Anterior Chest Research Articles

Abstract 15370: Excellent Short-Term Outcomes Achieved With Minimally Invasive Right Infra-Axillary Incision and Transaortic Modified Morrow Procedure

Introduction: The Morrow procedure serves as the gold standard surgical intervention for hypertrophic obstructive cardiomyopathy. However, the conventional approach has its limitations. Minimally invasive approaches have been proposed, but exposure, mitral valve disruption, and cosmetic outcomes remain challenging. This study presents a single-port mini-incision thoracotomy through the right infra-axillary region with no surgical scar on the anterior chest wall. The procedure has achieved excellent short-term surgical outcomes. Methods: A comprehensive retrospective analysis was conducted, examining clinical data from 110 patients who underwent video-assisted thoracoscopic transaortic modified Morrow procedure between August 2021 and March 2023. The patient cohort comprised 62 males and 48 females, ranging in age from 15 to 71 years. Echocardiography was employed to confirm moderate mitral regurgitation in 50 patients and severe mitral regurgitation in 24 patients. Preoperatively, 102 patients exhibited systolic anterior motion (SAM). All 110 patients underwent the transaortic modified Morrow procedure, utilizing a 4-cm incision in the right infra-axillary region, with femorofemoral cardiopulmonary bypass. Results: There was no conversion to full sternotomy. Postoperative gradients across the left ventricular outflow tract were (7.7±4.3) mmHg. Impressively, extubation was successfully performed on the operating table for 102 patients, who experienced a median postoperative hospital stay of (9.2±3.0) days. Drainage volume in the first 24 hours was (160.4±56.0) ml. Postoperative septal thickness was (11.0±1.8) mm, and no iatrogenic ventricular septal perforation or residual SAM was observed. Follow-up at 3~22 months showed no major complications. Conclusions: The single-port mini-incision thoracotomy through the right infra-axillary region is a safe and effective approach for the Morrow procedure, with excellent short-term surgical outcomes and no visible surgical scar. The procedure offers several advantages, including minimal invasiveness, reduced trauma, faster recovery, and improved cosmetic outcomes. The technique is feasible and reproducible and may be a promising alternative to traditional approaches.

Investigation of the impact of radiotherapy on the shoulder joint by ultrasonography in breast cancer patients

Objectives: This study aimed to investigate the impact of radiotherapy (RT) on the supraspinatus, long head of the biceps and subscapularis tendons, and shoulder subcutenous fat tissue. Methods: Patients diagnosed with breast cancer who received RT to the anterior chest wall and axillary-supraclavicular region after breast-conserving surgery or mastectomy in our hospital. Overall, 56 (36 RT, 20 control group) patients were enrolled in this study. Pre-RT, post-RT 6-week, 3-month, and 6-month ultrasonographic and clinical assessments were performed. Results: The mean interval between surgery and RT was 5.6 (range: 2-8) months. Ten (27.7%) patients developed ultrasonographic abnormalities during the post-RT period. However, only 2 of these patients had shoulder pain and restricted range of motion in the shoulder. The thickness of the supraspinatus, biceps and subscapularis tendons were similar between the dominant and non-dominant sides of the control and RT group patients (5.7 mm vs. 5.1 mm, 2.87 mm vs. 2.89 mm, and 4.13 mm vs. 3.97 mm; respectively, p > 0.05). Thirteen patients were given RT on the ipsilateral side, and 23 received RT on the contralateral side. The pre-RT supraspinatus tendon thickness was significantly higher in the ipsilateral group than in the contralateral group (p = 0.026). However, there was no significant difference in the post-RT period (p = 0.408). Conclusions: In breast cancer patients undergoing adjuvant RT, RT may cause temporary edema in shoulder tendons. In addition, shoulder pain and restricted range of motion of the shoulder joint can be present in these patients.

Clinical Features and the Outcome Evaluations of Keloid and Hypertrophic Scar Treatment with Triamcinolone Injection in Mekong Delta, Vietnam - A Cross-Sectional Study.

Excessive scarring is a common problem that can have significant cosmetic and psychological consequences for patients. Intralesional injection therapy, such as the use of triamcinolone, has emerged as an effective treatment option for hypertrophic scars. The objective of this study was to describe the morphological features of hypertrophic scars, categorize them, and evaluate the efficacy of triamcinolone injection therapy in treating these scars. A cross-sectional descriptive study of 80 patients with hypertrophic scars treated with triamcinolone intralesional injection at Can Tho University of Medicine and Pharmacy Hospital from 5/2018 to 5/2021. There were 80 patients in all, with a male/female ratio of 1/1.05 and a median age of 15-35. There were 129 scars in all, with scar age >1 year accounting for 83%, keloid scars accounting for 64%, and hypertrophic scars accounting for the remaining 36%. Scars are most commonly seen on the trunk, accounting for 53.5% of all scars, particularly on the anterior chest wall. When the source of scars was discovered, trauma and acne accounted for 24% and 23%, respectively, while the rest were predominantly spontaneous scars, accounting for 49%. Scarring and discomfort of mild to moderate severity were common clinical symptoms; scars larger than 5cm in size had more symptoms than scars smaller than 5cm. Prior to the therapy, the mean Vancouver Score Scale-VSS was 6.55±2.13. After 24 weeks of the therapy, 96.7% of patients had entirely improved itching symptoms, 75% had completely improved pain, and 25% still had minimal pain. After therapy, the mean Vancouver Score Scale-VSS was 2.55±1.81 (p<0.05). At week 24, 3.75% of patients experienced skin shrinkage, 3.75% experienced depigmentation, and 13.75% experienced vasodilation. Triamcinolone intralesional injection should be utilized as a first-line therapy for hypertrophic scarring.

A CASE REPORT OF NECROTIZING FASCIITIS OF THE NECK AND ANTERIOR CHEST WALL CAUSED BY ODONTOGENIC INFECTION IN ELDERLY: DIAGNOSIS AND MANAGEMENT IN RURAL AREA

Introduction: Necrotizing Fasciitis (NF) is bacterial infection spreading rapidly affecting soft tissue and muscular fascia. It's life threatening and fatal, leads to tissue necrosis, sepsis, and death. It has high mortality number especially in elderly. Purpose: To report a rare case of odontogenic NF in elderly patient extending to the neck, left upper limb and anterior chest wall, diagnosed and treated in district hospital with limited facilities. Case Report: A 65 years old male with painful left neck swelling and fluctuating gangrenous appearance start form the mastoid bone to infraclavicular area crossing to the right close with sternal area. Swelling and fluctuating area also found in left axillar and left arm. Thirteen hours after hospital admission, the patient was sent to operating room to do the wound debridement. Wound care was carried out daily in intensive care unit and inpatient ward. 14 days postoperatively patient was send out to continue the wound care in outpatient department. 28 days postoperatively, skin grafting was done. Conclusion: Fourteen days postoperatively patient was sent to outpatient department to continue his wound care. After wound care in order to wound prepare for skin grafting. 28 days postoperatively, 14 days after patient discharge from hospital, skin grafting was done to close the wound defect.

Echocardiography for Volume Assessment in Acute Myocardial Infarction.

Background Errors caused by improper volume estimation increase acute mortality rates in acute myocardial infarction (AMI). We aimed to determine volume status in AMI patients using echocardiography and to correlate the findings with clinical outcomes. Methods This cross-sectional, single-center study was performed at a tertiary care center in India between August 2017 and September 2020 involving AMI patients. We performed echocardiography for all patients. Parameters such as left ventricle (LV) and atrium size, LV end-diastolic pressure, inferior vena cava (IVC) size and size variation, velocity stroke volume, and velocity time integral variation were measured. B-lines were recorded by scanning 32 regions on the anterior chest in the supine position using cardiac probes of echocardiography. Results A total of 184 patients were enrolled in the study with male predominance (82.1%). The mean age of patients was 58.2 ± 10.7 years. Dilated (>2.1 cm) and collapsible (<50%) IVC, and B-lines were significantly associated with heart failure (HF) (p<0.001; r=0.87 and p<0.001; r=0.74, respectively). The area under receiver operating characteristics (AUROC) curve to diagnose HF at a cut-off value of >10 for B-lines was 0.897 (0.842-0.951). AUROC curve for IVC size in diagnosing hypovolemia was 0.063 (0.000-0.130). Conclusions Volume status based on IVC size and B-lines detected byechocardiography hasa strongprognostic valuein AMIpatients and should be included in the routine assessment of thesepatients.

High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries.

The pectoralis major muscle is the largest muscle of the anterior chest wall. The primary function of the muscle is to adduct and internally rotate the arm at the shoulder. The pectoralis major muscle is broken down into two main components or "heads" based upon muscle fiber origin: clavicular and sternal. Pectoralis major muscle injury results from direct trauma or indirect force overload. The inferior sternal head fibers are the most commonly torn. The pectoralis major tendon most commonly is torn at the humeral insertion. Magnetic resonance imaging and high-resolution ultrasound have value in diagnosing pectoralis major muscle injury and help guide clinical and surgical management. Non-operative versus operative management of pectoralis major tears is dependent upon accurate diagnosis of tear location and severity on imaging. Operative management is recommended for tears at the humeral insertion and for musculotendinous junction tears with severe cosmetic/functional deformity. The indications for surgical intervention have been further expanded to complete intra-tendinous tears, defined as the mid-tendon substance between the myotendinous junction and humeral insertion, and those located at the sternal head/posterior lamina. This paper reviews normal pectoralis major anatomy and the spectrum of injury on magnetic resonance imaging and ultrasound. The importance of regional anatomical landmarks in assessing for pectoralis major muscle injury will be described. Other pathologies, such as tumor and infection, can also affect the pectoralis major muscle and key imaging features will be discussed to help differentiate these entities. Operative and non-operative management of pectoralis major muscle injury is described with examples of pectoralis major repair on post-operative imaging.

Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation

IntroductionMinimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. MethodsA prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. ResultsThe study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. ConclusionIn long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4–6%. Hypoesthesia was mostly limited to 1–2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. Level of evidenceLevel IV.

SAPHO syndrome: current clinical, diagnostic and treatment approaches.

This review provides an overview of SAPHO (Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis), a rare autoinflammatory disease that primarily affects bones, skin, and joints. We conducted a search on Medline/PubMed using keywords such as SAPHO syndrome, chronic recurrent multifocal osteitis/osteomyelitis, and related terms. SAPHO syndrome is rare, with a reported frequency of 1 in 10,000 in the Caucasian population. However, the actual incidence of SAPHO syndrome is unknown, and the incidence of the disease is likely higher. The pathogenesis of SAPHO syndrome remains incompletely understood. Current evidence suggests that SAPHO results from a complex interplay between immune dysregulation, genetic susceptibility, and environmental factors. It's not clear if SAPHO syndrome is an autoimmune disease or an autoinflammatory disease, but current evidence suggests that it's more likely an autoinflammatory disease because of things like neutrophil hyperactivity, fewer natural killer (NK) cells, high levels of interleukin (IL)-1, and a good response to treatments that block IL-1. Osteo-articular (OA) involvement is a key clinical feature of SAPHO. It affects the anterior chest wall, axial skeleton, peripheral joints, mandible, long bones of the extremities, and pelvis. Dermatological involvement is a common target in SAPHO, with lesions observed in 60-90% of cases. Common skin lesions include psoriasis and acne, with hidradenitis suppurativa and neutrophilic dermatoses being less commonly seen. Other clinical findings include constitutional symptoms caused by systemic inflammation, such as fever, weight loss, and fatigue. There is no specific laboratory finding for SAPHO syndrome. However, during active disease, there may be an increase in positive acute phase markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complement levels, mild leukocytosis, and thrombocytosis. Diagnosis is crucial for SAPHO syndrome, which lacks a specific diagnostic finding and is often underrecognized. A comprehensive evaluation of a patient's medical history and physical examination is crucial. Treatment options include non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional and synthetic disease-modifying agents (cDMARDs and sDMARDs), biological therapies, bisphosphonates, and antibiotics. Biological treatments have emerged as a viable alternative for SAPHO patients who do not respond to conventional treatments.

Aseptic abscess associated with SAPHO syndrome: a case report.

Aseptic abscess (AA) is a rare autoinflammatory disorder, characterized by the formation of sterile abscesses in various organs, and is accompanied by inflammatory bowel disease. Antibiotic treatment is ineffective, but steroid therapy shows a good response. AA can be difficult to differentiate from infection because abscesses appear similar both radiologically and histopathologically. Herein, we present the case of a 56-year-old woman with AA in the anterior chest wall and synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.

Skeletal defects and bone metabolism in Noonan, Costello and cardio-facio-cutaneous syndromes.

Noonan, Costello and Cardio-facio-cutaneous syndromes belong to a group of disorders named RASopathies due to their common pathogenetic origin that lies on the Ras/MAPK signaling pathway. Genetics has eased, at least in part, the distinction of these entities as they are presented with overlapping clinical features which, sometimes, become more pronounced with age. Distinctive face, cardiac and skeletal defects are among the primary abnormalities seen in these patients. Skeletal dysmorphisms range from mild to severe and may include anterior chest wall anomalies, scoliosis, kyphosis, short stature, hand anomalies, muscle weakness, osteopenia or/and osteoporosis. Patients usually have increased serum concentrations of bone resorption markers, while markers of bone formation are within normal range. The causative molecular defects encompass the members of the Ras/MAPK/ERK pathway and the adjacent cascades, important for the maintenance of normal bone homeostasis. It has been suggested that modulation of the expression of specific molecules involved in the processes of bone remodeling may affect the osteogenic fate decision, potentially, bringing out new pharmaceutical targets. Currently, the laboratory imprint of bone metabolism on the clinical picture of the affected individuals is not clear, maybe due to the rarity of these syndromes, the small number of the recruited patients and the methods used for the description of their clinical and biochemical profiles.

Surgical emphysema and pneumothorax: Unfamiliar combination in Ehlers-Danlos syndrome

A 53-year-old gentleman presented with sudden onset swelling over the neck for the past 5 days. It was associated with dyspnoea on exertion. He was a known patient of Ehlers-Danlos syndrome since sixteen years of age. Initially, the swelling appeared over the neck which gradually progressed over to the anterior chest wall and the nape of the neck. There was no history of trauma, fever, surgery or similar complaints in the past. He was a known smoker. On examination, there was diffuse subcutaneous emphysema over the neck, and the anterior chest wall (Figure 1). Skin crepitus was present. The skin was hyper-extensile, fragile and easily stretchable (Figure 1). The patient was vitally stable. On rigid laryngoscopy, bilateral vocal cords were mobile. We admitted the patient and performed a CT scan of the neck and chest to assess the extent of the emphysema. CT scan confirmed an extensive subcutaneous emphysema over the neck, extending posterior to the oesophagus. There were multiple emphysematous bullae over the apical region of the right lung and an area of pneumothorax just in the vicinity of the bullae (Figure 2). The patient was planned for incision and evacuation of the air. A horizontal incision was given over the most prominent part of the swelling and the air was milked out gently. An Intercostal Chest Drain (ICD) was inserted and the condition was closely monitored. The recovery was uneventful. He was discharged after seven days of hospital stay.

Clinical and ultrasound features of Mondor's disease of the breast: a case series

Objective: Mondor's disease (MD) is a rare disease, more commonly known as thrombophlebitis of the superficial veins of the anterior chest wall. Patients with Mondor's disease, usually middle-aged women, have a cord-like, subcutaneous tender induration with or without infiltration of the skin and subcutaneous tissue that tends to resolve on its own within three to four weeks. However, these cases are fairly rare and the lack of clear diagnostic criteria makes them often misdiagnosed. In 50–60% of cases, no cause is identified (primary idiopathic disease), and in 40–50% of cases, some factors may be present, such as pregnancy or breast cancer. We aimed to demonstrate case series of MD of the breast, as a replenishment of the clinical base of this pathology. Methods: All patients underwent clinical examinations and breast sonography with triplex Doppler. Results: We described the clinical and sonographic picture of thrombophlebitis of the superficial veins of the mammary glands in 5 patients with an idiopathic course, during pregnancy, and in combination with breast cancer to indicate clear diagnostic criteria. Conclusion: Thus, the clinical cases presented in the article demonstrate different clinical features of Mondor's disease with a single outcome. The disease is a spontaneously regressive disease within one, rarely more than one month.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience.

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. 6 patients met inclusion criteria, all males aged 37-78years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Does an alternative breast support garment provide symptomatic relief for larger breasted women with chronic non-specific back pain?

Nonsurgical guidelines recommend implementing a correctly fitted bra when managing back pain among larger breasted women. Achieving this is challenging with current bra solutions, sizing principles, and fitting approaches. Persistent wearing of an ill-fitting bra can cause negative health implications, including non-specific back pain. This study investigated immediate and short-term biomechanical and pain responses to changing breast support garment among larger breasted women with non-specific back pain. Participants (n = 24) performed a standing task, drop jumps, and seated typing tasks while bra and spinal kinematic data were recorded. Five breast support conditions were assessed: participants' usual bra (control), a professionally fitted bra in the immediate term (standard) and after 4 weeks wear (standard28), and a bra with an alternative design, measurement, and fitting approach in both the immediate term (alternative) and after 4 weeks wear (alternative28). A bra fit assessment and clinical pain/disability questionnaires were included. All participants failed the bra fit assessment in the control bra, compared with 87.5% (n = 21) in the standard and 4.2% (n = 1) in the alternative bras. The standard28 and alternative28 bras provided symptomatic relief, with the alternative28 bra improving a greater number of outcome measures. Reduced nipple-sternal-notch distance was observed only in the alternative28 bra condition. Symptomatic relief may be associated with the resting position of the breast tissue on the anterior chest wall. The alternative bra may provide potential clinical benefit if implemented as part of a nonsurgical or conservative pain management strategy. Alternative breast support garments should be considered to provide solutions to the problems associated with traditional bras.

Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery.

Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures. This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion. A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group. Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.

Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience

IntroductionAnterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation. MethodsData were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed. ResultsA total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively. ConclusionsMost patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.

Evaluation of the Effect of Pressure-Controlled Ventilation-Volume Guaranteed Mode vs. Volume-Controlled Ventilation Mode on Atelectasis in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Clinical Trial.

Background and Objectives: Laparoscopic surgery, which results in less bleeding, less postoperative pain, and better cosmetic results, may affect the lung dynamics via the pneumoperitoneum. After laparoscopic surgery, atelectasis develops. The primary aim of the present study is to demonstrate the effects of two different ventilation modes on the development of atelectasis using lung ultrasound, and the secondary outcomes include the plateau pressure, peak inspiratory pressure, and compliance differences between the groups. Materials and Methods: In this study, 62 participants aged 18-75 years undergoing laparoscopic cholecystectomy were enrolled. The patients were randomly assigned into two groups: the volume-controlled ventilation (VCV) group (group V) or the pressure-controlled-volume guaranteed ventilation (PCV-VG) group (group PV). The lung ultrasound score (LUS) was obtained thrice: prior to induction (T1), upon the patient's initial arrival in the recovery room (T2), and just before departing the recovery unit (T3). The hemodynamic data and mechanical ventilation parameters were recorded at different times intraoperatively. Results: The LUS score was similar between the groups at all the times. The change in the LUS score of the right lower anterior chest was statistically higher in the VCV group than the PCV group. The peak inspiratory pressure (PIP) was found to be statistically higher in the V group than the PV group five minutes after induction (T5) (20.84 ± 4.32 p = 0.021). The plateau pressure was found to be higher in the V group than the PV group at all times (after induction (Tind) 17.29 ± 5.53 p = 0.004, (T5) 17.77 ± 4.89 p = 0.001, after pneumoperitoneum (TPP) 19.71 ± 4.28 p = 0.002). Compliance was found to be statistically higher in the PV group than the V group at all times ((Tind) 48.87 ± 15.37 p = 0.011, (T5) 47.94 ± 13.71 p = 0.043, (TPP) 35.65 ± 6.90 p = 0.004). Before and after the pneumoperitoneum, the compliance was determined to be lower in the V group than the PV group, respectively (40.68 ± 13.91 p = 0.043, 30.77 ± 5.73 p = 0.004). Conclusions: LUS score was similar between groups at all times. The PCV-VG mode was superior to the VCV mode in providing optimal ventilatory pressures and maintaining high dynamic compliance in patients undergoing laparoscopic abdominal surgery.

FRI504 Ectopic Hyperactive Mediastinal Thyroid Tissue: A Case Report

Abstract Disclosure: C. Dimech: None. G. Jaiswal: None. A. Bhargava: None. Ectopic thyroid tissue is usually located along the normal path of the caudal migration of thyroid tissue during embryonic life. Substernal goiters are thought to occur by either the enlargement of ectopic mediastinal thyroid tissue (primary mediastinal goiter) or abnormal extension of thyroid issue into the superior mediastinum (secondary mediastinal goiter). Typically these goiters remain asymptomatic, and rarely result in hyperthyroidism or local compression of the surrounding area. We report a case of an 89-year-old Caucasian female with history of a multinodular goiter status post right hemithyroidectomy, who initially presented for subclinical hyperthyroidism. Further evaluation revealed negative thyroid stimulating antibodies. A thyroid ultrasound demonstrated a surgically absent right lobe, with a small heterogenous left lobe. A nuclear medicine radioactive iodine uptake and scan showed hypermetabolic residual thyroid tissue with a large area of increased radiotracer uptake projecting over the right anterior chest, concerning for ectopic thyroid tissue. A subsequent chest CT without contrast revealed an approximately 5 centimeter partially calcified anterior mediastinal/retrosternal mass. Given the patient’s age and co-morbidities, a decision was made to treat the hyperthyroidism with methimazole and monitor the ectopic tissue for worsening symptoms of compression. In cases with severe compressive symptoms, or difficult to treat hyperthyroidism, a surgical option must be considered. Presentation: Friday, June 16, 2023

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation

We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

Mitral Valve Prolapse, Not Always an Easy Diagnosis

Abstract We present the case of a 61-year-old male patient, with no medical history, who was presenting for an anterior chest pain, which appeared suddenly during an effort, accompanied by palpitations, fatigue and dyspnea Physical examination revealed the presence of a 4/6 systolic murmur with maximal auscultation at the apex and radiation in the left axilla. Echocardiographic evaluation revealed diagnostically suggestive elements for severe posterior mitral valve prolapse without any rupture, color Doppler showing severe mitral regurgitation, a tricuspid valve prolapse, tricuspid regurgitation grade III and pulmonary hypertension. Coronary angiography revealed coronary arteries without hemodynamically significant lesions, and Holter ECG/24-hour monitoring detected atrial fibrillation in 44% of the monitoring time. In this context, the possible causes of the anterior chest pain were: microvascular angina, traction on the chordae or pulmonary hypertension. The patient had a surgical indication for mitral valve replacement or reconstruction. The department of cardiac surgery undergoes mitral valve replacement with a mechanical prosthesis with a favorable outcome.