4th Intercostal Space Research Articles

Stimulation of abdominal and upper thoracic muscles with surface electrodes for respiration and cough: Acute studies in adult canines

Objective: To optimize maximal respiratory responses with surface stimulation over abdominal and upper thorax muscles and using a 12-Channel Neuroprosthetic Platform. Methods: Following instrumentation, six anesthetized adult canines were hyperventilated sufficiently to produce respiratory apnea. Six abdominal tests optimized electrode arrangements and stimulation parameters using bipolar sets of 4.5 cm square electrodes. Tests in the upper thorax optimized electrode locations, and forelimb moment was limited to slight-to-moderate. During combined muscle stimulation tests, the upper thoracic was followed immediately by abdominal stimulation. Finally, a model of glottal closure for cough was conducted with the goal of increased peak expiratory flow. Results: Optimized stimulation of abdominal muscles included three sets of bilateral surface electrodes located 4.5 cm dorsal to the lateral line and from the 8th intercostal space to caudal to the 13th rib, 80 or 100 mA current, and 50 Hz stimulation frequency. The maximal expired volume was 343 ± 23 ml (n=3). Optimized upper thorax stimulation included a single bilateral set of electrodes located over the 2nd interspace, 60 to 80 mA, and 50 Hz. The maximal inspired volume was 304 ± 54 ml (n=4). Sequential stimulation of the two muscles increased the volume to 600 ± 152 ml (n=2), and the glottal closure maneuver increased the flow. Conclusions: Studies in an adult canine model identified optimal surface stimulation methods for upper thorax and abdominal muscles to induce sufficient volumes for ventilation and cough. Further study with this neuroprosthetic platform is warranted.

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

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. 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 > or = 4.0 cm was sensitive (96%) and specific (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 specific (63%) for left ventricular dilatation. 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.

Clinical location of the fourth and fifth intercostal spaces as a percent of the length of the sternum

ObjectivesTo verify accurate placement of the precordial ECG leads by identifying the 4th and 5th intercostal spaces as a function of the length of the sternum. This should decrease the percentage of lead misplacement leading to misdiagnoses. MethodsThe population consisted of patients and healthy volunteers. The proposed method compared palpation of the 4th and 5th intercostal spaces to a percentile of the sternal length. Location of the 4th and 5th intercostal space using a simple device was evaluated to assist in proper placement of the precordial leads to obtain accurate diagnosis. ResultsThe location of the 4th and 5th intercostal space is related to the length of the sternum. It is 77% of the sternal length that measures 15cm for the 4th intercostal space. The position of the V1 and V2 electrodes decreases to 57% when the sternal length is 26cm. Similar data was obtained to locate the 5th intercostal space with proper position of V4-V6 electrodes. Tables are provided to facilitate this process. An instrument was designed to measure the 4th and 5th intercostal space as a function of the sternal length. ConclusionsThe location of the 4th and 5th intercostal space is identified based on the length of the sternum.

Thoracoscopy as a safe and effective technique for exploring calves affected with bovine respiratory disease

BackgroundBovine respiratory disease (BRD) is one of the leading causes of economic losses in the beef and dairy industry. Reliable antemortem tools for diagnosing BRD would improve the efficacy of treatment and reduce costs. Here we examined whether the relatively simple technique of thoracoscopy can support BRD diagnosis under field conditions. We also compared various equipment set-ups in order to optimize the safety and efficacy of the procedure. A total of 24 thoracoscopic procedures were performed in 17 calves diagnosed with BRD and in 2 healthy control calves. Rigid and flexible endoscopes and industrial videoscopes were tested using various insertion approaches. The suitability of the technique was assessed in terms of duration, volume of air extracted, visualization score, and image quality. Safety was assessed in terms of rectal temperature, body weight, breaths/min, presence of fibrinogen, pain score, recovery time, intraoperative complications and risk of laceration or threatening collapse.ResultsInsertion of a flexible endoscope via a right, dorso-caudal approach at the 5th intercostal space allowed complete examination of the right lung in 15 min, as well as identification of main lung lesions and adherences in calves with BRD, without compromising calf welfare. While the dorso-caudal approach was optimal, it was associated with substantial discomfort when rigid endoscopes were used, minimal complications or mortality due to thoracoscopy were observed up to 28 days after the procedure. Videoscopes were as safe and easy to use as endoscopes, but endoscopes provided better image quality.ConclusionThis study provides the first field evidence that thoracoscopy can be safe to explore BRD-diseased calves. These results justify a larger study to rigorously assess the diagnostic performance of the technique.

A case report on traumatic diaphragmatic injury repaired with prolene mesh

Penetrating and blunt trauma rarely results into traumatic diaphragmatic hernia which oftenly undergo unrecognized. A 25 year old male admitted with chief complaints of difficulty in breathing since road traffic accident. Chest X-ray of the patient showed collapsed lung along with contents of abdomen in left hemithorax. Patient was stablised and contrast enhanced CT scan of chest was done which showed abdominal contents in left hemithorax with diaphragmatic injury on left side with no spillage of contents in thoracic cavity. Left posterolateral thoracotomy was done through 6th intercostal space. The abdominal contents were reduced back into the abdominal cavity with care and a circumferential tear of diaphragm was found with complete avulsion of diaphragm from chest wall anteriorly and laterally. Repair was done with prolene mesh as primary repair was not possible due to avulsion of margins from anterior and lateral walls. One left chest-drain was put which was removed on 3rd post-operative day. The patient was put on antibiotics in postoperative period and was started orally from 4th post-operative day after appearance of bowel sounds. The patient showed good recovery in postoperative period and was discharged on 8th postoperative day. Prompt diagnosis and surgical management is mandatory to avoid complications.

P1.08-054 Uniportal VATS Lobectomy in the Treatment of NSCLC

Uniportal Video-Assisted Thoracic Surgery (uniportal VATS) lobectomy represents the pinnacle of evolution for minimally invasive techniques in surgical management of lung cancer. Growing evidence suggest that Uniportal VATS procedures are technically feasible and safe with immediate outcomes comparable to traditional VATS approach. Uniportal approach has demonstrated equivalent disease-free survival, at intermediate follow-up for patients with early stage NSCLC, compared to conventional VATS. It represents a less invasive approach, and offers the advantage of minimizing the extent of the surgical access trauma thus resulting in postoperative pain reduction, muffled inflammatory response, early recovery and better cosmesis. Some authors described minimal changes in pulmonary function after uniportal surgery in patients with poor cardio-respiratory function. Here we present our experiences with uniportal VATS lobectomies for NSCLC. Between October 2015 and March 2016, twenty-four (24) patients with non-small lung cancer (NSCLC) underwent uniportal VATS lobectomy and mediasitnal lymph node dissection. Surgical access was performed through a 4-5 cm long utilitarian incision at the 5th intercostal space in the anterior axillary line. Anatomical resection of veins, arteries, bronchi and mediastinal lymph nodes followed established oncological principals. Once the operation was completed a single chest tube was inserted in the anterior part of the incision for uniportal VATS. Fifteen male and nine female patients with an average age of 62.6 years (49-76) were enrolled in the study. Average procedural time was 108 minutes (75min-154min). None of the patients required blood transfusion after the procedure or during the rest of their hospital stay. Average duration of chest drainage was 3.6 days (2-8) and mean hospital stay was 6.3 days (3-10). There were 14 patients with adenocarcinoma and 10 with squamous cell carcinoma. Two patients had prolonged air leak and were treated conservatively. There was no perioperative mortality. Our initial experiences with Uniportal VATS lobectomy is encouraging as it demonstrated benefits to patients due minimal surgical stress, faster recovery, reduced postoperative pain and shorter hospital stay. The authors strongly believe uniportal VATS surgery should be considered for primary surgical treatment of NSCLC.

SC20.04 Uniportal VATS

SC20.04 Uniportal VATS

Wireless Cardiac Monitors: A Different Kind of Breast Implant

Introduction: Implanted medical devices are increasingly common, and it is important for radiologists to recognize the normal appearance of these devices in order to inspire confidence among patients and referring physicians. The goal of this article is to teach the appearance of wireless cardiac monitoring devices and briefly review their function. Keywords: Wireless; Monitor; Breast; Cardiac device Discussion: Heart disease is the number one cause of death in the United States [1]. Monitoring for cardiac arrhythmias is important since they may cause serious adverse events including stroke, pulmonary embolism, and even to sudden death [2]. Rapid detection is crucial for diagnosis and appropriate treatment. Traditional monitoring devices, like the Holter monitor, are cumbersome, expensive, and often ineffective [3]. The devices depicted in these are wireless cardiac monitors. They are able to wirelessly detect and record cardiac activity. Some models contain integrated cellular technology that can transmit diagnostic data from the device to a physician’s office. They can even be programmed to send an alert to a smart phone [4,5]. They may be as small as one-third the size of an AAA battery and are designed to function for up to 3 years. Some models are safe to use in an MRI magnet [5,6]. Breast cancer is the second leading cause of cancer deaths in women [7]. There is a powerful overlapping risk factor that both breast cancer and cardiac disease has in common - age. Therefore the likelihood of seeing cardiac devices in this patient population will increase as biomedical technology advances. In fact many innovative companies are beginning to leverage technology to impact patient care [8]. As this trend progresses, the transition from population based care to individualized medicine tailored to the specific patient needs will continue [4]. The benefit of wireless cardiac monitors is that they allow both improved arrhythmia diagnosis and create the potential for individualized anticoagulation dosing rather than standard one-size-fits-all treatment. This approach to individualized therapy is undergoing evaluation currently in randomized trials [9]. These devices are implanted in the outpatient setting. Under sterile technique a tiny incision is made in the left lower inner quadrant of the breast. Then a specialized insertion tool is used to position the device within the breast. Ideally the device is positioned 45o to the sternum at the 4th intercostal space 2 cm laterally to the sternum. As with any foreign device implantation, possible complications include device rejection, migration, infection, and hematoma formation [10]. The characteristic imaging appearance of these devices allows for confident identification. The first clue is its location in the left medial breast which allows close proximity to the heart for improved monitoring ability. The antenna component is identifiable at one end of the device and should be directed toward the chest wall posteriorly (Figures 1 and 2). Note that, tomosynthesis images (3D mammogram) shows the presence of some of the internal components, including a battery and circuitry (Figures 3 and 4). Unlike more traditional cardiac devices, there are no wires extending from this monitor. These findings are in contrast to older cardiac devices such as pacemakers and automated implantable cardiac defibrillators which also require a battery pack and wires leading to the heart.

Transverse Sternal Split: a Safe Mini-invasive Approach for Perventricular Device Closure of Ventricular Septal Defect.

ObjectivePerventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique.MethodsThirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality.ResultsProcedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography.ConclusionTransverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Unexpected Postoperative Paraplegia after Thoracotomy in Lung Cancer: Incidental Migration of Oxidized Regenerated Cellulose Used for Hemostasis of Intercostal Space Bleeding

Background: We experienced a very rare complication, that is, an unexpected postoperative paraplegia due to the incidental migration of oxidized regenerated cellulose used for hemostasis of intercostal space bleeding. Patients and Methods: The objective is to analyze the cause and to take measures against the very rare complication from an empirical analysis and the literature. For a 78-year-old male with suspected lung cancer in the right upper lobe (S1), a thoracotomy was performed. For hemostasis of the bleeding from the 5th intercostal thoracotomy space, we used and placed oxidized regenerated cellulose at the continuous oozing bleeding sites. On the 3rd postoperative day, paralysis beneath thoracic vertebrae level 6 was observed. Immediate computed-tomographic (CT) scanning and magnetic resonance imaging (MRI) displayed a 17 × 9 × 14 mm epidural hematoma in the spinal canal at level 5 of the thoracic vertebrae. An emergent laminectomy for the thoracic vertebra was performed to remove the oxidative cellulose and haematoma, and the compression was released. The paraplegia gradually began to recover and maintain a standing position. After 1 year from the event, the patient can walk by himself with a crutch. Results: The causes were that the oxidative cellulose materials were used for the intercostal bleeding at the open thoracotomy. The migration of the oxidative cellulose materials into the epidural space and into thoracic spinal canal through the intervertebral foramen, or gradual penetration of the oxidative cellulose materials into the spinal canal due to respiratory costal movement. As a measurement of prevention, the hemostat materials should be completely removed after finishing of the hemostasis. In the case of a difficult hemostasis, consultation of an orthopedist or neurosurgeon to perform the appropriate hemostasis in good cooperation is required. Conclusion: If postoperative paraplegia is suspected, immediate CT scanning and/or MRI examination would become powerful diagnostic procedures as soon as possible to start an interventional treatment.

ULTRASOUND MEASUREMENT OF CHEST WALL THICKNESS IN ELITE RUGBY PLAYERS; A COMPARISON BETWEEN THE NEEDLE THORACOCENTESIS SITES

AimsThere are no known published studies to support current pitch side guidelines for the management of a tension pneumothorax in a sporting population (1). Temporary management of this condition involves...

What is the Optimal Range of Medial Pocket Dissection in Breast Augmentation? An Anatomical Study of Chinese Women.

The range of the medial dissection forbidden zone, defined as the no-touch zone in this study, is of great importance in breast augmentation. Currently, 30mm of the no-touch zone is marked and the pocket dissection does not pass medial to this zone, which lacks anatomical evidence. This study aimed to determine the optimal range of the no-touch zone in breast augmentation by precisely locating relevant anatomical structures. Preoperative multidetector-row CT angiography (MDCTA) was performed in 36 Chinese female patients who were to receive breast reconstruction. The MDCTA data were used to measure the healthy side's horizontal distance from the cutaneous perforators of the internal thoracic artery to the midline, from the sternal origin of the pectoralis major to the midline, from the sternal border to the midline, at the 2nd to 5th intercostal spaces in the subpectoral plane. All the target tissues were identified in MDCTA data. Mean distances from cutaneous perforators of the internal thoracic artery to the midline of the 2nd to 5th intercostal spaces were 19.66±4.08, 20.37±3.88, 21.00±3.63, and 21.35±4.80mm; and that from the sternal origin of pectoralis major to midline were 5.00±4.01, 4.83±2.85, 11.67±5.35, and 19.19±7.10mm; and that from the sternal border to the midline were 12.48±1.70, 14.02±2.05, 13.52±2.91, and 4.68±4.44mm. Most of perforators of the internal thoracic arteries are disrupted in the current surgical process, indicating that the restrictive factor that affects the range of the no-touch zone is the sternal origin of the pectoralis major, rather than the cutaneous perforators. The range of the no-touch zone can be minimized to 20mm in the 2nd and 3rd intercostal spaces, and can be 30mm in the 4th intercostal space. However, surgeons should be more cautious to avoid disrupting the origin of the pectoralis major when dissecting the pocket of the 4th and 5th intercostal spaces. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study

IntroductionThe purposes of this study were to measure the chest wall thicknesses (CWTs) at second intercostal space (ICS) mid-clavicular line (MCL) and fifth ICS MAL directly, and compare the actual success rates of needle thoracostomies (NTs) by inserting a 5-cm-long syringe needle. Predictive values of weight, body mass index (BMI) and CWT were also analyzed. Materials and MethodsThis study included 199 measurements of 50 adult fresh cadavers from both hemithoraces. Five-centimeter-long syringe needles were inserted and secured. Penetration into the pleural cavity was assessed, and CWTs at 4 locations were measured. Achieved power of this study for the primary aim of CWT comparison from 2nd and 5th ICSs was .94. ResultsOverall mean CWTs at 2nd ICS MCL and 5th ICS MAL were measured as 2.46 ± 0.78 and 2.89 ± 1.09, respectively, and 5th ICS MAL was found to be statistically thicker (P = .002). The success rate of NT at 2nd ICS MCL was 87% (95% CI, 80-94), and that at 5th ICS MAL was 78% (95% CI, 70-86; P = .3570). Only 6 (17.1%) of 35 failed NTs had a CWT greater than 5-cm. Needle thoracostomy has failed in 29 (14.9%) of 194 locations, despite a CWT less than 5-cm. Below a weight of 72 kg, BMI of 23 kg/m2, or CWT of 2.4 cm, all NTs were successful. Discussion and ConclusionsIn this report, we present the largest cadaver-based cohort to date to the best of our knowledge, and we observed a statistically nonsignificant 9% more NT success rate at 2nd ICS at a power of 88% and statistically significant more success rate in males at 5th ICS was (47.7%). We also observed thinner CWTs and higher success rates than previous imaging-based studies. A BMI of 23 kg/m2 or less and weight of 72 kg or less seem to accurately rule-out NT failure in cadavers, and they seem to be better predictors at the bedside.

Uniportal video-assisted thoracic surgery for left upper lobe: single-direction lobectomy with systematic lymphadenectomy.

A 62-year-old female was admitted to our hospital after computed tomography (CT) revealed a 2.5 cm × 2.1 cm mass in the left upper lobe. PET/CT scan diagnosed as malignant lesion with no signs of metastasis. Under general anesthesia, the patient was placed in right lateral decubitus position. A 4cm incision was made in the 4th intercostal space with plastic protector. The camera was placed in the upper part of the incision and the instruments were inserted below the camera. Left upper lobectomy along with systematic lymphadenectomy was performed. Total surgical time was 135 min and estimated blood loss was 70 mL. The chest tube was removed on the 2nd postoperative day and the patient was discharged on the 3rd postoperative day with no complication. This uniportal VATS single-direction lobectomy for the left upper lobe is feasible and amplifies the concept of thoracotomy-like minimally invasive surgery.

Evaluation of feasibility and outcome of isolated aortic valve replacement surgery through J-shaped upper ministernotomy: A comparative study versus full sternotomy

ObjectivesTo evaluate intraoperative (IO) and postoperative (PO) outcome of isolated aortic valve replacement (AVR) surgery through mini-sternotomy (MSAVR) versus full-sternotomy (FSAVR). Patients & methodsSixty-six patients were divided into two equal groups. For MSAVR, a “J” shaped sternal incision with the transverse limb at level of the 4th intercostals space was made. In the other group, aortic valve replacement was done through full median sternotomy. IO and PO data were collected. Patients' functional status was assessed using New York Heart Association (NYHA) classification. At 6-month PO patients' satisfaction by the skin incision outcome was evaluated using a 4-point scale questionnaire. ResultsSkin wound for FSAVR was significantly longer. MSAVR consumed significantly longer total operative time, but the need for blood transfusion was significantly less. Patients of MSAVR group had significantly lower amount of 1st PO day mediastinal tube drainage, and significantly shorter durations of mechanical ventilation, ICU stay and PO hospital stay with significantly lower pain scores. Mean functional scores determined at time of discharge significantly improved in both groups, but were significantly better in MSAVR patients. Wound satisfaction score was significantly high in MSAVR patients. ConclusionMSAVR is a feasible procedure despite of the narrow operative field that induced long operative times but it significantly reduced amount of postoperative drainage and improved recovery items. MSAVR is safe with minimal PO morbidities and allowed early rehabilitation and free sleep position without affection of sternal wound healing. Moreover, MSAVR provided cosmetically better wound that was strongly satisfying patients.

Multi-layer ventilation inhomogeneity in cystic fibrosis

Differences in regional lung function between the 3rd and 5th intercostal space (ICS) were explored in 10 cystic fibrosis (CF) patients and compared to 10 lung-healthy controls by electrical impedance tomography (EIT). Regional ratios of impedance changes corresponding to the maximal volume of air exhaled within the first second of a forced expiration (ΔIFEV1) and the forced vital capacity (ΔIFVC) were determined. Regional airway obstruction and ventilation inhomogeneity were assessed by the frequency distribution of these ratios (ΔIFEV1/ΔIFVC) and an inhomogeneity index (GITI). The mean of the frequency distribution of ΔIFEV1/ΔIFVC and the GITI in both thorax planes were significantly different between CF patients and controls (p<0.001). CF patients exhibited a significantly lower mean of ΔIFEV1/ΔIFVC frequency distribution (p<0.05) and a significantly higher degree of ventilation inhomogeneity (p<0.01) in the 3rd ICS compared to the 5th ICS. Results indicated that EIT measurements at more cranial thorax planes may benefit the early diagnosis in CF.

Examination of the recommended safe and unsafe zone for placement of surgical instruments in thoracentesis and video-assisted thoracic surgery: a cadaveric study

Thoracentesis and video-assisted thoracic surgery procedures can result in haemorrhage as a consequence of severing the collateral branches of the posterior intercostal artery. These branches have been shown to be most common in the 5th intercostal space (ICS). Tortuosity has been shown to be especially prevalent nearer to midline. A group of investigators have recommended the 4th and 7th ICS, 120 mm lateral to midline as a safe zone, least likely to hit branches when cutting into the ICS. The present study aimed to investigate that safe zone as a better entry points for procedures. In addition, investigation of the least safe 5th ICS was also performed. A total of 56 embalmed human cadavers were selected for the study. With the cadavers laid prone, 2 cm incisions were made at the 4th, 5th and 7th ICS, 120 mm lateral to midline bilaterally. The cadavers were then placed supine and the incisions were dissected. Careful attention was paid to identify if any collateral branches were cut. After thorough dissection of the 4th, 5th and 7th ICS incision sites, it was shown that damage to the 5th intercostal was seen most frequently. Based on this cadaveric study, a 2 cm incision at the 4th, 5th and 7th ICS 120 mm lateral from midline resulted in the most damage at the level of the 5th ICS. The 4th ICS had the least damage seen. Therefore, it is recommended that insertion should be placed at the level of the 4th ICS bilaterally.

131-04: Novel Extravascular Defibrillation Configuration with a Coil in the Substernal Space

Purpose: Subcutaneous (SQ) ICDs are regarded as alternatives to transvenous (TV) ICDs in certain patients (pts). However, a substantially higher shock energy up to 80J may be required primarily because both the parasternal shock coil and lateral ICD can are outside the rib cage. Proposed is a new defibrillation method of placing the shock coil into the space immediately behind the sternum. This study assessed the defibrillation efficacy of the substernal-lateral electrode configuration. Method: This prospective, non-randomized, feasibility study was conducted in pts about to undergo midline sternotomy or implant of a SQ or TV ICD. A tunneling tool (6996T, Medtronic) was used to insert an 8 cm coil defibrillation lead (6937, Medtronic) behind the sternum using a percutaneous sub-xiphoid approach under fluoroscopic guidance. A skin patch electrode (Fast Patch Plus, Physio Control) was placed on the left thorax at the 4th to 5th intercostal space. After ventricular fibrillation (VF) induction, a single 35J shock was delivered between the substernal coil and the left lateral patch using an external TV ICD (Protecta, Medtronic), with external rescue shock if needed. Summary of Results: Sixteen pts (12 males, 4 females; mean age: 61.6 ± 11.8 years; BMI: 25.6 ± 3.3; LVEF: 47 ± 18%) were enrolled at 5 sites in Europe and Hong Kong. Ten studies preceded sternotomy (2 coronary bypass grafting; 7 valve repair/replacement; 1 aortic aneurysm repair) and 6 preceded ICD implants (5 SQ and 1 TV). All were under general anesthesia except 4 out of 5 SQ ICD pts which were under conscious sedation. Mean lead placement time was 11.1 ± 6.6 minutes. Of the 14 pts with successfully induced VF episodes, 13 pts (92.9%) had successful defibrillation at 35J. The one failure was associated with high and lateral shock coil placement, and one external rescue shock was successful. Mean VF duration was 18.4 ± 5.6 seconds with shock impedance of 98.1 ± 19.3 ohms. Of the 11 pts with coil-patch electrograms, the average R-wave amplitude during normal sinus rhythm was 3.0 ± 1.4 mV. Conclusion: These preliminary data demonstrate that substernal defibrillation is feasible and that successful defibrillation can be achieved with the shock energy available in current TV ICDs. This may open new alternatives to TV ICD therapy.

Immediate Effects of Inverse Ratio Breathing Versus Diaphragmatic Breathing on Inspiratory Vital Capacity and Thoracic Expansion in Adult Healthy Females

Background: The normal inspiratory to expiratory ratio is 1:2.However, the duration of inspiration can be increased voluntarily till the ratio becomes 2:1.This is called as inverse ratio breathing. The effects of inverse ratio ventilation have been studied on patients with respiratory failure and Acute Respiratory Distress Syndrome. No studies have been carried out to study the effects of inverse ratio breathing in voluntarily breathing individuals. Hence this study was carried out to find the immediate effects of inverse ratio breathing versus diaphragmatic breathing on inspiratory vital capacity and thoracic expansion.Methods: 30 healthy adult females in the age group 20-25 years were included in the study. Inspiratory vital capacity and thoracic expansion at 2nd, 4th and 6th intercostal space was measured using a digital spirometer and an inelastic inch tape respectively. Diaphragmatic breathing was administered for one minute and the same parameters were measured again. A washout period of one day was given and same outcome measures were measured before and after individuals performed inverse ratio breathing with the help of a visual feedback video for one minute.Results: Data was analysed using Wilcoxon test. There was extremely significant difference between the mean increase in the inspiratory vital capacity and thoracic expansion at the 2nd, 4th and 6th intercostals space after inverse ratio breathing as compared to diaphragmatic breathing (p < 0.0001).Conclusion: Inspiratory vital capacity and thoracic expansion increase significantly after inverse ratio breathing.

THE ULTRASONOGRAPHIC FINDINGS OF THE LIVER, GALL BLADDER AND THEIR RELATED VASCULATURES IN HEALTHY EGYPTIAN BUFFALOES (BUBALUS BUBALIS)

This study provided a full description of the normal ultrasonographic findings of the hepatobiliary system and its blood vessels in Egyptian buffaloes. The reported results particularly those of ultrasonography were compared with the normal reference values of cattle that had been previously recorded. This study was carried out on thirty healthy buffaloes. Complete clinical examination, hematological pictures profiling, blood biochemical analysis of total blood serum proteins, albumins, globulins, aspartate aminotransferase (AST), alkaline phosphatase (AP), γ-glutamyltranspeptidase (GGT), triglycerides and cholesterol, radiography and ultrasonographic examination were conducted with all these animals. The results showed that the clinical findings, blood pictures and blood biochemical levels agreed with the previously reported reference values of healthy buffaloes. The outlines of cranial abdomen, line of diaphragm and the cardiac silhouette were displayed normally on the radiographs. The acoustic windows for ultrasonographic examination of the hepatobilliary system was the right 11th intercostal space. The gall bladder could not be imaged from the right 12th intercostal space. The description of these normal ultrasonographic findings of the aforementioned organs will be valuable in detection of the abnormalities of these organs.