Fourth Intercostal Space Research Articles

Aortic valve replacement through J-shaped partial upper sternotomy.

The introduction of minimally invasive techniques in general surgery, in the late 1980s, influenced cardiac surgery as well. This led to the emergence of several minimal access approaches for aortic valve replacement (AVR). Currently, the upper partial sternotomy with unilateral J-shaped extension to the right through the fourth intercostal space is the most popular minimal access approach. This approach offers the comfort factor of sternotomy, improved cosmetic result, preserved respiratory mechanics, and last but not the least cost saving as no new equipment is required. On the other hand, inability to visualize the whole heart, adequately de-air the left heart, and failure to apply epicardial pacing wires are some of the perceived disadvantages of this approach. This article provides a comprehensive review of the indications, contraindications, technical aspects, outcomes, advantages and disadvantages of AVR through J-shaped partial upper sternotomy.

Minimally invasive approach for redo mitral valve surgery.

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

Application of Endovascular Occlusion of Both Caval Veins in Minimally Invasive Isolated Redo Tricuspid Surgery through Right Thoracotomy

To summarise the experiences of applying vena cava endovascular occlusion technique in minimally invasive isolated redo tricuspid surgery. Forty-six consecutive patients received minimally invasive redo tricuspid surgery through right thoracotomy at our institute. All the patients had isolated significant tricuspid regurgitation after previous cardiac surgeries. Preoperative chest computed tomography showed high risk of conventional median sternotomy and vena cava exposure. A right anterolateral thoracotomy incision was made from the fourth intercostal space. The arterial cannula was placed in femoral artery, and balloon cannulas were used for bicaval cannulation. The venous cannulation was guided by transoesophageal echocardiography. Tricuspid valve operation was performed with heart beating after both venous cannulas were endovascularly occluded by inflating the balloons. There were no complications related to this cannulation technique. Two patients needed position adjustment or re-inflation of the balloon to obtain complete occlusion. The average time of cardiopulmonary bypass establishment was 55 ± 15 min and pump time was 58 ± 23 min. The length of stay was 8 ± 7 days. There was no early death in hospital. Endovascular occlusion of both vena cava in isolated redo tricuspid surgery was safe, effective and reliable. This approach significantly simplified the complexity of the surgery.

Correlation of intracardiac electrogram with surface electrocardiogram in Brugada syndrome patients

The objective of this study was to correlate the electrocardiogram (ECG) modification during an Ajmaline challenge in patients affected by the Brugada syndrome and implanted with an implantable cardioverter-defibrillator (ICD) with the morphological changes of their ICD's intracardiac electrogram (IEGM). Sixteen type 1 Brugada syndrome patients implanted with a St Jude Medical AnalyST(®) ICD were enrolled and underwent ajmaline challenge. Intracardiac electrograms and 12 lead ECG signals were collected over the duration of the study and analysed off-line. The right precordial ECG leads were in both the third and fourth intercostal space by putting V5 and V6 in V1 and V2 at the third intercostal space. Two patients were excluded from the analysis due to signal noise issues. Of the remaining 14 patients, 12 and 2 patients were adjudicated to have positive and negative ajmaline challenges, respectively, based on standard ECG criteria. In the ajmaline positive patients, the IEGM T wave amplitude changes were more prominent than those of the IEGM ST segment (-898 ± 463 vs. -55 ± 381 µV, P < 0.05). Furthermore, all of these T wave amplitude changes were in the negative polarity, whereas the change in polarity of the ST segment was mixed. The changes in the IEGM T wave amplitude and ST segment were significantly smaller in the ajmaline negative patients compared with those in the ajmaline positive patients [211 ± 158 (P < 0.05) and 107 ± 54 (P < 0.05) µV, respectively). Over all 14 analysable patients, the change in the ECG ST segment over the timecourse of the ajmaline challenge correlated better with the IEGM T wave amplitude change (R = 0.72 ± 0.33) than the IEGM ST segment change (R = 0.63 ± 0.33). Applying an IEGM T wave amplitude change cut-off of 400 µV for predicting the outcome of the ajmaline challenge yielded 92% sensitivity (11/12) and 100% specificity (2/2). In Brugada patients, ajmaline challenge elicits significant T wave amplitude changes within the ICD IEGM, greater than those of the IEGM ST segment. This study is the first step to provide new tools able to continuously monitor the type I Brugada aspect in patients affected by the Brugada syndrome.

Re: Double arterial perfusion strategy for extensive thoracic aortic surgery to avoid lower body hypothermic circulatory arrest

Czerny and his co-workers report a technique of double arterial perfusion to avoid lower body hypothermic circulatory arrest in 10 patients undergoing extensive thoracic aortic repairs [1]. A median sternotomy combined with a left fourth intercostal space incision was utilized to provide exposure of the entire thoracic aorta. There was no hospital mortality, 2 patients (20%) sustained a stroke, and one each developed acute renal failure and myocardial infarction. Their technique represents another modification of the onestage approach to treat extensive thoracic aortic aneurysmal disease, some of which develops after previous procedures on the thoracic aorta such as repair of acute type A dissection. The authors employed a double arterial perfusion strategy and double-clamping of the descending thoracic aorta to avoid lower body hypothermic circulatory arrest, and selectively perfused the brachiocephalic vessels with a separate roller pump at a temperature of 20°C. This was stated to be a potential advantage over techniques that employ hypothermic perfusion of the lower body with intervals of ischaemia [2, 3]. Although lower body ischaemia is presumably avoided with their technique, acute renal failure developed in 1 patient and no information regarding hepatic or intestinal function was provided. With procedures that involve replacement of most or all of the descending thoracic aorta, the risk of spinal cord ischaemia increases, and some degree of hypothermia may be advantageous. As an example, performance of the distal anastomosis of the graft to the aorta at or near the aortic hiatus in the diaphragm would preclude distal aortic clamping. None of the patients in the present series had a replacement of more than two-thirds of the descending thoracic aorta. No major pulmonary complications were reported, and the authors attribute this to minimal manipulation of the left lung, since it was limited only to the area of the distal anastomosis of the graft to the descending thoracic aorta. In the setting of chronic aortic dissection however, control of bleeding from patent intercostal arteries is mandatory and sometimes troublesome, and can require exposure of the entire opened descending thoracic aorta and greater manipulation of the left lung. Despite these minor criticisms, the authors are to be commended for pursuing the strategy of a one-stage approach for the treatment of extensive thoracic aortic disease. Given the limitations of the two-stage and hybrid techniques for the treatment of extensive thoracic aortic disease, particularly in patients with chronic aortic dissection, we strongly support the authors’ recommendation that continued evaluation and refinement of techniques that involve a one-stage approach are indicated [4–6].

Right lower lobe resection.

This video (Video 1) describes the right lower lobe resection. A 1.5-cm incision was made at the 7th intercostal space along the midaxillary line as the main operation port. A 3.5-cm incision was made at the fourth intercostal space, in which an incision protection sleeve was attached. The operator then explored the thoracic cavity to identify that the lesion was located at the right lower lobe.

GW24-e3624 Myocardial regeneration in acute myocardial infarction rat model

ObjectivesTo investigate the myocardial proliferation/regeneration and myocardial cell apoptosis during different time points and in different parts of the heart in acute myocardial infarction (AMI) young and aged rat model.Methodsyoung...

GW24-e2167 Transcatheter closure greater than or equal 10mm membraneous ventricular septal defects

ObjectivesTo evaluate the feasibility of transcatheter closure ≥ ventricular septal defect (VSD).Methods379 cases with ≥ 10 mmVSDs underwent attempted transcatheter closure with various devices in this study. Of those,166 were...

Minimally invasive cardiac surgery-coronary artery bypass graft

Coronary artery bypass graft (CABG) is among the most common operations performed in the world. Different surgical strategies can be used with different invasiveness. This paper describes a recent development of the technique that merges the advantages resulting from both the adoption of an 'off-pump no-touch aorta operation' and a 'complete arterial revascularization through a left minithoracotomy' in a single procedure. This operation is currently known with the acronym MICS (minimally invasive cardiac surgery)-CABG (minimally invasive cardiac surgery). It is an off-pump operation performed through a minithoracotomy in the fourth or fifth left intercostal space across the midclavicular line. The left internal thoracic artery (LITA) is harvested under direct vision using a special rib-retractor with multiple interchangeable thoracotomy blades, including blades to use with lift systems for proximal artery harvesting, while the right radial artery (RA) is harvested endoscopically. A Y-connection is made between the two arteries. The LITA is used to bypass the left anterior descending coronary artery, while the right RA is used on the obtuse marginal branches and/or the posterior descending coronary artery. A special coronary stabilizer and a heart positioner with a shaft for remote thoracic insertion are needed.

Passive leg raising: influence of blood pressure transducer site

Dear Editor, We read with interest the published articles about the passive leg raising (PLR) test [1, 2]. The authors applied the changes of arterial pulse pressure and pulse contour-derived cardiac output to predict the fluid response during the PLR test; however, they did not demonstrate the exact position of the blood pressure transducer and whether the site was changed during the PLR test. They might have ignored the influence of the blood pressure transducer site. If the PLR test started from the semi-recumbent position and finished at the horizontal position with the leg raising [3], the blood pressure transducer site could be changed relative to the heart. The altered length may be about 10–30 cm for an adult patient. We supposed that altered length could cause a small change in blood pressure, but large for pulse contour-derived cardiac output. Responding to arterial transducer raising vertically, pulse contourderived cardiac output would increase and blood pressure would decrease in our primary sample study. Because of this, it is unknown which site should be chosen for the transducer during the PLR test. Some may argue that we could attach the transducer to a fixed level associated to the heart, but it is difficult for femoral blood pressure monitoring, and may require some special attached device. For invasive blood pressure monitoring, current recommendations suggest the transducer must be level with the phlebostatic axis. The site of the phlebostatic axis is at the intersection of the fourth intercostal space and mid-axillary line. This point represents the position of the left atria and therefore reflects central blood pressure. The study showed significant errors occur when subjects are in non-supine positions [4]. Thus, the blood pressure transducer level may be effective for the result of the PLR test. The value of knowing the PLR test is not being challenged here, nor is the value of dynamic changes in arterial waveform derived variables being questioned [5]. We are suggesting that the blood pressure transducer site should be taken as an impact factor in the PLR test, and it would be worthy of further study.

Thoracoacromial Artery Perforator Flap

Concerns and criticism have been reported on the feasibility and vascular reliability of the thoracoacromial artery perforator flap because of the inconsistent size of the pectoral branch of the thoracoacromial artery and its cutaneous perforators. The authors have investigated its vascular basis through a cadaver dissection and described their clinical experience in the surgical strategy, range of application, and indications for the thoracoacromial artery perforator flap. Twelve fresh human cadavers were dissected to define the anatomy of the branches of the thoracoacromial artery and their perforators and the anatomical landmarks for clinical application. Single pectoral branch perforators were injected to measure the extension of the thoracoacromial artery perforator vascular territory. A constant thoracoacromial artery perforator was present in the septum between the clavicular and sternocostal heads of the pectoralis major muscle in 21 of 24 hemichests. The mean caliber of the perforator was 0.7 mm and the mean length of the vascular pedicle was 7.1 cm. The territory of the thoracoacromial artery perforator flap extended up to the fourth intercostal space inferiorly. Between 2006 and 2011, the thoracoacromial artery perforator flap was used to reconstruct head and neck defects in seven patients. All patients healed uneventfully. The authors' studies provide evidence of the vascular supply and the clinical application of the thoracoacromial artery perforator flap. The recruitment of the chest skin through a thoracoacromial artery perforator flap resulted in an adequate color match, texture, and pliability for local adjacent defect restoration and for head and neck reconstruction. Therapeutic, IV.

Accurate interpretation of the 12-lead ECG electrode placement: A systematic review

Background: Coronary heart disease (CHD) patients require monitoring through ECGs; the 12-lead electrocardiogram (ECG) is considered to be the non-invasive gold standard. Examples of incorrect treatment because of inaccurate or poor ECG monitoring techniques have been reported in the literature. The findings that only 50% of nurses and less than 20% of cardiologists correctly place leads V1 and V2 of a standard 12-lead ECG is of great concern. Objective: The review discusses the evidence base underpinning the use of 12-lead ECG electrode placement on patients with suspected heart disease and summarizes the results of 10 research papers. Methods: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), the British Nursing Index (BNI), Embase and Medline were searched, from 2000 up to May 2012 using the key words ‘electrocardiography’, ‘positioning’, ‘electrodes’, ‘electrocardiogram’, ‘lead placement’ and ’12-lead ECG’. The search was limited to studies in the English language. The quality of each study was rated against set inclusion and exclusion criteria. Results: All the studies found that the incorrect connection of the electrode cables can alter ECG patterns simulating or concealing abnormalities, such as myocardial infarction (MI). Adherence to correct anatomical precordial lead placement methodology continues to be limited, especially with respect to leads V1 and V2 at the fourth intercostal space (ICS), which can potentially yield recorded waveforms that mimic the ECG diagnosis of septal MI. Conclusions: False ECG diagnosis of MI resulting from improper lead placement has the potential to trigger the wasteful use of healthcare resources and even cause harm to patients.

Video-assisted thoracoscopic surgery sleeve lobectomy with bronchoplasty: an improved operative technique

We summarize our experiences of video-assisted thoracoscopic surgery (VATS) sleeve lobectomy with bronchoplasty for non-small-cell lung cancer and discuss the indications and technical details of the operation. From September 2011 to December 2012, 15 patients underwent VATS sleeve lobectomy with bronchoplasty at our institution (right upper lobe 10, right middle and lower lobes 1, left lower lobe 2 and left upper lobe 2), with mediastinal lymphadenectomy. Three incisions were utilized. The utility incision was made at the fourth intercostal space, anterior axillary line. Simple continuous and simple interrupted suturing of the membranous and cartilaginous portions of the bronchus were performed for the anastomosis. All procedures were uneventful, with a median operative time of 165 min, a median bronchial anastomosis time of 44 min and a median blood loss of 150 ml. There were no conversions to thoracotomy. There were 14 squamous carcinomas and 1 adenocarcinoma. All patients recovered well, and 1 experienced a minor complication. The median duration of chest tube drainage was 5.4 days, and the median length of hospital stay was 7 days. All patients were followed postoperatively for a range of 1-16 months without tumour recurrence. VATS sleeve lobectomy with bronchoplasty is safe and effective. The utility incision placed at the fourth intercostal space, anterior axillary line, is convenient for the anastomosis, and the suturing technique is expeditious and secure. Preserving the azygos vein does not compromise exposure for the anastomosis. This technique is very suitable for centrally located lung cancers <3 cm in diameter, particularly when the cancers are located within the brachial lumen.

Anatomical structures underneath the sternum in healthy adults and implications for chest compressions

ObjectiveChest compressions are pivotal determinants of successful resuscitation. The aim of our study was to identify the variations of the anatomical structures underneath the sternum and to investigate possible implications for chest compressions. MethodsA retrospective study of all patients who underwent a routine chest computed tomography from January 2009 to January 2010 in a tertiary teaching general hospital was performed. The sternum and the area underneath were divided in 2 regions, one consisting of the second and third intercostal spaces, referred to as 2-3 segment, and one consisting of the fourth and fifth intercostal spaces, referred to as 4-6 segment. ResultsDuring the study period, 677 consecutive scans were analyzed. The most frequent structures beneath 2-3 segment were the left atrium (77.42%) and right atrium (69.82%), followed by the right ventricle (36.64%), left ventricle (35.94%), and left ventricular outflow (31.80%). Underneath 4-6 segment, the most frequent structures were the right ventricle (99.31%) and left ventricle (99.77%), followed by the right atrium (97%), left atrium (96.77%), and left ventricular outflow (36.64%). Interestingly, the difference in occurrence of atria and ventricles in both segments was significant irrespective of sex. ConclusionsThe occurrence of cardiac chambers under the lower part of the sternum is very high, making it a reasonable position for hand placement during chest compressions. However, optimal hand position may differ with age and among healthy individuals owing to variations in thoracic anatomy.

Pre-Operative 3D CT Imaging for Virtual Planning of Minimally Invasive Aortic Valve Surgery

MANY DIFFERENT APPROACHES ARE AVAILABLE FOR PERFORMING MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT (AVR). The most commonly used incision is the upper hemi-sternotomy, which extends from the sternal notch to the right fourth intercostal space (ICS). Variations in the location of the valve within the

Percutaneous transhepatic biliary drainage complicated with hepatic hydrothorax

Percutaneous transhepatic biliary drainage complicated with hepatic hydrothorax

Video-assisted vs open mediastinal lymphadenectomy for Stage I non-small-cell lung cancer: results of a prospective randomized trial†

Since the introduction of video-assisted lobectomy for non-small-cell lung cancer (NSCLC) into clinical practice, it has been discussed controversially whether mediastinal lymphadenectomy can be performed as effectively as an open procedure via thoracotomy. Therefore, we address this issue in a prospective randomized trial conducted in our institution. In total, 66 patients with completely staged clinical Stage I NSCLC were included and randomized either into a video-assisted group (n = 34) or into the conventional lobectomy group (n = 32). The video-assisted thoracoscopic (VATS) lobectomy was performed by using a 4- to 5-cm utility incision in the fourth or fifth intercostal space and two additional 10-mm ports without rib spreading. The conventional lobectomy was done via an anterolateral thoracotomy. Lymph nodes were classified according to the International Association for the Study of Lung Cancer classification; for right-sided tumours, lymph nodes number 2R, 4R, 7, 8, 9, 10, 11 and 12 were dissected, and for left-sided tumours, lymph nodes number 5, 6, 7, 8, 9, 10, 11 and 12. For the subsequent analyses, lymph nodes were grouped into different zones consisting of Zone 1 (2R and 4R), Zone 2 (7), Zone 3 (8R and 9R), Zone 4 (10R, 11 R and 12R), Zone 5 (4 L), Zone 6 (5 and 6), Zone 7 (8L and 9L) and Zone 8 (10 L, 11 L and 12L). Both groups were comparable with respect to different clinical pathological parameters (age, tumour size and comorbidity). In the video-assisted group, 2 patients were excluded due to conversion to an open thoracotomy. The number of mediastinal lymph nodes removed was as follows: VATS (right side) 24.0 lymph nodes/patient, open right-sided 25.2 lymph nodes/patient, VATS (left side) 25.1 lymph nodes/patient and open left-sided 21.1 lymph nodes/patient. With respect to the zones mentioned above, we found the following results: VATS vs open (mean number of lymph nodes/patient): Zone 1: 9 vs 8.5; Zone 2: 6.3 vs 5.6; Zone 3: 2.4 vs 3.2; Zone 4: 6.5 vs 6.9; Zone 5: 0 vs 0.5; Zone 6: 3.2 vs 3.7; Zone 7: 4.6 vs 3.2 and Zone 8: 10.5 vs 8.9. There were no statistically significant differences between the procedures, either with respect to the overall number of lymph nodes or with respect to the number of lymph nodes in each zone. Mediastinal lymph node dissection can be performed as effectively by the video-assisted approach as by the open thoracotomy approach. Furthermore, the video-assisted approach allows a better visualization of different lymph node zones.

Misdiagnosis of pneumothorax by ultrasonography after central venous catheterization in a patient with pleural adhesion

Misdiagnosis of pneumothorax by ultrasonography after central venous catheterization in a patient with pleural adhesion

Minimally invasive redo mitral valve surgery without aortic crossclamp

Reoperations of the mitral valve have a higher rate of complications when compared with the first surgery. With the field of video-assisted techniques for the first surgery of mitral valve became routine, reoperation cases began to arouse interest for this less invasive procedures. To assess the results and the technical difficulties in 10 patients undergoing minimally invasive redo mitral valve surgery. Cardiopulmonary bypass was installed through a cannula placed in the femoral vessels and right internal jugular vein, conducted in 28 degrees of temperature in ventricular fibrillation. A right lateral thoracotomy with 5 to 6 cm in the third or fourth intercostal space was done, pericardium was displaced only at the point of atriotomy. The aorta was not clamped. Ten patients with mean age of 56.9 ± 10.5 years, four were in atrial fibrilation rhythm and six in sinusal. Average time between first operation and reoperations was 11 ± 3.43 years. The mean EuroSCORE group was 8.3 ± 1.82. The mean ventricular fibrillation and cardiopulmonary bypass was respectively 70.9 ± 17.66 min and 109.4 ± 25.37 min. The average length of stay was 7.6 ± 1.5 days. There were no deaths in this series. Mitral valve reoperation can be performed through less invasive techniques with good immediate results, low morbidity and mortality. However, this type of surgery requires a longer duration of cardiopulmonary bypass, especially in cases where the patient already has prosthesis. The presence of a minimal aortic insufficiency also makes this procedure technically more challenging.

Needle Thoracentesis Decompression: Observations From Postmortem Computed Tomography and Autopsy

Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax. Current doctrine recognizes two suitable sites: the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line.A review was conducted of postmortem computed tomography and autopsy results in 16 cases where NTD was performed as an emergency procedure.In 16 cases with 23 attempted procedures, the outcome was confirmed in 17 attempts. In 7 placements, the catheter was in the pleural cavity; in 7 placements, the catheter never entered the pleural cavity; and in 3 placements, cavity penetration was verified at autopsy even though the catheter was no longer in the cavity. Success was noted in 6 of 13 anterior attempts and 4 of 4 lateral attempts, for an overall success rate of 59% (10 of 17). In the remaining 6 attempted procedures, a catheter was noted in the soft tissue on imaging; however, presence or absence of pleural cavity penetration was equivocal. All placements were attempted in the combat environment; no information is available about specifically where or by whom.NTD via a lateral approach was more successful than that via an anterior approach, although it was used in fewer cases. This supports the revision of the Tactical Combat Casualty Care Guidelines specifying the lateral approach as an alternative to an anterior approach.