLITUDE IN A SURFACE EKG SIMULATION STUDY FOR INSERTABLE CARDIAC MONITOR

Cosmetic concerns or anatomic differences between males and females may influence implantation location of Insertable Cardiac Monitor (ICM). To assess device, implant and patient factors impacting electrogram sensing by proxy of precordial single-lead surface EKG recordings. 150 participants each had 12 separate tracings of single-lead surface EKG acquired using Northeast Holter (DR200/HE) placed at the parasternal 4th intercostal space to mimic ICM recordings. 3M electrodes were positioned at different vector length (75mm & 45mm) for each of three vector angles (vertical, oblique, horizontal) repeated in two postures (upright & supine). Height and weight were assessed for body surface area (BSA) calculation and impedance-based body fat percentage (BF%) was measured. All EKG strips were uploaded into DigitizeIt software for offline analysis by blinded technicians. Kruskal-Wallis test with Dunn’s multiple pairwise comparisons was performed to assess gender differences in EGM amplitudes. A total of 1,800 tracings from 150 participants [55.5% male, median age 59years (IQR 35 – 73)] were assessed. Compared to male participants, females had lower weight [73 (60 - 87) vs. 84kg (75 – 98), p<.001] but higher BF% [24.4 ± 8.8 vs. 35.2 ± 9.6%, p<.001]. There was no difference between gender for pairwise comparisons of median P-wave amplitude in each vector angle using different vector lengths (Panel A). Male participants had larger R-wave in vertical orientation for both vector lengths, but no difference for R-wave amplitude was seen for other angles (Panel B). Overall median amplitude of P-wave was 45% larger (.042 vs. .029mV, p<.001) and R-wave was 53% larger (.81 vs. .53 mV, p<.001) for vector length of 75 vs 45mm. The oblique vector angle had the largest P-wave amplitude of .038mV (.022 – .054) and R-wave of 0.76mV (0.52 – 1.08). P-wave amplitude was identical between both gender at all vector angles. Marginal differences in R-wave amplitude are noted between males and females for vertical vector only, but not with oblique or horizontal angle. Although the oblique angle had the largest P- and R-wave amplitudes, a longer sensing vector provides larger EGM amplitudes which may be important for achieving adequate electrogram sensing when ICM implant orientation is influenced by cosmetic or anatomical considerations.

PO-02-106 GENERAL ANESTHESIA VERSUS CONSCIOUS SEDATION WITH LOCOREGIONAL ANESTHESIA IN S-ICD IMPLANTATION: A MONOCENTRIC RETROSPECTIVE ANALYSIS

In patients not requiring pacing, the subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a safe and effective alternative to the transvenous implantable cardioverter-defibrillator (TV-ICD) for the treatment of life-threatening ventricular arrhythmias. The S-ICD’s larger size requires a larger pocket for insertion and peri-procedural lead tunnelling carries high nociceptive potential, resulting historically in 65% of S-ICD implantations being performed under general anesthesia (GA). This study seeks to demonstrate that conscious sedation with locoregional anesthesia (CS-LA) is a safe and effective alternative to general anesthesia (GA) in S-ICD implantation. A total of 138 S-ICD implantations (90 under CS-LA) at our institution between 2013 and 2020 were studied The CS-LA technique was performed with conscious sedation, local anesthesia of the pocket and xyphoid incision sites, and post-procedural intercostal nerve blocade of the 4th to 7th intercostal spaces with a mixture of 10mL of 0.5% bupivacaine and 20mL of 2% lidocaine without epinephrine. Analgesic efficacy in the 24 post-operative hours was evaluated by Numerical Pain Rating Scale (NPRS) score and by total analgesic medication dosage received. Safety was evaluated by comparing the incidence of significant adverse events (AE): hypotension <80 mmHg or requiring vasopressors, bradycardia <40 bpm, or desaturation <90% for more than two minutes or requiring non-invasive ventilation maneuvers. Post-procedural pain at 15 minutes and at 24 hours was significantly less in the CS-LA group, with a difference of -0.90 (p=0.04) and -1.21 (p=0.004) respectively. Post-procedural opioid consumption was 10.64mg of per os morphine equivalents (p=0.046) lower than in the CS-LA group. No significant difference in the likelihood of at least one adverse event occurring was noted, with CS-LA demonstrating OR 1.95 (95% CI [0.86, 4.40], p=0.11) for at least one AE. Only one patient in the CS-LA arm required conversion to GA, due to excessive agitation during the procedure. S-ICD implantation under CS-LA was superior at 15 minutes and 24 hours to GA in terms of analgesic efficacy and post-procedural patient comfort. CS-LA’s safety profile was similar to GA, with no significantly increased risk of suffering at least one adverse event.

Minimally invasive cardiac surgery via bilateral thoracotomy in treatment of left ventricle aneurysm: a case report

BackgroundLeft ventricle aneurysm (LVA) as a sequela to myocardial infarction or iatrogenic injury is required surgical treatment with full median sternotomy. Herein, we report a case of successful surgical treatment of left ventricle aneurysm performed by minimally invasive cardiac surgery (MICS).Case presentationWe describe a case of a LVA treated by minimally invasive cardiac surgery in an 82-year-old woman who reported to the hospital with the complaint of chest pains at rest. Computed tomography (CT) coronary angiography revealed a left ventricle apical aneurysm. The aneurysm was suspected to be a pseudoaneurysm caused by a previous myocardial infarction. Surgery was performed under general anesthesia, with the patient in a supine position. A small incision was made in the 3rd intercostal space through which an aortic root vent cannula and aortic clamp were inserted, followed by exposing the aneurysm via incision of the left 6th intercostal space. The aneurysm was resected and pathologically examined, revealing it to be a “true” aneurysm. The left ventricle wall was closed using polypropene mattress sutures. Postoperative CT scan revealed successful resection of the aneurysm. Usually, a surgical treatment with full median sternotomy and left ventriculostomy is indicated for LVA. We decided to treat the LVA with bilateral thoracotomy MICS. We preferred to perform this procedure under cardiac arrest to ensure safe and secure closure of the aneurysm. The right small thoracotomy was necessary for aortic cross-clamping and aortic root venting.ConclusionsThe procedure was safe and simple and yielded excellent postoperative outcomes. Therefore, we speculate that this method can be applied to the management of larger aneurysms.

How I do VATS segmentectomy: the two-port approach

: The authors describe their bi-portal videoassisted thoracoscopic approach to perform anatomic segmentectomies. Operating room setting and details of individual segmentectomies performed through this approach are described. The approach consists of a 3–4 cm anterolateral utility incision performed at the level of 4th or 5th intercostal space and another 1–1.5 cm incision at the level of the 6–7th intercostal space performed just anterior to the posterior axillary line. In general, a wound protector is applied in the utility incision and a trocarless technique is used in the inferior port. The utility and the inferior incisions are used often interchangeably and the type and sequence of instrument introduced through one or the other port change depending on the type of segmentectomy. In general, for upper lobe segmentectomies, the thoracoscope is introduced in the utility incision, while for lower lobe segmentectomies it is positioned in the inferior port. All procedures start with lung inspection to identify the position of the tumour in relation to the preoperative imaging. A pre-emptive intercostal analgesia is performed. Subsequently, the segmentectomy procedure is performed with individual dissection and division of the segmental hilar structures and final division of the intersegmental plane. A systematic lymph node dissection is always performed.

Complete uni-port video-assisted thoracoscopic surgery for surgical stabilization of rib fractures: a case report

BackgroundRib fractures are a common injury in trauma. Potential complications include pain, pneumonia, respiratory failure, disability, and death. Surgical stabilization of rib fractures (SSRF) has become an available treatment option, and complete video-assisted thoracoscopic surgery (VATS) for SSRF is gradually accepted because of minimally invasive and pain relief. To our knowledge, complete uni-port VATS for SSRF has not yet been reported.Case presentationA 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. He was found with left 7th through 11th rib fractures with a pulmonary contusion from computed tomography (CT). A 4 cm incision was made in the 7th intercostal space in the midaxillary line, and complete uni-port VATS for SSRF were operated. The patient's pain was significantly relieved after the operation, and the scar was tiny and unapparent.ConclusionsComplete uni-port VATS for SSRF is a novel and modificatory method of operation with the benefit of minimal invasion, meanwhile, intrathoracic injuries could be treated at the same time. Further study is warranted.

Minimally Invasive Coronary Revascularization. Technical Aspects and Current Results

Coronary artery bypass surgery has been for decades the gold standard for the treatment of coronary artery disease, especially in patients with 3-vessel disease. Despite the excellent results achieved through the application of this technique, problems related to median sternotomy and the use of cardiopulmonary bypass such as wound infections and cerebral stroke still play an important role in the postoperative course of these patients. Minimally invasive coronary revascularization techniques aim at reducing the rate of such complications while offering the same quality of revascularization.&#x0D; Minimally invasive coronary surgery includes a set of coronary revascularization techniques that are completed without the use of cardiopulmonary bypass or through a left mini-thoracotomy at the level of the 4th or 5th intercostal space and aim at reducing the level of the aforementioned complications compared to the standard technique. Hybrid coronary revascularization is an alternative approach that combines surgical revascularization with percutaneous coronary interventions to extend the treatment spectrum even further. Through the application of these techniques, surgeons aim at minimizing the risk of infection of the surgical wound and significantly reduce the number of post-operative cerebral strokes. Also, numerous studies have shown that minimally invasive coronary surgery can offer better results in terms of duration of the mechanical ventilation, length of stay in intensive care, transfusions of blood products and consequently in reducing treatment costs.&#x0D; Minimally invasive revascularization techniques are not only an important alternative to standard coronary surgery, but in the near future will constitute the standard treatment for this group of patients. This article aims to describe the techniques used to achieve minimally invasive coronary revascularization and to highlight the outcomes of the different approaches.CABG,

Uniportal video-assisted thoracoscopic thymectomy in Hospital Kuala Lumpur: a retrospective observational review of outcomes for patients diagnosed with thymomatous and non-thymomatous myasthenia gravis.

The standard treatment for thymomatous myasthenia gravis (TMG) patients is thymectomy, whereas its role in non-TMG (NTMG) is still under debate. The objective of this study is to assess myasthenia gravis (MG) outcomes of thymectomy using the uniportal video-assisted thoracoscopic surgery (UVATS) technique for both groups and evaluate the procedure's efficacy and safety. We retrospectively collected data from January 2019 to December 2022 at Hospital Kuala Lumpur. The Myasthenia Gravis Activities of Daily Living (MG-ADL) scoring and the Myasthenia Gravis Foundation of America's Post Interventional Score (MGFA-PIS) measured our primary outcome. Secondary outcomes included surgery-related morbidity. All patients underwent a UVATS thymectomy, with the incision at the right anterior axillary line at the 5th intercostal space. Out of 26 patients, 22 were analysed. The MG-ADL scores indicated a significant mean score reduction post-surgery [6.9; 95% confidence interval (CI): 4.42 to 9.67; P<0.001]. NTMG patients exhibited a greater decrease in MG-ADL mean score than TMG patients {9.5 [standard deviation (SD) 4.8] vs. 6.1 (SD 5.4) P<0.001}. The MGFA-PIS showed complete stable remission (CSR) rates of 43% for TMG and 25% for NTMG patients. Surgical morbidity was observed in 13% of patients, of which were myasthenic crisis, difficult extubation due to carbon dioxide (CO2) retention and subcutaneous emphysema. Thymectomy via UVATS is an effective and safe approach for improving symptoms in both TMG and NTMG patients.

New acoustic window for assessing the inferior vena cava collapsibility in humans in the prone position

Objective: Ultrasound assessment of inferior vena cava (IVC) collapsibility is performed to determine the volume status of critically ill patients. We propose a new acoustic window for visualizing a vein in a prone patient. Case Presentation: A healthy volunteer took part in the study. The study protocol includes two stages: 1) performing a magnetic resonance imaging (MRI) examination to determine the projection of a certain IVC area on the posterior chest surface (holotopy), 2) performing an ultrasound scanning in the area of IVC projection in order to identify it and determine its dimensions. Conclusion: The 11th intercostal space parallel to the paraspinal line allows to visualize the IVC in the prone position. This gives a potential opportunity to use it to assess the IVC collapsibility. Its potential advantage is the ability to assess the compressibility of IVC in the antero-posterior direction.

1107: EVALUATION OF LIPOSOMAL BUPIVACAINE VERSUS USUAL CARE AND ITS EFFECT ON PAIN FOR CARDIAC SURGERY

Introduction: The objective of this study is to compare clinical effects of standard of care and liposomal bupivacaine. The primary outcome of this study will be to compare the pain scores associated with liposomal bupivacaine compared to standard of care of standard bupivacaine. Methods: A prospective, randomized, single-blinded, active-controlled, parallel group trial was conducted on cardiac surgery evaluating opioid analgesic consumption and effectiveness of pain control in patients who received liposomal bupivacaine vs. bupivacaine/epinephrine. The study was conducted at a 503-bed tertiary care community hospital. Participants included patients of at least 18 years of age undergoing a cardiac surgical procedure at the study institution. The standard of care group received 0.25% bupivacaine with epinephrine at 1 mL/kg total dose and the treatment arm received liposomal bupivacaine 266 mg/20 ml added to 40 ml 0.25% bupivacaine with epinephrine. Both treatment arms received either therapy as a single-dose infiltration from the first to the 8th intercostal space. Results: A total of 43 patients received liposomal bupivacaine and 44 patients received bupivacaine/epinephrine. The difference in average opioid (morphine equivalent) usage between liposomal bupivacaine and bupivacaine/epinephrine on post-operative (POD) day 1 was 11 mg (IQR 5.25-24.3 mg) and 14 mg (IQR 5-26.175 mg) and on POD 4, the difference was 1.5 mg (IQR 0-4.875) and 0 mg (IQR 0-3). There was no difference in average pain scores and adverse effects between the two groups. Conclusions: The results of this current study found that the administration of liposomal bupivacaine intra-operatively cardiac surgery show less opioid use as compared to the standard of care. The study is ongoing and enrolling more patients.

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Abstract Background A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case. Methods General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed. Results Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient. The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned. Conclusions We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling. Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

Abstract 14825: Utilizing a Novel Horizontal Approach for Implantable Loop Recorders

Introduction: Implantable Loop Recorders (ILR) are used in detecting and monitoring arrhythmias. These subcutaneous devices remain in place for years for continuous cardiac monitoring. There have been few studies on how best to position an ILR for maximum accuracy and comfort. Currently, manufacturers recommend insertion of the ILR at a 45-degree angle from the sternum at the 4th intercostal space and a minimum R wave amplitude of 0.2mV for adequate sensing. We adopted the technique of implanting all ILRs horizontally between the 4th and 5th ribs and examined patient outcomes. Methods: Data was obtained through chart review of 288 patients who received a horizontally placed ILR from 2019 to 2021. Patient’s age, sex, BMI, indication for ILR, ILR manufacturer, episodes of artifact and complications were collected. The R wave magnitude (mV) immediately succeeding implantation was recorded from the procedure note. Results: Of our patients, 91% received a Medtronic ILR, 6% had a Boston Scientific ILR and 3% had a Biotronik ILR. The mean age was 60 ± 14 years, with 51% of patients being male. Within the sample, 27% had a BMI less than 25 kg/m 2 , 33% were overweight, and 40% were obese. Approximately 271 patients had a documented R wave amplitude at implantation, with the average being 0.44 mV ± 0.41 (95% CI 0.39 to 0.48). Of 240 patients with follow-up, 8% had an arrhythmia recorded that was found to be a false positive episode. There were no major complications. Conclusions: Using the horizontal approach, we obtained adequate sensing based on average R wave amplitude. We had very few false positive arrhythmias, as only 8% of our patients were noted to have a false positive reading versus 25% reported in other studies. This approach minimizes involvement of breast tissue and thus reduces risk of peri-procedural bleeding and ILR migration and increases patient comfort. The outcomes of our population indicate that this is a viable approach and may be superior to standard.

Abstract 14714: Marked Gradient Reduction Through a Transcoronary Alcohol Ablation of Septal Hypertrophy in a Patient With Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

A 66-year-old male with a history of carpal tunnel syndrome and hypertension presented with dyspnea (NYHA III), angina pectoris, and sinus bradycardia. On clinical examination, the patient was stable and euvolemic. A systolic murmur (III/VI) was audible in the 4th left intercostal space laterally, augmented after a Valsalva maneuver. An electrocardiogram revealed normal sinus rhythm, heart rate of 81 bpm, normal voltage, and non-specific ST-changes in I, II, III, aVF, V5, and V6. The patient underwent a transthoracic echocardiography, which revealed thickened ventricular walls (IVSd 23 mm, PWd 20 mm), hyperdynamic left ventricular ejection fraction (LVEF 75%), LVOT gradient of 150 mmHg maximum (after Valsalva maneuver), apical sparing on strain analysis, and a dilated atria. A coronary angiography ruled out coronary artery disease. A endomyocardial biopsy revealed hypertrophic cardiomyopathy combined with focal cardiac amyloidosis (Figure 1). Subtyping and genetic analysis revealed transthyretin (ATTR) wild-type amyloidosis. Accordingly, therapy with Tafamidis 61 mg daily was initiated. Given the relevant amount of hypertrophy depicted on the biopsy samples, the high LVOT gradient, and the patient’s debilitating symptoms despite maximal medical therapy, the decision was made to attempt a transcoronary alcohol ablation of the septal hypertrophy (TASH). The TASH reduced the LVOT gradient from 150 mmHg to 35 mmHg. After the procedure, the patient experienced significant symptom improvement (NYHA II) and was discharged the next day. This case illustrates the feasibility of marked LVOT gradient reduction in patients with amyloidosis and hypertrophic cardiomyopathy through a TASH procedure. Figure 1: Histology reveals hypertrophic cardiomyocytes and cardiac amyloidosis on Congo red staining.

Time to Resuscitate Cardiopulmonary Resuscitation: The 3R/CPR Refill-Recoil-Rebound

Introduction: Sudden cardiac arrest (SCA) remains a major healthcare issue worldwide with gloomy outcomes due to poor perfusion of cardiopulmonary resuscitation (CPR), deemed unsuitable for hemostatic conditions, cardiotorsal anatomy, electrophysiology, and thoracic biomechanics. Alternatively, we propose a new management, implementing rational exploitation of the stagnant blood masses: manually with a novel technique of cardiac massage and mechanically with a circulatory flow restoration (CFR) device.&#x0D; Methods: Simulated chest compressions were performed through the 5th intercostal space in professional Lifeguards volunteers, placed in the left lateral decubitus position with raised legs and abdominal compression.&#x0D; Results: Bypassing the sternal barrier, refilling the heart, and then compressing the chest with a recoil-rebound maneuver (3R / CPR) can significantly promote return of spontaneous circulation (ROSC). The effectiveness of the CFR device versus CPR has previously been demonstrated in the literature.&#x0D; Conclusion: Unlike current CPR, the 3R/CPR adapts human morphology and provides adequate myocardial perfusion promoting ROSC safely, under all circumstances. Preclinical computational models can confirm the effectiveness of the technique.

Normative Value of Chest Expansion in Healthy Children Between 5 to 12 Years of Age Group

Background: Chest expansion measurement is included as a standard mode of measurement to evaluate patient’s baseline status of respiratory function. There are various anatomical and physiological differences between adult and paediatric respiratory system hence, adult values of chest expansion cannot be used as reference values in paediatric population. Also, there is lack of recent data that has evaluated chest expansion values in paediatric age group. So, the present study was undertaken to find out normal chest expansion values in children between 5-12 years of age. It is important to know the reference value for precise interpretation. Methodology: A cross sectional observational study was carried out in 600 children between age group of 5-12 years and with normal BMI(without H/O any cardiac/respiratory illness, musculoskeletal or neurological diseases, spinal deviations, cough and cold). Chest expansion measurements were assessed in sitting position at three levels that is, 2nd, 4th and 6th intercostal spaces(ICS), using an non- elastic measuring tape. It was taken as thoracic circumference at the end of maximum exhalation and inspiration. An average of three such readings at each level was taken into consideration. Results: To find value of chest expansion at 2nd, 4th and 6th ICS levels a average values of the three measurements taken at each level at same time was taken into consideration. Conclusion: The normative values of chest expansion in healthy children between age group of 5-12 years is 2nd Intercostal space- 1 inch/ 2.5 cm, 4th Intercostal space- 1 inch/2.5 cm, 6th Intercostal space- 1.7 inch/ 4.25cm. KEY WORDS: Chest Expansion, Normative Values, Children, Paediatric.

How arrhythmic risk changes over time in patients with low risk Brugada syndrome

Abstract Background Brugada Syndrome (BrS) is an inherited disorder associated with an increased risk of sudden cardiac death (SCD) and is diagnosed by the presence of a Brugada type I ECG pattern, either spontaneous or drug-induced. A spontaneous ECG pattern is one of the two main risk factors for SCD, along with syncope. However, there is still no clear evidence on how and how often to screen patients with drug-induced BrS to detect a spontaneous ECG pattern, therefore allowing to reassess their arrhythmic risk. Purpose To determine how many subjects develop a spontaneous ECG pattern among a pool of patients with low risk BrS (drug-induced pattern without history of syncope at the time of diagnosis) observed through systematic ECG Holter monitoring. Methods We retrospectively collected data for all patients with low risk BrS treated at our center for at least 12 months between 2016 and 2021. Each patient was tested yearly with at least one 12-lead 24-hour ECG Holter monitoring with high precordial leads (V1-V2, V3-V4, V5-V6 respectively in 2nd, 3rd and 4th intercostal space parasternal left and right). In case of spontaneous pattern detection at two recordings, patients underwent electrophysiological study (EPS) and in case of inducible ventricular arrhythmias, implantable cardiac defibrillator (ICD) placement. Results We included 63 patients with low risk BrS. During a median follow-up of 48 months: 1 patient died for SCD (1.6%), 1 experienced syncope (1.6%) and 19 exhibited a spontaneous ECG pattern (30.2%). Of these 19 patients: 18 were males and 5 had a mutation of SCN5A; the average age at the time of spontaneous pattern detection was 48.1±11.5 years. The average number of ECG holters/per patient/per year was 1.1±0.6, the average number of ECG Holters until the detection of a spontaneous pattern was 3.3±1.8, whilst the average number of months in between the diagnosis and the detection of a spontaneous pattern was 43.2±41.1. After the observation of a spontaneous pattern: 6 patients were excluded from further investigation (as they had already undergone EPS or refused), 1 was directly treated with ICD and 12 underwent EPS, 4 of whom consequently underwent ICD placement. Among these 5 patients who underwent ICD placement – 7.9% of the original 63 patients – we observed 1 appropriate ICD intervention (antitachycardia pacing), 1 inappropriate ICD shock and 1 ICD related complication. Conclusions In our population of patients with low risk BrS the detection of a spontaneous ECG pattern is the most common determinant of risk reclassification. Systematic ECG Holter monitoring disclosed the presence of a spontaneous ECG pattern in a relevant number of subjects, allowing to reassess their arrhythmic risk and indication for ICD placement. Our study stresses the importance of periodic evaluation of low risk BrS patients with ECG Holter monitoring and the need for further investigation to define the optimal monitoring strategy. Funding Acknowledgement Type of funding sources: None.

Dorsal incision shows more efficacy and safety to traditional incision in single-portal video-assisted thoracoscopic surgery segmentectomy of LS9+10: a non-randomized prospective clinical trial

Segmentectomy is increasingly performed as a surgical technique. Traditional anterior axillary line and mid-axillary line video-assisted thoracoscopic surgery (VATS) incision meets difficulties when dealing with left segment 9+10 (LS9+10), as the distance and angle of view make it uneasy to expose the trachea, blood vessels and intersegment plane. As an alternative, dorsal incision may be advantageous as which faces the key structures of LS9+10, may facilitate the management of trachea and blood vessels of LS9+10, but there was no clinical proof reported ever. This study is targeted to compare the efficacy and safety of these two incisions in segmentectomy of LS9+10. The dorsal incision is made behind the posterior axillary line, 8th intercostal space. Patients with ground glass opacity (GGO) which solid ingredients is less than 25%, locates at LS9+10, and segmentectomy of LS9+10 could ensure the cut edge were enrolled in the study and were allocated to the traditional incision group or dorsal incision group based on the parity of hospital number. Efficacy outcomes such as the duration of surgery and safety outcomes including postoperative air-leakage duration, length of hospital stay, amount of bleeding and pain score were recorded. The Independent-samples t-test and Mann-Whitey U test were applied in data analysis. A total of 68 patients were enrolled and allocated into the traditional incision group and dorsal incision group. In the traditional incision group, the average surgery time was 71.03±6.87 min (median 71.5 min), while that in the dorsal incision group was an average of 62.72±6.24 min (median 61.0 min, P=0.001). The postoperative duration of air-leakage was 2.16±1.63 and 1.36±1.33 days for traditional incision group and dorsal incision group (P=0.030), respectively. The traditional incision group had a greater length of postoperative hospital stay (3.69±1.36 days) than the dorsal incision group (3.08±1.03 days, P=0.041), when amount of bleeding and pain score showed no differences between these two groups. Data suggested a statistically significant advantage for the dorsal incision procedure. Dorsal incision can facilitate the segmentectomy of LS9+10, and significantly reduce the surgery time, postoperative duration of air-leakage and length of hospital stay.

STREPTOCOCCUS AGALACTIAE ENDOCARDITIS OF THE NATIVE VALVE IN THE PATIENT WITH END-STAGE RENAL DISEASE

STREPTOCOCCUS AGALACTIAE ENDOCARDITIS OF THE NATIVE VALVE IN THE PATIENT WITH END-STAGE RENAL DISEASE

A reappraisal of pediatric thoracic surface anatomy.

Accurate knowledge of surface anatomy is essential for physical examination, invasive procedures, and anatomy education. Individual factors such as age make surface landmarks variable so accurate descriptions are needed. The aim of this study is to describe age-related surface landmarks for intrathoracic structures in children. A total of 156 thoracic computed tomography scans of children aged 0-18 years were categorized into six groups, and the associations between major intrathoracic structures and surface landmarks were analyzed. Sternal angle is an accurate surface landmark for the azygos vein-superior vena cava junction in all age groups. However, the aortic arch (except in the 0-1year group), the bifurcation of the pulmonary trunk and the tracheal bifurcation in those aged 15-18 years were not within this plane. The left brachiocephalic vein was located behind the ipsilateral sternoclavicular joint except in the 1-3 years group, and the right was behind it in children older than 6 years. The apex of heart was at the 5th intercostal space level in the 0-1 and 12-18 years groups; however, it was higher in the other groups. The lower borders of the lungs were at the sixth costal cartilage level in the midclavicular line, eighth intercostal space level in the midaxillary line, and T12 adjacent to the vertebral column in the 15-18 years group; the lower borders were at higher levels in younger children. Defining the variations in surface anatomy by in vivo studies will increase its clinical and pedagogical value.

Iatrogenic Pneumopericardium in a Male Full-Term Newborn with Spontaneous Pneumothorax

Abstract Neonatal pneumopericardium, a collection of air in the pericardial sac, is less common form of air leak syndrome, but unfortunately with high mortality rate. We report a rare case of male fullterm newborn who soon after birth presented with respiratory distress. Chest radiograph showed spontaneous bilateral pneumothorax after which a chest drain was placed between anterior and midaxillary line in the 5th right intercostal space. The infant soon presented with tachypnea, dyspnea, muffled heart sounds, acidosis indicating cardiorespiratory worsening. On chest radiograph ‘’Halo” sign appeared indicating pneumopericardium. We believe that spontaneous reposition of a chest drain damaged the pericardial sac which combined with ventilation mechanism (‘’Macklin effect”) most likely led to pneumopericardium. After partial chest drain extraction the infant showed signs of improvement, but had to be closely monitored due to risk of tension pneumopericardium. Careful thoracal drain placement and fixation is crucial to prevent iatrogenic pneumopericardium, which can lead to deadly tension pneumopericardium.

A RARE CASE OF DORV IN ADULTHOOD

Background: Double outlet right ventricle (DORV) is a rare cardiac malformation in children and even more rare when it comes to adulthood. Clinical Presentation: We report a boy with DORV with Mitral atresia and hypoplastic Left Ventricle who presented to us with breathlessness on climbing 2 flight of stairs at the age of 22 years.He was not seriously limited when he came to our hospital with complaint of breathlessness on exertion. The mother first noticed him getting breathless on climbing 2 flight of stairs at 5 years of age.The patient had history of recurrent infections in the past with failure to gain weight since childhood.On Examination the Pulse was 90 beats per minute,Spo2 was 85% on Room Air in all four limbs, BP was 90/60 mmhg, no tachypnea.There was Grade 2 clubbing present with cyanosis on the nails of all four limbs. Patient had cleft lip and cleft palate with pes cavus in left foot. On inspection, precordial bulge seen on left side with bony cage deformity and apex impulse in left 5th intercostal space lateral to midclavicular line and visible pulsations in 3rd intercostal space. On palpation, Diastolic thrill present in 2nd left intercostal space with grade 3 parasternal heave. On Auscultation, Grade 3/6 loud harsh diastolic murmur heard over the left precordium and interscapular and infrascapular area with diaphragm of stethoscope in supine position.Soft high pitched early diastolic murmur heard best at left upper sternal border and increased during inspiration. 2D echo suggestive of Double outlet Right ventricle with mitral atresia with hypoplastic left ventricle with pulmonary arterial hypertension and severe pulmonary regurgitation. Discussion: To our knowledge very few cases of DORV survives upto this age without any serious limitation that have been reported.DORV if diagnosed early and operated between the age of 1 year to 3 years have satisfactory results. Some cases that remain asymptomatic or are diagnosed late leads to development of pulmonary hypertension which makes them poor candidates of surgery.It was surprising as this patient have survived till now without any serious limitation or symptoms.