4th Intercostal Space Research Articles

Relationship between age and location of the apex beat among apparently healthy Nigerian children

Background: Normal location of apex beat varies with age in children. Location of apex beat is an integral part of routine cardiovascular system examination in clinical practice. However, there is paucity of literature on apex beat location in Nigerian children. Objective: The aim of this study was to locate apex beat position in apparently healthy Nigerian children from birth to ten years, and to relate the location with age. Subjects and Methods: This was a cross sectional study carried out in Sagamu, Nigeria. A sample size of two hundred and thirty-seven was calculated from a previous study. Hence two hundred and thirty-seven apparently healthy Nigerian children who satisfied the inclusion criteria were enrolled for the study. Apex beat location in the intercostal space was determined and distance of apex beat from the midline, midclavicular line and nipple lines were measured. The measured distances were related to age using linear regression and Pearson correlation. Results: The mean distance of apex beat from the midline from birth to 10 years ranged from 2.3cm to 6.4cm. The distance of apex beat from the midline increased progressively with age. In children up to the age of three years, the apex beat was in the 4th left intercostals space. In 91.7%, 51.3% and 14.3% of children aged four, five and six years respectively, the apex beat was present in the 4th left intercostal space. Above six years, it was located in the 5th left intercostals space. Conclusion: The location of the apex beat from the midline was strongly related with age Thus, the distance of apex beat from the midline can be predicted from age in months.Keywords:  Apex beat, Children, Mid-clavicular line, Nigeria, Nipple line

Echocardiography of the normal camel (Camelus dromedaries) heart: technique and cardiac dimensions

BackgroundEchocardiography and intra-cardiac dimensions have not previously been reported in adult camels despite its potential application for medical purpose. The aim of this study was to describe the results of a prospective study, aiming to report normal cardiac appearance and normal chamber dimensions in adult camels (Camelus dromedarius).ResultsOn the right side, when the probe was placed in the 5th or 4th intercostal space (ICS), the caudal long-axis four-chamber view of the ventricles, atria, and the interventricular septum was obtained. Placing the probe slightly more cranially in the 4th ICS, the caudal long-axis four-chamber view and the caudal long-axis view of the left ventricular outflow tract (LVOT) were imaged. In 7 camels, a hybrid view between a “four-chamber” and “LVOT view” was imaged from the same position. The short-axis view of the ventricles was obtained in the 4th ICS where the transducer was rotated between 0° and 25°. Placement of the transducer in the 3rd ICS allowed visualisation of the right ventricular outflow tract (RVOT). On the left side, when the probe was placed in the 5th or 4th ICS, a four-chamber view was obtained. The LVOT is imaged in the 4th ICS and the RVOT was seen from the 3rd ICS.ConclusionsThis study showed that it is possible to obtain good-quality echocardiograms in adult camels and provide normal cardiac dimensions. This study could be used as a reference for further studies concerning camels with cardiac diseases.

A Murine Closed-chest Model of Myocardial Ischemia and Reperfusion

Surgical trauma by thoracotomy in open-chest models of coronary ligation induces an immune response which modifies different mechanisms involved in ischemia and reperfusion. Immune response includes cytokine expression and release or secretion of endogenous ligands of innate immune receptors. Activation of innate immunity can potentially modulate infarct size. We have modified an existing murine closed-chest model using hanging weights which could be useful for studying myocardial pre- and postconditioning and the role of innate immunity in myocardial ischemia and reperfusion. This model allows animals to recover from surgical trauma before onset of myocardial ischemia. Volatile anesthetics have been intensely studied and their preconditioning effect for the ischemic heart is well known. However, this protective effect precludes its use in open chest models of coronary artery ligation. Thus, another advantage could be the use of the well controllable volatile anesthetics for instrumentation in a chronic closed-chest model, since their preconditioning effect lasts up to 72 hours. Chronic heart diseases with intermittent ischemia and multiple hit models are other possible applications of this model. For the chronic closed-chest model, intubated and ventilated mice undergo a lateral blunt thoracotomy via the 4th intercostal space. Following identification of the left anterior descending a ligature is passed underneath the vessel and both suture ends are threaded through an occluder. Then, both suture ends are passed through the chest wall, knotted to form a loop and left in the subcutaneous tissue. After chest closure and recovery for 5 days, mice are anesthetized again, chest skin is reopened and hanging weights are hooked up to the loop under ECG control. At the end of the ischemia/reperfusion protocol, hearts can be stained with TTC for infarct size assessment or undergo perfusion fixation to allow morphometric studies in addition to histology and immunohistochemistry.

A Murine Closed-chest Model of Myocardial Ischemia and Reperfusion

Surgical trauma by thoracotomy in open-chest models of coronary ligation induces an immune response which modifies different mechanisms involved in ischemia and reperfusion. Immune response includes cytokine expression and release or secretion of endogenous ligands of innate immune receptors. Activation of innate immunity can potentially modulate infarct size. We have modified an existing murine closed-chest model using hanging weights which could be useful for studying myocardial pre- and postconditioning and the role of innate immunity in myocardial ischemia and reperfusion. This model allows animals to recover from surgical trauma before onset of myocardial ischemia. Volatile anesthetics have been intensely studied and their preconditioning effect for the ischemic heart is well known. However, this protective effect precludes its use in open chest models of coronary artery ligation. Thus, another advantage could be the use of the well controllable volatile anesthetics for instrumentation in a chronic closed-chest model, since their preconditioning effect lasts up to 72 hours. Chronic heart diseases with intermittent ischemia and multiple hit models are other possible applications of this model. For the chronic closed-chest model, intubated and ventilated mice undergo a lateral blunt thoracotomy via the 4th intercostal space. Following identification of the left anterior descending a ligature is passed underneath the vessel and both suture ends are threaded through an occluder. Then, both suture ends are passed through the chest wall, knotted to form a loop and left in the subcutaneous tissue. After chest closure and recovery for 5 days, mice are anesthetized again, chest skin is reopened and hanging weights are hooked up to the loop under ECG control. At the end of the ischemia/reperfusion protocol, hearts can be stained with TTC for infarct size assessment or undergo perfusion fixation to allow morphometric studies in addition to histology and immunohistochemistry.

Revascularização do miocárdio minimamente invasiva videoassistida

In general, surgeries currently tend to be less invasive and cardiac surgery has started to follow this trend. To evaluate the evolution of one hundred patients undergoing minimally-invasive coronary artery bypass grafting. Access to the heart was attained through a small; 6-cm thoracotomy, located in the 4th left intercostal space, starting at the nipple. Through the same intercostal space, 3 cm after the primary incision, a 6.5-mm optical device was inserted at 30º. Where the saphenous vein was used, the pericardium was opened above the aorta and the latter was partially clamped with a systolic pressure of 80 mmHg, with the proximal anastomosis being carried out in the conventional manner. The distal anastomoses were carried out in the conventional manner. The procedure was performed off-pump using single lung ventilation. The mean age was 63.9 ± 10.66 years. Sixty-eight (68%) patients were males. Fifty-three (53%) were in functional class III or IV. Left ventricular function was normal in fifty-three (53%) patients. Forty-two (42%) had undergone previous angioplasty. A total of 153 anastomoses were performed, ranging from 1 to 3. The average ventilation time was 4.06 ± 4.08 hours. Seventeen (17%) patients had atrial fibrillation and eight (8%) had pneumonia. There were two deaths in this series. Revascularization was safe with low mortality and morbidity. With the advent of new devices, this surgery may have a greater applicability.

Dorsolateral musculocutaneous perforators of posterior intercostal artery: An anatomical study

The posterior intercostal artery (PICA) is divided into four segments, vertebral, costal, intermuscular, and rectus, based on the neurovascular branching pattern. Dorsal branches arise from the vertebral segment. Several musculocutaneous perforators and a lateral branch originate from the costal segment. Musculocutaneous branches arise from the intermuscular and rectus segments. The purpose of this study is to describe in detail the musculocutaneous perforators of the costal segment of the posterior intercostal artery. Fresh cadavers were injected with a modified lead oxide-gelatin mixture. Intercostal spaces (8-11) were dissected in twelve cadavers (six preserved cadavers and six fresh cadavers). Angiograms were assembled with Adobe Photoshop. Two fresh cadavers underwent CT angiography and three dimensional reconstructions of the intercostal perforators were performed using Materialise's Interactive Medical Image Control System (MIMICS). In twelve cadavers, a total of 356 perforators (size > 0.5 mm) were found to arise from the posterior intercostal arteries in 96 intercostal (IC) spaces. 154 perforators (>0.5 mm) were found in the costal segment of the PICA. An average of 6.4 perforators was found in each hemithorax. All perforators were found within 2 cm of the midscapular line. At least one perforator was found in all intercostal spaces. Two or more perforators were found in 40% of the 8th and 9th IC spaces and 60% of the 10th and 11th IC spaces. Perforators were oriented perpendicular to the direction of the muscle fibres of the latissimus dorsi and were usually present one or two intercostal spaces below their origin from the PICA. Perforators of the costal segment of the PICA are described in detail. We propose to call these currently unnamed musculocutaneous perforators "dorsolateral" branches of the PICA, as they are located between dorsal and lateral branches of PICA.

Idiopathic Hemorrhagic Pericardial Effusion as a Precursor to Epicardial Lymphosarcoma in Three Cows

A 2-year-old female Holstein heifer was referred for evaluation of acute onset brisket edema and jugular venous distension. The heifer was 223 days in milk and 139 days pregnant and had been producing milk at expected levels until the day before presentation. Physical examination at admission to the University of Wisconsin Veterinary Medical Teaching Hospital revealed a bright and alert individual with a rectal temperature of 100.6 F, and pulse and respiratory rates of 76 beats and 34 breaths per minute, respectively. Muffled heart sounds were present and both jugular veins were turgid, visibly distended, and displayed retrograde fill. An echocardiogram at admission using a 2.5–3.5 MHz phased array transducer from a right parasternal approach identified an approximately 8-cm distension of the pericardial sac by anechoic fluid that was evident during all phases of the cardiac cycle. Some thickening of the epicardial surface was noted with strands of more hyperechoic tissue floating on the epicardial surface with the ultrasonographic appearance of fibrin. Cardiac contractility appeared subjectively poor although functional cardiac measurements were not obtained because of the depth of pericardial fluid. A serum sample obtained at admission tested positive by both ELISA and AGID techniques for antibodies to the bovine leukosis virus (BLV). Pericardiocentesis yielded bloody fluid with a PCV of 14%, total protein concentration of 5.2 g/dL, and total nucleated cell count (TNCC) of 5.75 9 10/lL. The nucleated cells were comprised of 14% neutrophils, 64% small lymphocytes, and 22% macrophages. The lymphocytes were cytologically normal. Approximately 5.5 L of hemorrhagic pericardial fluid was removed through a 24 French chest tube placed in the left 5th intercostal space, decreasing the visible depth of pericardial fluid to approximately 2 cm. The heifer was given 0.1 mg/kg dexamethasone IV q24h for 3 days and underwent daily ultrasonographic assessment of pericardial fluid volume and subjective evaluation of cardiac function. By day 3 of hospitalization, minimal pericardial fluid remained (<10 mm) but focal areas of epicardial fibrin still could be seen. Jugular venous distension had resolved and the heifer’s heart rate was normal. It had normal appetite and milk production had improved. The heifer was returned to its farm of origin and continued to do well, producing 68 lb of milk at a subsequent test date approximately 50 days post discharge. Unfortunately, it was found dead approximately 100 days after discharge. Necropsy showed thickening of the epicardial surface of the heart with multiple fibrous attachments connecting the epicardial surface to the pericardium. The epicardial surface was matted with extensive areas of fibrosis admixed with fibrin and hemorrhage. Multiple thoracic lymph nodes were enlarged with similar multifocal white to tan infiltrates. Histologically, the epicardium was expanded with fibrosis and highly vascular papillary projections in which there were many atypical neoplastic lymphocytes alongside a mononuclear inflammatory infiltrate of small lymphocytes and plasma cells. The myocardium had areas of fibrosis but no neoplastic infiltrate. Histologically, lymphosarcoma was confirmed in the thoracic lymph nodes.

Detection of Wall Motion Abnormalities during Ambulatory Echocardiography Using a Novel Ultrasound Transducer

This investigation was designed to determine whether transient wall motion abnormalities due to myocardial ischemia induced by walking could be detected by ambulatory echocardiography. Two groups were studied. Group 1 consisted of 10 males (mean age 34 years) who had no symptoms of angina. Group 2 consisted of eight selected patients (mean 61 years) with angina and angiographic evidence of coronary artery disease. The 2.5 MHz transducer is spherical in its distal part and mounted in an external housing to permit steering in 360°. The external housing was attached to the chest wall using an adhesive patch. The transducer was placed in the 3rd or 4th intercostal space at the left sternal border to permit imaging of the left ventricle (LV) in its short axis and attached to the chest wall. The transducer was interfaced with an Acuson Cypress echocardiography system which was placed on a mobile cart. To permit portability, the echocardiography system was powered by a capacitor (UPS device). The subjects were asked to walk along the corridor as fast as possible for 10 minutes or until the onset of symptoms while pushing the cart. The short axis of the LV was displayed on a monitor and recorded on optical disks. The heart rate, systolic blood pressure (SBP), and double product of Group 1 at rest were 77 ± 3 beats/min, 119 ± 13 mmHg, and 9,150 ± 868, respectively, and increased to 106 ± 8 beats/min, 129 ± 15 mmHg, and 1,3793 ± 2,176 with walking. The baseline heart rate, SBP, and double product were 71 ± 12 beats/min, 130 ± 14 mmHg, and 8,555 ± 1,928 in Group 2 and increased to 94 ± 14 beats/min, 135 ± 20 mmHg, and 12,480 ± 3,830 with walking. All patients in Group 1 had normal wall motion at rest and during walking. Patients in Group 2 had normal wall motion during rest and new wall motion abnormalities were noted in all subjects during walking (anterior septum and/or anterolateral wall in seven, posterolateral wall in one). The wall motion abnormalities resolved shortly after discontinuation of walking. Ambulatory echocardiography permitted the detection of transient wall motion abnormalities in patients with coronary artery disease (CAD). This technique could be potentially useful in evaluating selected patients for myocardial ischemia.

Ultrasonography of the urinary tract in 29 female Saanen goats

The left and right kidneys, ureters, urinary bladder and urethra of 29 female clinically healthy Saanen goats were examined via transcutaneous and transrectal ultrasonography. In order to establish reference values the examinations were performed using a 5.0 MHz linear transducer to scan the right caudal costal part of the abdominal wall, right and left dorsal flanks and right and left inguinal regions of standing goats. A 5.0 MHz intracavity probe was used for transrectal ultrasonographic examination of the urinary bladder and urethra. The kidneys were examined in longitudinal and cross section and assessed subjectively. They could usually be seen from the 12th intercostal space on the right side and dorsal right flank. The right kidney was 8.0 ± 0.67 cm long and the left was 8.4 ± 0.64 cm long. The ureters could not be visualized in any of the goats. The length of the urinary bladder was 5.1 ± 1.38 cm, and its largest cross-sectional diameter was 2.6 ± 1.01 cm. The urethra was seen in 23 goats and appeared as echogenic lines with no visible lumen. The transition from the neck of the bladder to the internal urethral orifice extended beyond the brim of the pelvis in only one goat.

Role of color duplex sonography in pre-operative internal mammary artery perforators assessment for breast reconstruction using contralateral lower pole flap

Reconstruction of a breast after mastectomy using the contralateral lower pole breast flap is an appealing procedure because it uses the tissues that were going to be excised during reduction of the sound breast to achieve symmetry. The literature mentioned that these flaps are supplied by the lower internal mammary artery perforators (IMAPs) with no further details.The aim of this study was to determine the site, size and number of the 4th and 5th IMAPs by using preoperatively color Duplex ultrasound and to assess its accuracy with intraoperative exploration. Twenty breasts in ten patients who presented for reduction mammoplasty were included in this study. Preoperative color Duplex ultrasound determined IMAPs in the 4th and 5th intercostal spaces. Intraoperative localization of these perforators assured the accuracy of the color Duplex. Statistically, the 4th IMAP diameters were significantly larger than the 5th IMAP diameters (P<0.05). The study concluded that color Duplex ultrasound is an accurate tool to preoperatively determine the 4th and 5th IMAPs.

Electrocardiography Recordings in Higher Intercostal Space for Children With Right Ventricular Outlet Obstruction Reconstruction Operation

Background and ObjectivesWe checked traditional and high-level precordial electrocardiogram (ECG) leads in patients who had undergone right ventricular outlet obstruction (RVOT) reconstruction surgery and evaluated the effect of ECG lead position on their QRS duration.Subjects and MethodsWe enrolled 34 patients who had undergone surgery for congenital heart disease with RVOT obstruction and who had received followed up care that included recorded ECG at a pediatric cardiac out-patient clinic. The control group included 29 patients who did not have hemodynamically significant intracardiac abnormality. We recorded traditional standard 12-leads ECG from the 4th intercostals space, and moved the precordial leads to the 3rd and 2nd intercostals spaces, and recorded ECGs repeatedly.ResultsIn all groups, there was no significant difference of mean QRS duration and QTc interval between traditional standard 12-leads ECGs and ECGs at higher intercostals spaces. There was no significant difference of ECG parameters between groups. In the control group, the degree of the change between the 4th intercostals space (ICS) QRS and 3rd ICS QRS was significant (p=0.031), and although, it was insignificant, ECGs at the 3rd ICS showed decreased QRS duration in group 1 (V1: 3rd ICS 119.21±21.53 msec vs. 4th ICS 122.80±31.78 msec. V2: 3rd ICS 113.68±19.43 msec vs. 4th ICS 118.24±19.16 msec).ConclusionAlthough the positional change of ECG leads did not result in a significant effect on measuring QRS duration after surgery, ECG leads at the 3rd ICS rather than at the 4th ICS may cause alteration of ECG readings. Therefore, we suggest that ECGs should be recorded in as accurate a position as possible.

Adrenocortical carcinoma extending into the inferior vena cava in a patient with right kidney agenesis: Surgical approach and review of literature

INTRODUCTIONAdrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery. PRESENTATION OF CASEWe describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB). DISCUSSIONWe discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed. CONCLUSIONIntracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory.

Transabdominal ultrasonographic appearance of the gastrointestinal viscera of healthy camels (Camelus dromedaries)

The purpose of this study was to describe the ultrasonographic picture of the gastrointestinal tract in healthy camels (Camelus dromedarius). For this purpose, 22 camels were examined. The rumen and its glandular sacs were filling most of the left side of the abdomen. The rumen wall was smooth and echogenic. The ventral part of the reticulum could be best imaged in 17 (77%) camels from the left and right paramedian region just behind to the sternal pad. The reticulum in these animals had a thick wall (1.17±0.27cm) that appeared as a half-moon-shaped structure with a biphasic contraction. The omasum was best viewed through the right 8th to 6th intercostal spaces in 18 (82%) camels. In the remaining 4 (18%), it was visualized through four consecutive intercostal spaces (right 9th to 6th). It had a wall thickness of 1.1±0.7cm and a transverse diameter of 8.74±3.4cm. The abomasum could be best visualized from the right 9th and 8th intercostal spaces in 14 (64%) camels, while it was observed in the 9th intercostal space in 3 (14%) animals and in the 8th and 7th intercostal space in 5 (22%) camels. Small intestinal structures were best seen low in the right paralumbar fossa. It was thin-walled (0.43±0.14cm) and had a diameter of 2.62±0.47cm. The cecum was imaged chiefly in the caudal right flank. It was thin-walled (0.37±0.05cm), had a diameter of 13.8±1.6cm. The proximal loop of the large colon appeared as thick, echogenic, continuous and slightly curved lines. It was thin-walled (0.51±0.08cm) and had a diameter of 3.5±0.8cm. The spiral colon was confined in all camels to the caudal ventral half of the abdomen. It appeared as structures with thick echoic lateral walls with a number of echogenic arched lines next to each other. Free peritoneal fluid pockets were imaged in two locations in 19 (86%) camels. Ultrasound-guided abdominocentesis was successful in 15 (68%) of the examined camels. This study provides the ultrasonographic appearance of the normal gastrointestinal tract in healthy camels that could be used as a reference for the interpretation of suspected digestive abnormalities.

Effect of left superior pulmonary vein fat pad on atrial fibrillation in dogs

Objective To explore the effect of ablation of left superior pulmonary vein fat pad(LSPV-FP) on atrial fibrillation(AF).Methods Twelve healthy adult mongrel dogs were anesthetized and ventilated;both cervical vagosympathetic trunks were exposed for stimulation.Thoracotomies at the 4th intercostal space of left and right chest were performed to expose the LSPV-FP.The effective refractory period(ERP)/ERP-dispersion(dERP) of atrium and LSPV,AF inducibility,and the ventricular rate of AF were measured in the following statuses: baseline,vagosympathetic trunk stimulation(VTS),LSPV-FP ablation,and VTS post LSPV-FP ablation.Results At baseline status,stimulation of the left or right vagosympathetic trunks significantly shortened the ERP of atrial([84.44±29.50] ms vs [129.7±15.83] ms,[85.42±26.11] ms vs [129.7±15.83] ms,P0.05),increased the dERP of atrial([71.67±14.03] ms vs [34.17±18.32] ms,[57.5±24.17] ms vs [34.17±18.32] ms,P0.05),the difference of ERP between proximal and distal of LSPV(P0.05),AF inducibility([5.33±1.231] times vs [0.75±0.96] times,[4.67±1.155] times vs [0.75±0.96] times,P0.05),and deceased the ventricular rate of AF([143.6±22.42] beats/min vs [226.3±28.50] beats/min,[146.4±30.72] times/min vs [226.3±28.50] times/min,P0.05).LSPV-FP ablation significantly attenuated all the above electrophysiological changes induced by left VTS(P0.05),but showed no effects on those induced by right VTS.Conclusion Left vagosympathetic trunk plays an important role in the development and maintenance of AF partially through LSPV-FP.

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study

The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery. A randomized, controlled, prospective, double-blind study. A tertiary care teaching hospital. Thirty children scheduled for cardiac surgery with a median sternotomy. A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure. The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001). Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy.

Congenital Intercostal Lung Herniation Combined with an Unusual Morgagni's Hernia

A 70-year-old male visited urgent care due to coughing for 1 month and left chest pain. He had no history of trauma. The initial chest computed tomography (CT) showed the 7th left intercostal lung herniation. A follow-up CT showed an intercostal lung herniation combined with a bowl herniation, which had developed due to a Morgagni's hernia. An emergency operation was performed due to the incarceration of the bowl and lung. The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. We concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion, and the recurrent coughing was the aggravating factor of herniation.

Insights into the location of type I ECG in patients with Brugada syndrome: Correlation of ECG and cardiovascular magnetic resonance imaging

Brugada syndrome is characterized by ST-segment abnormalities in V1-V3. Electrocardiogram (ECG) leads placed in the 3rd and 2nd intercostal spaces (ICSs) increased the sensitivity for the detection of a type I ECG pattern. The anatomic explanation for this finding is pending. The purpose of the study was to correlate the location of the Brugada type I ECG with the anatomic location of the right ventricular outflow tract (RVOT). Twenty patients with positive ajmaline challenge and 10 patients with spontaneous Brugada type I ECG performed by using 12 right precordial leads underwent cardiovascular magnetic resonance imaging (CMRI). The craniocaudal and lateral extent of the RVOT and maximal RVOT area were determined. Type I ECG pattern and maximal ST-segment elevation were correlated to extent and maximal RVOT area, respectively. In all patients, Brugada type I pattern was found in the 3rd ICS in sternal and left-parasternal positions. RVOT extent determined by using CMRI included the 3rd ICS in all patients. Maximal RVOT area was found in 3 patients in the 2nd ICS, in 5 patients in the 4th ICS, and in 22 patients in the 3rd ICS. CMRI predicted type I pattern with a sensitivity of 97.2%, specificity of 91.7%, positive predictive value of 88.6%, and negative predictive value of 98.0%. Maximal RVOT area coincided with maximal ST-segment elevation in 29 of 30 patients. RVOT localization determined by using CMRI correlates highly with the type I Brugada pattern. Lead positioning according to RVOT location improves the diagnosis of Brugada syndrome.

Pentacuspid aortic valve causing severe aortic regurgitation

and cardiopulmonary bypass was established. Ventilation was discontinued, and 2-cm skin incision was made at the 4th intercostal space for assisted window. Then 3 other small skin incisions were made to facilitate insertion of the endoscope and robotic arm. The pericardium was incised to expose the ascending aorta and right side of the heart. The ascending aorta was clamped, and antegrade cardioplegia was delivered from the ascending aorta. The right atrium was incised, and typical primum type ASD was observed. ASD closure with a biologic patch was performed. Cardiopulmonary bypass was tapered and stopped, and the heart started beating by itself. Left-sided single-lung ventilation was restarted. The tidal volume suddenly decreased, and strong positive-pressure ventilation was performed for a few seconds. At that time, sudden short ventricular tachycardia was noted. Moreover, the patient’s blood pressure decreased from 120 mm Hg to 85 mm Hg, and his central venous pressure increased from 5 mm Hg to 12 mm Hg. Transesophageal echocardiography revealed twisted atrial septum. Cardiac herniation was observed directly by endoscope (Video 1). The patient was maintained on durable ventilation, but his hemodynamic condition was unchanged. The left bronchus was blocked, and right-sided single ventilation was started after rotation of the patient’s

A rare association of long QT syndrome and syndactyly: Timothy Syndrome (LQT 8)

A rare association of long QT syndrome and syndactyly: Timothy Syndrome (LQT 8)

Ultrasonography of the rumen in 30 Saanen goats

This study describes the results of ultrasonographic examination of the rumen in 30 healthy Saanen goats. A linear or convex transducer with a variable frequency of 5 to 13 MHz was used to scan standing, non-sedated goats. The location and size of the rumen, the distance between the wall of the rumen and abdominal wall and the appearance and size of the gas, fibre mat and fluid layers of the ruminal contents were assessed. The rumen was seen as a large organ medial to the left abdominal wall. The wall of the rumen appeared as a thick echogenic line. The longitudinal groove was seen as an echogenic notch, which divided the rumen into the dorsal and ventral sacs. The rumen could be visualized from the 9th to 12th intercostal space (ICS) and flank on the left side in all the goats. The rumen was largest in the 12th ICS at 41.6 ± 5.13 cm and smallest in the 8th ICS at 11.3 ± 4.29 cm. The dorsal sac of the rumen was largest in the left cranial flank (17.4 ± 4.43 cm) and the ventral sac was largest in the 12th ICS on the left (29.1 ± 6.03 cm). In the cranial left flank, the rumen was situated immediately adjacent to the abdominal wall in all the goats. The spleen was located between the rumen and abdominal wall in the 8th to 12 th ICS in many of the goats. The gas, fibre mat and fluid layers of the ruminal contents could be visualized in all the goats. The gas layer was 9.9 ± 3.05 cm, the fibre mat layer 16.0 ± 4.55 cm and the fluid layer 12.2 ± 5.57 cm.