4th Intercostal Space Research Articles

Standardization of the apex beat in the full left lateral position and its diagnostic value in detecting left ventricular dilatation

Aims The aims of this study were to determine the characteristics of the apex beat in the full left lateral position in healthy adults, and to assess its value in the diagnosis of left ventricular dilatation.Methods and results 77 healthy adults and 27 patients with left ventricular dilatation were evaluated by history, physical examination, electrocardiography, apexcardiography and complete transthoracic echocardiographic examination. The location, size and quality of the apex beat were determined in the 90-degree left lateral position. A palpable apex beat, located in the 5th or 6th intercostal space, was recorded in 87% of the healthy adults. The lateral margin was palpated in a 3-cm-wide area from the left anterior axillary line (LAAL) towards the mid-clavicular line (MCL). The mean diameter and area were 2.5 ± 0.5 cm and 5.0 ± 2.5 cm2, respectively. In 51% the apex impulse intensity was of medium degree, in 25% weak and in 24% strong. It was palpable in all patients with left ventricular enlargement in the 5th, 6th or 7th intercostal space. The lateral margin was located in a 4.5-cm-wide area, 3.5 cm left from the LAAL to 1 cm right from it. The mean diameter and area were 5.0 ± 1.0 cm and 20.0 ± 7.0 cm2, repectively. The intensity was weak in 56% and medium degree in the rest. The diameter ≥ 4.0 cm was sensitive (96 %) and specifi c (96 %) for the enlarged left ventricle. The location of the apex beat with the cut-off point in the LAAL was equally sensitive but less specifi c (63 %) for left ventricular dilatation.Conclusions Palpation of the apex beat in the full left lateral position is very suitable for detecting the left ventricular dilatation at bedside. The size of the apex beat appears to be a more reliable diagnostic sign of left ventricular dilatation than its location.

Delayed management of penetrating cardiac injury – Less urgency, more options

A 34 year old male sustained a stab injury to his left parasternal edge at the 4th intercostal space. Following a delay of 48 h, he presented to his local secondary hospital. At the time of admission he had a blood pressure of 73/38 mmHg – no other clinical signs of cardiac tamponade – and this normalised with intravenous fluids. Basic x-rays were performed and computed tomography (CT) of his chest was undertaken. This demonstrated a haemopericardium with left sided haemothorax (Fig. 1). Following, the patient was urgently transferred to our Level 1 Trauma Unit. On arrival, vitals were normal. Arterial blood gas results were pH 7.44, lactate 0.4 mmol/L and base excess 7.3 mmol/L. Electrocardiogram demonstrated T wave flattening at lead 3 and ST elevation at V3. Retrospective analysis of his chest X-rays from the secondary hospital revealed straightening of the left heart border, highly suspicious of haemopericardium. Transthoracic echocardiography was also performed and confirmed pericardial effusion. Troponin was elevated at 1.1 mg/L. The patient was taken to the operating theatre. A pericardial window was initially performed which demonstrated

Ultrasonographic description of the caudal and ventral lung borders in normal Warmblood horses

Summary The aim of the study was to describe the caudal and ventral lung border in clinically normal horses more precisely than it had been described previously and also to resolve the contradictions of data published in standard textbooks. Twenty-two healthy Warmblood horses were used in the study. The lung border was determined by 2-dimensional ultrasonography at the following anatomical levels: tuber olecrani, tuberositas deltoidea of the humerus, tuberculum majus of the humerus, tuber ischiadicum and ventral, mid- and dorsal points of the tuber coxae. Examinations were performed bilaterally at the end of inspiration and expiration. Distances between the actual lung borders and corresponding anatomical levels were measured and compared statistically. The results showed that the olecranon could not be used as an anatomical landmark. Instead, the deltoid tuberosity could be used as an alternative, as the lung border was found in the 7th intercostal space (ICS) in 14 horses and in the 8th ICS in 8 horses. The lung border at the level of the tuberculum majus was found in the 10th ICS in every horse. At the level of the tuber ischiadicum, the lung border was detected equally in the 14th (11 horses) and 15th (11 horses) ICS. At the level of the ventral and midpoint of the tuber coxae, the lung border was found in the 15th or 16th ICS. No lung border was found at the level of the dorsal point of the tuber coxae or in the 17th ICS.

Blood parameters in female Zandi lambs as affected by liver biopsy methodology

The aim of the present study was to investigate the normal blood parameters of Iranian fat-tailed sheep (Zandi) and their changes due to rapid liver biopsy technique with a tru-cut biopsy needle. In ten ewe lambs, blood samples were collected from jugular vein and biopsy needle was inserted through the dorsal one third of the 11th intercostal space, on the right hand side of the lambs and liver specimen was collected. Physical examinations were performed on alternate days during the experiment. Blood collection was done on both before (day1) and after (day17) the biopsy. All animals were slaughtered at day17. Values were compared using paired t test. While biopsy did not make any significant changes in mean values of body temperature, heart rate, respiratory rate, PCV, WBC, neutrophil, lymphocyte, eosinophil, monocyte, total serum protein, AST, ALT, and serum calcium (p > 0.05), it made a significant difference on the values of ALP (p < 0.001), serum inorganic phosphate (p = 0.035), and magnesium (p = 0.013). Necropsy examination revealed the points of hitting the biopsy needles on the diaphragmatic surface of the livers, surrounded by a zone of intense hyperemia. Peritoneal adhesions accompanying with typical strands of fibrous connective tissue between diaphragmatic surface of the liver and adjacent abdominal wall were found in two cases.

Atrioventricular Valve Dyssynchrony Resulting From Severe Mitral Regurgitation

A nearly 4-year-old Ethiopian girl with a 1-year history of weight loss and rapid breathing who had just immigrated to the United States presented to the emergency department with respiratory distress and increasing lethargy. Over the preceding year, she had been found to have increasing tachypnea, anorexia, a 5-kilogram weight loss, fatigue, intermittent emesis, and decreased urine output. There were multiple notable findings on the physical examination. Abnormalities of the vital signs included a respiratory rate of 52 breaths per minute, blood pressure of 70/53, and an oxygen saturation of 85% on room air. In general, she was cachectic and lethargic. There was jugular venous distension with accentuated a waves. There were diffuse fine inspiratory crackles across the lung fields. There was asymmetrical protrusion of the left anterior chest with a visible, dynamic cardiac impulse. On auscultation, there was a regular rhythm with an S3 present. There was a III/VI, holosystolic, midfrequency, blowing murmur in the 5th intercostal space at the midclavicular line with radiation to the apex and the left axilla. A diastolic rumble was not appreciated. The liver edge was 4 centimeters below the right costal margin. Pulses were normal at the brachia and femoral arteries, bilaterally. There was no peripheral edema or clubbing. Blood work revealed a negative troponin and a B natriuretic peptide of 2761 picograms per milliliter. A chest radiograph was performed, which showed cardiomegaly with enlargement of the left superior cardiac border, bilateral pulmonary edema, and superior deviation of the left mainstem bronchus suggestive of left atrial dilatation (Figure 1). A 15-lead electrocardiogram demonstrated sinus rhythm with left atrial enlargement and ST segment elevation in the anterior precordial leads (Figure 2). Figure 1. A chest radiograph taken in an anteroposterior projection demonstrates: pronounced cardiomegaly with a cardiothoracic ratio of 71%; a double contour of …

CSPE Young Investigator Award Session

CSPE Young Investigator Award Session

Ultrasonographic assessment of liver dimensions in dairy cows with different hepatic triacylglycerol content1

The objective of this study was to investigate the relationship between hepatic triacylglycerol content (TAG) and hepatic size and shape assessed by transcutaneous ultrasonography in dairy cows. In a second part, the usefulness of ultrasonographic measurements pertaining to the size and shape of the liver for the diagnosis of fatty liver was evaluated. Transcutaneous ultrasonographic examination of the liver was carried out in 133 German Holstein cows (BW: 578 ± 6kg; age: 5 ± 0.2yr; withers height: 145 ± 0.3cm). The size of the liver, angle of the ventral liver margin, and thickness of the liver over the portal vein and caudal vena cava were measured in the 10th and 11th intercostal spaces via ultrasonography. As the gold standard, TAG was determined enzymatically in liver biopsies. Hepatic TAG ranged from 5 to 292mg/g of liver fresh weight (FW). Cows were allocated to 4 groups according to their hepatic TAG content (TAG ≥150mg/g of FW, n = 32; ≥100to150mg/g of FW, n = 34; ≥50to100mg/g of FW, n = 38; <50mg/g of FW, n = 29). Weak to moderate correlations (r = 0.26to 0.49) between the ultrasonographic liver measurements and hepatic TAG indicated an increased size and angle of the liver with increasing hepatic fat accumulation. All mean liver ultrasonographic measurements revealed differences between TAG classes (P < 0.001), with the greatest values in cows with hepatic TAG concentrations ≥150mg/g of FW. Stepwise multiple linear regression for hepatic TAG prediction (r(2) = 0.34, P < 0.001) and stepwise discriminant analysis used only ultrasonographic measurements obtained via the 10thintercostal space and age. Regression analysis revealed that TAG prediction widely overestimated measured TAG in the low TAG range and underestimated TAG in the high TAG range. The sensitivity and specificity based on discriminant analysis for differentiation of the TAG groups were 0.61 and 0.61 (<50vs. ≥50mg/g of FW), 0.67 and 0.71 (<50vs. ≥100mg/g of FW), 0.83 and 0.82 (<50vs. ≥150mg/g of FW), 0.70 and 0.77 (<100vs. ≥100mg/g of FW), and 0.83 and 0.85 (<100vs. ≥150mg/g of FW), respectively. Results revealed that with a hepatic TAG content of approximately 100mg/g of FW, the liver increased in size and its margins became rounded. Pronounced increases in the size and thickness of the liver and in the angle of the liver occurred only in cows with very severe fatty liver (TAG ≥150mg/g of FW). However, the determination of ultrasonographic measurements of liver size and shape appeared to be of limited diagnostic value in the recognition of fatty liver because of increased interindividual variance in dairy cows.

Modified Anterolateral Approach Provides Improved Accessibility to the Lung Hilum Vascular Region for Giant Mass Lung Cancer Pneumonectomy

Surgical management of patients with a huge pulmonary mass remains a challenge. The surgical risk is amplified by potential hemorrhage, problematic surgical exposure, difficult handling of the tumor, and poor vascular control. We describe a technique that uses a modified anterolateral thoracotomy to accomplish pneumonectomy. An anterolateral thoracotomy was entered through the 4th or 5th intercostal space. The intercostal muscles of the involved interspace were dissected off long enough but without dividing the overlying chest wall muscles. This crucial maneuver allowed a wide rage of rib spreading. The pulmonary hila and lateral aspect of the mediastinum were thus best exposed. Seven patients with large mass pulmonary cancer were admitted for surgical resection via this approach. Intrapericardial access to pulmonary vessels was obtained for pneumonectomy in all patients, including combined carinoplasty and superior vena cava reconstruction for one case. The perioperative courses were smooth and R0-resection was achieved in all cases. The modified anterolateral approach permits very good exposure and control of the pulmonary vessels at the hilum, enabling the resection maneuver to be effective, quick, and safe.

The Clinical Characteristics of Cases Exhibiting Suggestive Brugada ECG (Type-S) at Higher Intercostal Spaces

Background: Recent findings report that in Brugada syndrome, the long-term prognosis of patients with non-type-1 ECG, including mild coved ST-elevation (STE)<2 mm, was similar to that of patients displaying type-1 ECG. Based on these evidences, the computerized diagnosis of Brugada-type ECG have been reported to be classified into 3 types: Type-1 (coved STE≥2 mm), Type-2/3 (saddleback STE≥2 mm), and suggestive Brugada ECG: Type-S (coved STE between 1–2 mm). Type-1 ECG can be occasionally unmasked only when recorded at higher intercostal spaces (HICS). This study focused on Type-S recorded at HICS. Method: Screening ECG from 12850 consecutive patients (6616 males) undergoing health checkups was reviewed. Among the total patients, 156 patients (1.2%) (134 males) identified as having RSR'-pattern ECG in leads V1 and/or V2 without Brugada-type ECG at 4th intercostal space, were enrolled. We analyzed ECGs recorded at 3rd and 2nd intercostal spaces (HICS). Results: In 8 of 156 cases (5%), RSR'-pattern shifted to Type-S ECG at HICS. All 8 cases were asymptomatic and male. Their age ranged between 42 and 68. Conclusion: Our results indicated that men with RSR'-pattern ECG who are in their middle years may have a potentially Brugada-type ECG.

Incarcerated spontaneous transdiaphragmatic intercostal hernia

IntroductionProlapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency. Presentation of caseA 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect. DiscussionThe clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient's history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient. ConclusionSpontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.

Usefulness and Limitation of Ultrasonography in the Diagnosis of Intestinal Intussusception in Cows

The present study was conducted on 6 chronically ill Jersey/Red Sindhi cross-bred cows, which were suspected for intestinal obstruction on the basis of history and clinical signs. These cows were ultimately diagnosed with intestinal intussusception based on a combination of clinical, ultrasonographic and surgical examinations. “Bull's eye lesion” was the most prominent ultrasonographic finding, diagnostic for intussusception either trans-abdominally or transrectally. Dilated intestinal loops greater than 3.1 cm (mean ± SE, 4.41 ± 0.25) were imaged in the lower flank and the 12th intercostal space on the right side. Ultrasonography proved to be a useful tool in supplementing and substantiating the transrectal findings in cases of the bovine intestinal intussusception. However, ultrasonography was not significantly helpful where transrectal examination of the cows did not reveal any suspected intestinal mass.

Ultrasonography of the omasum in 30 Saanen goats

BackgroundPrimary diseases of the omasum are uncommon in goats, although the omasum may be involved in various gastrointestinal disorders. Examination of the caprine omasum via ultrasonography requires a good understanding of the normal appearance of the organ. However, in contrast to cattle, there is a lack of reference information on this topic in goats. Thus, the goal of the present study was to describe the results of ultrasonography of the omasum in 30 healthy Saanen goats.ResultsUltrasonography was carried out in standing, non-sedated goats using a 5.0 MHz linear transducer. The location and size of the omasum, thickness of the omasal wall and visualisation of the abomasal laminae, contents and contractions were assessed. The omasum was visible from the 9th intercostal space (ICS) in all the goats, and from the 8th and 10th ICSs in 29 and 24 goats, respectively. The omasum was seen medial to the liver, but only the omasal wall closest to the transducer was visible. The dorsal omasal limit formed a dorsally convex curve running from cranioventral to caudodorsal and was furthest from the dorsal midline in the 6th ICS. The ventral omasal limit formed a ventrally convex curve. The size of the omasum was largest (10.2 ± 3.1 cm) in the 9th ICS and decreased cranially and caudally from this position. Active omasal motility was recorded in 20 goats with 0.3 to 2.0 contractions per minute.ConclusionsThe findings of this study provide reference ranges for the interpretation of the location and size of the omasum in goats with suspected omasal abnormalities. Ultrasonography is an ideal diagnostic tool for evaluation of the omasum, which is not accessible to conventional examination techniques, such as inspection, palpation, percussion and auscultation.

Ultrasonographic Examination of the Rumen in Healthy Cows

10 healthy Indian Jersey/Red Sindhi crossbred nonpregnant cows were subjected to transabdominal ultrasonography to develop baseline topographical data of the rumen. The wall of the rumen could be identified as a thick echogenic line adjacent to the left abdominal wall from left flank to 8th intercostal space. The motility pattern of rumen was characterized by approximately 1 contraction every minute. The mean amplitude of the ruminal contraction was 3.2 cm. Ultrasonography of the rumen in healthy cows is a useful adjunct to the noninvasive diagnostic investigation of the rumen.

Intercostal Vessels and Nerves are at Risk for Injury During Supracostal Percutaneous Nephrostolithotomy

We characterized key intercostal anatomical relationships relevant to supracostal percutaneous nephrostolithotomy using anatomical dissection. We performed 20 cadaveric dissections of the 11th intercostal space to characterize key anatomical relationships relevant to percutaneous upper pole renal access. Specific data recorded included intercostal rib distance at the lateral border of the paraspinous muscles, and the mid scapular and posterior axillary lines. We also recorded the distance between the 12th and 11th ribs to the intercostal nerve, artery and vein at the same 3 sites. The average intercostal distance was 21, 23 and 26 mm at the lateral border of the paraspinous muscles, and the mid scapular and posterior axillary lines, respectively. The intercostal nerve was exposed to injury in 85%, 100% and 100% of patients at the 3 sites, respectively. The intercostal artery was exposed below the 11th rib in 30%, 60% and 70% of cadavers, respectively, and it was 6 mm from the rib in 25% of interspaces. The intercostal vein, which was exposed below the 11th rib in 0%, 5% and 10% of cadavers, respectively, was least likely to be injured. Intercostal vessels are at risk for damage during percutaneous nephrostolithotomy in a significant number of patients. Access placement lateral to the paraspinous muscles and in the lower half of the 11th intercostal space may decrease damage to the intercostal artery and nerve. Injury to the intercostal vessels and nerve may explain the increased risk of bleeding and pain during supracostal percutaneous nephrostolithotomy. Minimizing injury may decrease blood loss and pain.

Huge Aortic Aneurysm After Balloon Angioplasty for Coarctation of the Aorta in an Infant

A 11-month-old boy was referred to our unit for operation. When he was 20 days old, he had balloon dilatation of the aortic coarctation at another institution. He also had a small ventricular septal defect. During the follow-up, asymptomatic aneurysm formation at the previous coarctation site was determined. On physical examination, there was a systolic mummur at the 4th intercostal space. The echocardiographic examination revealed a small perimembraneous-outlet ventricular septal defect and the aneurysm at the coartation site. Cardiac angiography revealed the giant aneurysm of the descending aorta that was 4.4 cm in diameter (Fig. 1; Clip 1). The surgical approach was made though a left posterolateral thoracotomy. At surgery, the aneurysm (Fig. 2) was incised longitudinally (Fig. 3) and both lateral walls and the anterior wall of the aorta that was involved in the aneurysm were resected. The remainder posterior wall was intact and was not integrated in the aneurysm tissue. Patch aortoplasty was performed with a Hemashield patch (Boston Scientific, Natick, MA). The patch was sutured to the aorta in the standard fashion using a running 5/0 prolene suture (Fig. 4). The postoperative course was uneventful. The patient was discharged on the fourth postoperative day. The patient was well at the 25-month follow-up.

Substernal Thyroid Masses

Substernal Thyroid Masses

Ultrasonographic examination of the spleen in 30 goats

The ultrasonographic appearance, location and size of the spleen in 30 healthy female Saanen goats are described. The intercostal spaces of the left thoracic wall were scanned with a 5.0 MHz linear transducer in standing goats. The appearance of the splenic parenchyma, the position of the ultrasonographically visible dorsal and ventral margins of the spleen and the distance between them, the thickness of the spleen and the diameter of the splenic vessels were determined. The spleen could be visualised in at least one examination position and it always lay between the rumen and abdominal wall. The spleen bordered the lung dorsally and was located adjacent to the left abdominal wall in the last intercostal space and area immediately caudal to the last rib. The spleen had an echogenic capsule, and its parenchyma showed a homogenous fine echotexture / echo pattern throughout the whole visible part of the spleen. The splenic vessels were seen within the parenchyma. The visible dorsal margin of the spleen ran from cranioventral to caudodorsal. The distance from the dorsal margin of the spleen to the midline of the back was greatest in the 8th intercostal space (19.7 ± 4.19 cm) and smallest in the region immediately caudal to the last rib (7.0 ± 1.07 cm). The size of the spleen was smallest in the 8th intercostal space (3.1 ± 1.24 cm) and greatest in the 11th intercostal space (8.7 ± 2.78 cm). The thickness of the spleen ranged from 2.2 ± 1.14 cm caudal to the last rib to 6.4 ± 1.78 cm in the 11th intercostal space.

E0032 Role of atrial substrate remodelling in inducibility of atrial fibrillation after epicardial ganglionic plexi ablation

ObjectiveInvestigating the long-term effect of ganglionated plexi (GP) ablation on atrial fibrillation (AF) after GP ablation.Methods13 dogs were randomly divided into sham-operated group and GP ablation group. All animals underwent...

Thromboaspiration Leading to Complete Coronary Artery Stripping in Acute Myocardial Infarction After Blast Injury

A54-year-old man without medical history was admitted in our hospital with hemorrhagic shock caused by left compressive hemothorax (Figure 1) after a suicidal gunshot. The entrance site of the projectile was in the 4th left intercostal space. Figure 1. Chest radiograph (posteroanterior view, white arrow shows the bullet). Surgical exploration performed within the 1st hour revealed dissection of the left internal mammary artery and multiple injuries of the lung parenchyma, which could be successfully repaired. Extensive superficial epicardial dilacerations were observed at the level of the mid left anterior descending coronary artery, without penetrating myocardial or coronary artery injury and without pericardial effusion. Coronary flow appeared to be preserved. On transfer into the intensive care unit of the sedated and mechanically ventilated patient, routine 12-lead ECG showed signs of anterior …

MORPHOMETRIC EVALUATION, BY ULTRASONOGRAPHIC EXAM, OF THE PORTAL VEIN, CAUDAL VENA CAVA AND ABDOMINAL AORTA IN HEALTHY DOGS OF DIFFERENT BODY WEIGHTS

The diameters and areas of portal vein, caudal vena cava and abdominal aorta are useful measurements in dogs. These values can be easily measured by ultrasonographic exam, and variations of normality can be an important indicator of hepatic or extra-hepatic alterations. This study aimed to measure the diameter and areas of portal vein, caudal vena cava and abdominal aorta in healthy dogs, with normal corporal score, divided in groups according to the body weight, and assess whether the data are influenced by animal weight. Thirty dogs were examined and divided into three groups (Group A: ≤ 10 kg Group B: from 10.1 to 20.0 kg; Group C: ≥ 20.1 kg). To measure the diameters and areas of portal vein, caudal vena cava and abdominal aorta, the animal was kept in left lateral decubitus position and the transducer was placed on the right lateral abdominal wall, at approximately the 10th or 11th intercostal space, in the porta hepatis region. The diameters and areas of the portal vein, caudal vena cava and abdominal aorta were significantly lower for dogs in Group A with respect to other groups and the dogs from Groups B and C had similar results with each other. The diameters and areas of the portal vein, caudal vena cava and abdominal aorta may vary with the animal size, and reference values must be specific for small, medium and large dogs.