3rd Intercostal Space Research Articles

Diagnostic yield of a smartphone-operated, 6-lead device in Brugada syndrome

Abstract Background The spontaneous type 1 ECG pattern (ECG-T1) is diagnostic of Brugada syndrome (BrS) and implies an increased arrhythmic risk, while pharmacologically-induced ECG-T1 without other clinical features only makes the diagnosis possible, according to ESC guidelines. Given the dynamic nature of the ECG patterns in BrS, tools to increase the detection of ECG-T1 are needed to improve BrS diagnosis and adequately assess the arrhythmic risk. Purpose To assess the diagnostic yield of a smartphone-operated, 6-lead device (6L-mobile ECG) in BrS. Methods Eighteen patients with spontaneous or drug-induced ECG-T1 (Figure 1-a), 18 patients with type 2 ECG pattern (ECG-T2, figure 2-a) and 18 controls were included. A 12-lead ECG and a 6L-mobile ECG were obtained by placing leads V1 and V2 in 2nd, 3rd and 4th intercostal space (ICS). The 6L-mobile ECG was placed with the 2 frontal electrodes in contact with the patients’ chest. Each 12-lead ECG and 6L-mobile ECG recording was classified as ECG-T1, ECG-T2 or non-diagnostic (ND), by considering the lead/ICS with the most evident pattern for analysis. Results Sixteen 6L-mobile ECG recordings were diagnostic of ECG-T1 (figure 1-b), 18 of ECG-T2 (figure 2-b) and 20 were ND. Unipolar 6-L mobile ECG recordings at any ICS had a 77% sensitivity and 94% specificity for the diagnosis of ECG-T1 (NPV 89%, PPV 88%, p<0.0001). For ECG-T2, the 6L-mobile ECG showed a 89% sensitivity and 94% specificity (NPV 94%; PPV 89%, p<0.0001). Conclusions The 6-L mobile ECG device showed a high diagnostic yield for type 1 and type 2 ECG patterns and may emerge as a new diagnostic and monitoring tool in BrS.

#2923 Intracardiac vascular access as a last resort for hemodialysis in patients with exhausted traditional vascular access: a case report

Abstract Introduction The dysfunction of vascular access (VA) constitutes one of the main problems faced by nephrologists and patients in chronic hemodialysis (HD). This challenge becomes particularly worrying in patients who have depleted their upper extremity venous resources and have no longer arteriovenous fistula available, requiring the placement of a central venous catheters. It leads to an increase in morbidity and mortality and a higher of infections, thrombosis and exhaustion of access points. In such cases, alternatives to conventional VA are limited, with intracardiac access being an emerging option, albeit with very limited documented experience. Case Report We describe the case of a 68-year-old male with a history of hypertension, nasopharyngeal carcinoma in 2012 treated with chemotherapy and radiotherapy. In 2018 he was diagnosed with low-grade urothelial bladder carcinoma (PT1G1) that infiltrated the subepithelial corion while sparing the muscular layer. He also had severe hydronephrosis with impaired renal function, requiring radical cystoprostatectomy with Bricker bladder reconstruction and subsequent bilateral nephrostomy due to persistent dilatation and progressive deterioration of renal function. He began chronic HD in June 2020 through a left femoral catheter due to the inability to access the upper thoracic vascular tree due to stenosing fibrosis from previous radiotherapy. He was placed on the waiting list for a kidney transplant (KT) in the right iliac fossa but experienced multiple catheter dysfunction episodes, requiring the placement of a right femoral venous catheter to continue with his HD sessions. Additionally, peritoneal dialysis was not considered due to previous urological surgery. Considering the limitation of VA and the possibility of KT as its best alternative, we opted for the insertion of a tunnelled intracardiac catheter at the right atrium. This procedure was conducted by the Cardiac Surgery Department on 03/12/2021 through a median sternotomy in the 4th intercostal space. A permanent hemodialysis catheter was inserted in the right atrium through the 3rd intercostal space and fixed with a purse-string suture. It was then tunnelled under the breast to the 2nd intercostal space through a counter-incision. The cuff was appropriately placed in the subcutaneous tissue (Figs 1 and 2). The intervention proceeded without any complication and the catheter exhibited normal functionality. After that, the patient received anticoagulation with enoxaparin the days between dialysis sessions. Consequently, the right femoral catheter was safely removed. Two weeks later, the patient successfully received a KT from a deceased donor. He was discharged on the day 11st post-KT with any complication and maintains a good renal function after 2 years of follow-up with a serum creatinine 1.7 mg/dL (eGFR: 39 ml/min). The intracardiac catheter was removed one month later through a mini-thoracotomy. Conclusions Intracardiac VA is an unusual and high-risk resource that seems an alternative in patients with exhausted VA with no alternative emergency renal replacement therapy, so it should be considered as the last resort. In the case of our patient, the implantation of this catheter allowed for the continuation of dialysis and access to KT.

A rare clinical case of malignant ectopic retrosternal goiter of a large size in a patient with aberrant right subclavian artery

Background. Ectopic goiter accounts for only 0.2 % to 1 % of all mediastinal goiters. The aberrant right subclavian artery (arteria lusoria) is an extremely rare anomaly of the major vessel, with a prevalence not exceeding 0.3 % in the general population. This paper presents the first case of malignant ectopic retrosternal goiter of a large size in combination with the aberrant right subclavian artery. Clinical case description. A 61-year-old male presented to the thoracic surgery department of P. Herzen Moscow oncology Research institute with a large posterior mediastinal mass measuring 108×106×79 mm and adjacent to the right lobe of the thyroid gland. The tumor displaced the trachea and esophagus. Open biopsy through a thoracotomy incision revealed thyroid gland cells without signs of atypia. A detailed examination revealed mediastinal vascular anomaly – retrotracheal position of the right subclavian artery. a complete longitudinal sternotomy, complemented by a right-sided thoracotomy at the 3rd intercostal space, served as the surgical approach. The operation lasted 320 minutes, with a blood loss of 3500 ml. The postoperative period was uneventful. The morphological examination of the surgical specimen revealed nodular hyperplasia of the ectopic thyroid tissue with the growth of well-differentiated follicular carcinoma without metastatic involvement of removed lymph nodes. Considering the identified follicular carcinoma, total thyroidectomy was performed. Conclusion. In surgical planning, it is crucial to assess the location of major mediastinal vessels and their relationship with the goiter. Therefore, all patients with mediastinal lesions should undergo preoperative contrast-enhanced ct. Retrosternal goiter predisposes to a higher rate of malignancy compared to cervical goiter. If the lower edge of the goiter is at the level of or below the aortic arch, cervical access should be supplemented with sternotomy. In cases of a massive thoracic component, additional thoracotomy is justified.

Technical exploration and early results of two-port total thoracoscopic aortic-mitral double-valve replacement

Objective: To examine the clinical outcomes of patients undergoing total thoracoscopic aortic-mitral double-valve replacement. Methods: This is a retrospective case series study. The clinical data of 50 patients who underwent double-valve replacement under a total thoracoscopic two-port approach from November 2021 to August 2022 in the Department of Cardiovascular Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. There were 32 males and 18 females, with an age of (55.3±8.8) years (range: 21 to 62 years). Among them, 36 cases had rheumatic heart disease and 14 cases had infective endocarditis. The 3rd intercostal space between the right anterior axillary line and the midclavicular line was selected as the main operating hole, the total thoracoscopic double-valve replacement were successfully carried out. Baseline data, intraoperative information, surgical outcomes, and postoperative complications were collected for all patients. Results: The cardiopulmonary bypass time was (168.2±30.9) minutes (range: 125 to 187 minutes), the aortic cross-clamping time was (118.8±16.5) minutes (range: 96 to 147 minutes). Five patients received bioprosthetic valves, and 45 received mechanical prosthetic valves. Postoperative mechanical ventilation lasted (9.6±3.4) hours (range: 5.1 to 14.2 hours), the ICU stay was (24.8±7.3) hours (range: 16.3 to 30.1 hours), and the postoperative hospital stay was (6.5±1.2) days (range: 5.0 to 8.0 days). Four patients received red blood cell transfusions of (2.7±0.9) units (range: 2 to 4 units), and the postoperative chest drainage volume was (222.1±56.3) ml (range: 175 to 289 ml). No deaths occurred intraoperatively or in the early postoperative period. One patient required reoperation due to bleeding in the aortic incision. Three patients had mild to moderate paravalvular leakage around the prosthetic aortic valve, with no cases of third-degree atrioventricular block or conversions to median sternotomy. Conclusions: The early outcomes of total thoracoscopic double valve replacement surgery are satisfactory, demonstrating safety and efficacy. This surgical approach expands the scope of total thoracoscopic cardiac surgery, which warrants further investigation and research.

Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair

BackgroundRecently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it’s not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually.Case presentationWe report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms.ConclusionIn a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.

Single port endoscopic thoracic sympathectomy with holmium laser for treating palmar hyperhidrosis at Thai Binh Provincial General Hospital

Introduction: thoracoscopic sympathectomy for treating palmar hyperhidrosis often uses 2 ports. Research to evaluate the results of the method using 1 port < 5mm with Holmium Laser fiber.
 Object and Method: Description, prospective.
 Within 2 months from June 2023 to July 2023, 47 patients underwent single port endoscopic thoracic surgery using holmium laser to transect the sympathetic ganglia at T3 level for patients with palm sweating (26 patients) and T3-T4 level for patients with palm and axillary sweating (21 patients). The male-to-female ratio was 44.7% to 55.3%, with an average age of 18 ± 7.4 years (minimum age of 11 years, maximum age of 52 years). Surgical method: A single entry port trocar 14Fr located at the 3rd intercostal space, the posterior border of the pectoralis major muscle between the anterior and midaxillary lines, using a 12Fr endoscopic lens with integrated tunnel for Holmium Laser fiber. Patients were monitored and evaluated for early post-operative results: technical failure requiring the placement of a second port, complications during and after surgery and the degree of improvement in palmar hyperhidrosis, the rate of compensatory hyperhidrosis after 1 month and the patient's quality of life after surgery.
 Results:
 There were no technical failures. The time for transecting the sympathetic ganglion (one side) with Holmium Laser was 78 ± 40.76 seconds. All patients had dry hands after surgery, with two out of forty-seven patients having excessively dry hands. There were no complications during or after surgery, and no patients developed Horner’s syndrome. The average time to discharge after surgery was 30 ± 11.4 hours. Fourteen out of forty-seven patients had compensatory sweating after one month postoperatively at an acceptable level.
 Conclusion: The method of using a port < 5mm with an endoscopic lens integrated with a Holmium Laser fiber tunnel is safe, effective, less traumatic and highly aesthetic.

Epidural Anesthesia in Management of Pregnant Eissenmenger’s Syndrome Patient Undergoing Caesarean Section

Background: Eisenmenger syndrome is very rare in pregnant women. Debates remain concerning the management of Eisenmenger syndrome in this patient population, and the prognosis is unclear in terms of maternal and fetoneonatal outcomes. Managing anesthesia in maternal patients with a cardiac abnormality might be particularly difficult because these individuals have inadequate circulatory reserves and altered maternal cardiovascular physiology.
 Case presentation: We present a 26-year-old 34 weeks pregnant woman with Eisenmenger’s syndrome (ES) scheduled for an elective caesarean section. The clinical findings reveal slight tachypnea with peripheral oxygen saturation of 82% with oxygen supplementation using a cannula at 3 lpm. The patient's baseline hemodynamics are stable, but a third-degree murmur is heard in the 3rd and 4th left intercostal space. The patient was managed with epidural anesthesia using bupivacaine 0.5% 20 ml without adjuvant. The epidural catheter was inserted in an interspinous process between L3-L4. The surgery was done in 90 minutes with stable hemodynamics, and postoperatively, the patient was monitored in the intensive cardiac care unit (ICCU).
 Conclusion: Epidural anesthesia has been shown to provide favorable outcomes due to its slow onset and reducing the likelihood of abrupt hemodynamic changes.

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.

The 'island technique' for aortic arch and FET surgery: an 'evergreen' or a 'rekindled flame'?

The 'island technique' for aortic arch and FET surgery: an 'evergreen' or a 'rekindled flame'?

Co-activation of the diaphragm and external intercostal muscles through an adaptive closed-loop respiratory pacing controller.

Respiratory pacing is a promising alternative to traditional mechanical ventilation that has been shown to significantly increase the survival and quality of life after the neural control of the respiratory system has been compromised. However, current pacing approaches to achieve adequate ventilation tend to target only the diaphragm without pacing external intercostal muscles that are also activated during normal inspiration. Furthermore, the pacing paradigms do not allow for intermittent sighing, which carries an important physiological role. We hypothesized that simultaneous activation of the diaphragm and external intercostal muscles would improve the efficiency of respiratory pacing compared to diaphragm stimulation alone. We expanded an adaptive, closed-loop diaphragm pacing paradigm we had previously developed to include external intercostal muscle activation and sigh generation. We then investigated, using a rodent model for respiratory pacing, if simultaneous activation would delay the fatigability of the diaphragm during pacing and allow induction of appropriate sigh-like behavior in spontaneously breathing un-injured anesthetized rats (n = 8) with pacing electrodes implanted bilaterally in the diaphragm and external intercostal muscles, between 2nd and 3rd intercostal spaces. With this novel pacing system, we show that fatigability of the diaphragm was lower when using combined muscle stimulation than diaphragm stimulation alone (p = 0.014) and that combined muscle stimulation was able to induce sighs with significantly higher tidal volumes compared to diaphragm stimulation alone (p = 0.014). Our findings demonstrate that simultaneous activation of the inspiratory muscles could be used as a suitable strategy to delay stimulation-induced diaphragmatic fatigue and to induce a sigh-like behavior that could improve respiratory health.

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.

Metastatic proximal-type epithelioid sarcoma presenting as a chest lesion with a pathological fracture of the humeral neck

Introduction: Proximal-type epithelioid sarcoma is a rare soft tissue neoplasm which occurs mostly in young males and is much rarer than classic distal sub type. A young male, with a known diagnosis of neurofibromatosis type 1 (NF1) presenting with metastatic proximal-type epithelioid sarcoma is reported. Case Report: A 30-year-old male with known NF1, hypothyroidism, epilepsy, presented with a right shoulder pain of two weeks duration. Plain radiographs revealed an expansile lytic lesion, an aggressive periosteal reaction in right humeral head with an underlying pathological fracture. A well-defined extrapulmonary mass with a lobulated margin in upper zone of right hemithorax with inferior rib erosion of 3rd rib and the 3rd intercostal space widening were also observed. Contrast-enhanced computed tomography (CECT) chest and abdomen confirmed peripherally located poorly enhancing soft tissue mass with lobulated margins arising from posterior chest wall along with a subdiaphragmatic deposit. Multiple lytic lesions in right head of humerus with an underlying pathological fracture of surgical neck, T2, T6, and L3 vertebral bodies, and pelvic bones were observed too. Diagnosis of malignant peripheral nerve sheath tumor with metastases was made and ultrasound-guided biopsy of chest wall lesion was performed. Histology and immunohistochemistry (IHC) revealed a proximal type epithelioid sarcoma. The patient was managed with palliative surgery and oncological follow-up. Conclusion: Presentation of proximal-type epithelioid sarcoma with disseminated metastases in a patient with NF1 masquerading malignant peripheral nerve sheath tumor (MPNST) and the challenges of diagnosis on clinical, radiological, and histopathology as well as IHC perspectives of this rare disease entity is highlighted.

Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery

PurposeInternal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins.MethodsWe evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made.ResultsEfficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed.ConclusionOur study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

Pulmonary valve replacement via ministernotomy, early experience

The population of patients requiring pulmonary valve replacement (PVR) following surgery of the right ventricular outflow tract during infancy is growing. Full conventional sternotomy is widely used for PVR, while left anterior minithoracotomy has been described only in selected cases. Our aim is to describe our early experience with upper left ministernotomy as a systematic approach for PVR in teenagers and adult patients. From December 2019 to December 2021, 13 consecutive patients underwent PVR via ministernotomy at our institution. The indications were severe pulmonary regurgitation in 11 patients and severe conduit stenosis in 2 patients. Ten patients (76.9%) already had at least 1 sternotomy. Pulmonary homografts, stentless porcine bioprostheses or stented pericardial bioprostheses were implanted. Age at operation was 24.6 years old (17.6–38.4). There were no deaths, no cardiac injuries and no conversions to full sternotomy. The 3rd intercostal space was the most frequently used for the leftward extension of the ministernotomy ( Fig. 1 ). In 6 patients (46.1%), a residual intracardiac shunt was present and aortic cross-clamping was necessary. Median cardiopulmonary bypass and cross-clamping times were 70 (64–105.5) and 50 (40–75) minutes, respectively. Median intensive care and hospital stays were 2 (1–2.5) and 7 (6–11) days, respectively. All patients are doing well after a median follow-up of 16.2 months (13.5–19.0). Ministernotomy is a safe approach for PVR and redo PVR in teenagers and adults. This approach combines the advantages of minimally invasive surgery (expedited recovery) and those of a midline incision such as the access to the ascending aorta and the absence of additional scar in cases of redo PVR.

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.

Minimalinvaziv aortabillentyu-beultetes soran nyert kezdeti tapasztalataink

Introduction: Due to the aging population, aortic valve stenosis is the most frequently diagnosed acquired cardiac disease amongst adults. Various surgical techniques have been developed and median sternotomy has become the standard practice for exploration. Improvements in cardiological intervention techniques allow surgery to provide the same quality with less invasiveness.Objective: Our aim was to compare the results of the isolated aortic valve surgeries (AVR) performed as either full or partial sternotomy during the study period in terms of pre-, intra-, and postoperative variables.Patients and methods: We examined the results of the isolated AVR performed at Gottsegen National Cardiovascular Center between January 2019 and March 2020 (99 AVR and 151 mini-AVR). During mini-AVR we opened the sternum with J shape ministernotomy up to the 3rd or 4th intercostal space while in median sternotomy we separated the sternum in its total length.Results: Blood consumption (unit) (AVR: 2.90 [2.90]; mini-AVR: 1.85 [2.12]; p<0,05), days of hospitalization (AVR: 9.75 [2.99]; mini-AVR: 8.85 [2.85]; p<0,05) and length of surgery (minutes) (AVR:148.49 [34.4]; mini-AVR: 134.6 [34.8]; p<0,05) were significantly better in the mini-AVR group. In terms of preoperative variables, the two groups were not homogeneous therefore we corrected the strong predictive variables. As a result, levels of bio-statistical significance have disappeared but there is still a trend in favour of minimally invasive surgery.Conclusions: Mini-AVR surgery is considered a more cost-effective intervention compared to standard surgery in terms of less surgical trauma, reduced blood consumption, and shorter operative time.

Revisiting where to apply preimplant mapping to improve P-wave sensing of insertable cardiac monitors.

BackgroundInsertable cardiac monitors (ICMs) are used for long‐term cardiac rhythm monitoring. They have proven useful in diagnosing arrhythmias. They are conventionally inserted at the 4th intercostal space without preimplant mapping.MethodWe develop a new method, VisP, that finds an optimal insertion position by applying the lightweight preimplant mapping to nine candidate positions beyond the conventional ones. We retrospectively analyze consecutive 60 patients who underwent ICM insertion (Reveal LINQ™) between April 2019 and March 2021 and compare the two groups with and without VisP.ResultsAfter 9 patients were excluded because of ectopic atrial rhythms or atrial fibrillation, 51 patients were analyzed. Thirty‐one patients underwent the conventional insertion (non‐mapping), whereas 20 patients underwent VisP. VisP achieved large P‐wave amplitudes while retaining the R‐wave amplitude for all patients; in contrast, P waves were not detected for 11 patients out of the 31 patients in the non‐mapping group (35%). On average, the P‐wave amplitude was 0.065 mV for VisP, compared to 0.029 mV for the non‐mapping group (p‐value< .001). The average R‐wave amplitude was 0.69 mV for VisP and 0.71 mV for non‐mapping (p‐value = .88), indicating the R‐wave difference is insignificant between the two groups. VisP selected the 4th, 3rd, and 2nd intercostal spaces for 7, 11, and 2 patients, respectively, meaning that 13 out of the 20 cases (65%) fell out of the conventional insertion location of the 4th intercostal space.ConclusionsVisP improves the diagnostic ability of ICMs by finding an optimal position that yields reliable sensing of P waves while keeping high R‐wave sensing.

Clinical results after hybrid coronary revascularization with totally endoscopic coronary surgery

BackgroundThe optimal revascularization strategy remains uncertain in multivessel coronary artery disease (MVCAD). The durability of the surgical grafts should be weighed against the decreased invasiveness of percutaneous coronary intervention (PCI). Hybrid coronary revascularization (HCR), a combination of PCI and surgery, could be a feasible alternative. This study aimed to investigate the occurrence of major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality after both endoscopic coronary artery bypass grafting (Endo-CABG) and the HCR procedure.MethodsIn this single-center retrospective observational study, 347 consecutive patients have been subjected to an Endo-CABG procedure, of which 103 underwent HCR between January 2016 and January 2018. A propensity score matching analysis was performed to match 103 Endo-CABG alone patients to the 103 HCR patients. The Endo-CABG procedure was performed through 3 endoscopic ports (5 mm) in the 2nd, 3rd, and 4th intercostal space and a utility port of 3 cm.ResultsIn both the HCR and matched endo-CABG alone group, the 30-day mortality was acceptable (0% in the HCR group and 1.94% in the matched Endo-CABG alone group, p = 0.155). Additionally, the occurrence of MACCE after a mean follow-up of 1188 ± 538 days was similar in both groups (9.71% and 11.65% for the HCR and matched Endo-CABG alone group, respectively, p = 0.652). Still, the long-term all-cause mortality over this period was significantly higher in the matched Endo-CABG alone group (2.91% after the HCR procedure and 11.65% after matched Endo-CABG alone, p = 0.002).ConclusionHCR has some advantages over Endo-CABG alone regarding the all-cause mortality, cross-clamping time, intensive care unit, and hospital length of stay. Therefore, HCR may be a suitable alternative therapy for patients with MVCAD.

Unusual Course of Posterior Intercostal Vein at the 3rd Intercostal Space – A Case Report

The posterior intercostal veins drain the thoracic wall and lie in the costal grooves along with the intercostal arteries and nerves posterior to the thoracic sympathetic chain. During routine dissection of the posterior mediastinum of a formalin-fixed male cadaver in the Anatomy department of an undergraduate and postgraduate teaching medical college in India, a large-sized posterior intercostal vein was identified crossing anterior to the thoracic sympathetic chain at the level of the 3rd intercostal space on the right side. The presence of such variation may hinder the surgical procedure of the posterior mediastinum and will pose an increased risk of intraoperative or postoperative bleeding. Knowledge of such variation is necessary to avoid laceration of the posterior intercostal vein, which is the potential cause of bleeding in the region of the thorax.

Conservative Management of Traumatic Intercostal Lung Hernia: A Case Report

Pulmonary herniation is an uncommon phenomenon. It has been described sporadically in obscure case reports and rare case series. Owing to its sparse occurrence, a calibrated algorithm for its management does not exist. Even then, the popular consensus advises surgical management comprising prosthetic mesh repair. Hereby, authors report a case of a 24-year-old male, who developed left lung herniation after blunt trauma to the chest wall. Non Contrast Computed Tomography (NCCT) of chest revealed herniation of left lung through 3rd intercostal space, a hernia defect of 1.8 cm and a small left pneumothorax. Patient was managed conservatively with intercostal drainage and was discharged on day 5 of admission. This case report aims to delineate the conditions where conservative management of lung hernias can be undertaken successfully.