Intercostal Space Research Articles

Phrenic nerve neurorrhaphy with a sural nerve graft in unilateral diaphragmatic paralysis

Unilateral diaphragmatic paralysis can present following damage or impairment to a phrenic nerve. In cases where current treatment methods are not feasible, the use of a double phrenic nerve neurorrhaphy with an autologous sural nerve graft should be investigated. In preserved rats, the feasibility of this technique was explored. The sural nerve was excised from the left thigh. Entering into the thoracic cavity bilaterally through the fifth intercostal spaces, the right and left phrenic nerves were identified. The right phrenic nerve was cut to create a distal nerve stump. The sural nerve was grafted onto the distal stump of the right phrenic nerve and the side of the left phrenic nerve. Using six preserved rat cadavers, the end-to-side graft was successfully explored and performed. It was determined that approximately 2.5–3 cm of the sural nerve will be required to be harvested for the graft. The sural nerve was an appropriate size for grafting onto the phrenic nerves. Four 10–0 Nylon sutures were sufficient for each neurorrhaphy. A double phrenic nerve neurorrhaphy with an autologous sural nerve graft is potentially feasible in rat models.

Modified thoracoabdominal nerve block through perichondrial approach (M-TAPA): an anatomical study to evaluate the spread of dye after a simulated injection in soft embalmed Thiel cadavers

Background and objectivesThere is still no consensus on the analgesic range and mechanisms of action of modified thoracoabdominal nerve block through perichondrial approach (M-TAPA). This cadaveric study aimed to determine...

Complete uni-port video-assisted thoracoscopic surgery for surgical stabilization of rib fractures: a case report

BackgroundRib fractures are a common injury in trauma. Potential complications include pain, pneumonia, respiratory failure, disability, and death. Surgical stabilization of rib fractures (SSRF) has become an available treatment option, and complete video-assisted thoracoscopic surgery (VATS) for SSRF is gradually accepted because of minimally invasive and pain relief. To our knowledge, complete uni-port VATS for SSRF has not yet been reported.Case presentationA 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. He was found with left 7th through 11th rib fractures with a pulmonary contusion from computed tomography (CT). A 4 cm incision was made in the 7th intercostal space in the midaxillary line, and complete uni-port VATS for SSRF were operated. The patient's pain was significantly relieved after the operation, and the scar was tiny and unapparent.ConclusionsComplete uni-port VATS for SSRF is a novel and modificatory method of operation with the benefit of minimal invasion, meanwhile, intrathoracic injuries could be treated at the same time. Further study is warranted.

A Preclinical Feasibility Study of Single-Port Robotic Subcostal Anatomical Lung Resection and Subxiphoid Thymectomy Using the da Vinci® SP System.

Despite the recent introduction of technologically advanced single-port (SP) robotic systems, their use in the field of thoracic surgery has been rarely explored. Here, we report our preclinical experience concerning SP robotic thoracic surgery using the da Vinci® SP system. The da Vinci® SP system was used to perform subcostal anatomical lung resection and subxiphoid thymectomy in three cadavers. The operative settings that best met the surgeon's requirements for each resection were also determined. Four subcostal anatomical lung resections and two subxiphoid thymectomies were completed. While both procedures did not require additional incisions, the use of an observation port in the intercostal spaces was strongly recommended to safely create subcostal access. Dissection of hilar structures and mediastinal lymph nodes was feasible. However, due to the current unavailability of a robotic stapler, a handheld stapling instrument was required to perform a transection of vital structures. When the stapling process proved to be difficult, the table surgeon temporarily removed a robotic arm to acquire the necessary space to complete the procedure. Our data represent a promising preclinical step in understanding the feasibility of using the da Vinci® SP system to perform an SP subcostal anatomical lung resection and a subxiphoid thymectomy.

Techniques of inserting deep inferior epigastric perforator flap obliquely in immediate breast reconstruction after total mastectomy

This study aimed to share the experience of inserting a deep inferior epigastric perforator (D.I.E.P) flap obliquely in immediate breast reconstruction after total mastectomy. Forty patients underwent immediate breast reconstruction with flap D.I.E.P after total mastectomy. The flaps were placed obliquely, with the upper edge facing downward and inward. After being placed in the recipient region, parts of the flap at both ends were removed, the upper end was fixed into the II-III intercostal space next to the sternum, and the lower end was folded to create a projection of the lateral lower pole of the breast. The flap pedicle was anastomosed to the thoracodorsal vessels (TDVs) if the contralateral flap pedicle was used; conversely, the mammary vessels (IMVs) were used. Satisfaction with breast shape was assessed after 6 months using the BREAST-Q questionnaire. A total of 37/40 flaps were well vascularized; 36/37 patients with a survival flap were interviewed, showing that the average BREAST-Q evaluation score of satisfaction with breast shape was 62.22 (51-78). The number of answers for satisfied and very satisfied with breast shape accounted for 94.44%. Inserting the D.I.E.P flap obliquely has the advantage of being easy to shape the breast contour, creating a moderate projection and symmetry to the opposite breast. The author suggested using the IMVs as the receiving vessels when using the pedicle of the flap on the ipsilateral side and the TDVs when the contralateral pedicle flap was used.

Minimally Invasive Coronary Revascularization. Technical Aspects and Current Results

Coronary artery bypass surgery has been for decades the gold standard for the treatment of coronary artery disease, especially in patients with 3-vessel disease. Despite the excellent results achieved through the application of this technique, problems related to median sternotomy and the use of cardiopulmonary bypass such as wound infections and cerebral stroke still play an important role in the postoperative course of these patients. Minimally invasive coronary revascularization techniques aim at reducing the rate of such complications while offering the same quality of revascularization.
 Minimally invasive coronary surgery includes a set of coronary revascularization techniques that are completed without the use of cardiopulmonary bypass or through a left mini-thoracotomy at the level of the 4th or 5th intercostal space and aim at reducing the level of the aforementioned complications compared to the standard technique. Hybrid coronary revascularization is an alternative approach that combines surgical revascularization with percutaneous coronary interventions to extend the treatment spectrum even further. Through the application of these techniques, surgeons aim at minimizing the risk of infection of the surgical wound and significantly reduce the number of post-operative cerebral strokes. Also, numerous studies have shown that minimally invasive coronary surgery can offer better results in terms of duration of the mechanical ventilation, length of stay in intensive care, transfusions of blood products and consequently in reducing treatment costs.
 Minimally invasive revascularization techniques are not only an important alternative to standard coronary surgery, but in the near future will constitute the standard treatment for this group of patients. This article aims to describe the techniques used to achieve minimally invasive coronary revascularization and to highlight the outcomes of the different approaches.CABG,

The specific signs of lung ultrasound to diagnose pulmonary hemorrhage of the newborns: Evidence from a multicenter retrospective case-control study.

Pulmonary hemorrhage (PH) is one kind of critical lung diseases in newborn infants, which is the most difficult one to be diagnosed by ultrasound. This study was to investigate the specific ultrasonic signs of PH in order to better diagnose neonatal PH by using lung ultrasound (LUS). A total 168 newborn infants were enrolled in this study, which included PH, pneumonia, meconium aspiration syndrome, and newborns without lung diseases, there were 42 cases in each group. In a quiet state, infants were placed in the supine, lateral or prone position for the examination. Each lung was divided into the anterior, lateral and posterior regions, then each region of both lungs was scanned with the probe perpendicular to the ribs or parallel to the Intercostal spaces. The major results showed that: (1) the common LUS manifestation of PH includes lung consolidation, air bronchograms, fluid bronchograms, pleural effusion, shred signs, pleural line abnormality and B-lines, while fibrin deposition sign is a rare sign of PH. (2) Co-existing of lung consolidation with fluid bronchograms and pleural effusion is the specific sign of PH with a sensitivity of 81.0%, specificity of 98.4% and the positive predictive value (PPV) was 94.4%. (3) Fibrin deposition sign is an uncommon specific LUS sign of PH with a sensitivity 28.6%, specificity of 100% and the PPV was 100%. (4) Nine patients (21.4%) were diagnosed with PH based on ultrasound findings before oronasal bleeding. (5) The survival rate of infants with PH was 100% in this study. LUS is helpful for the early diagnosis of neonatal PH and may therefore improve the prognosis. The lung consolidation with fluid bronchograms and pleural effusion as well as fibrin deposition sign are specific to diagnose PH by using LUS.

Application of deep learning for bronchial asthma diagnostics using respiratory sound recordings.

Methods of computer-assisted diagnostics that utilize deep learning techniques on recordings of respiratory sounds have been developed to diagnose bronchial asthma. In the course of the study an anonymous database containing audio files of respiratory sound recordings of patients suffering from different respiratory diseases and healthy volunteers has been accumulated and used to train the software and control its operation. The database consists of 1,238 records of respiratory sounds of patients and 133 records of volunteers. The age of tested persons was from 18 months to 47 years. The sound recordings were captured during calm breathing at four points: in the oral cavity, above the trachea, at the chest, the second intercostal space on the right side, and at the point on the back. The developed software provides binary classifications (diagnostics) of the type: "sick/healthy" and "asthmatic patient/non-asthmatic patient and healthy". For small test samples of 50 (control group) to 50 records (comparison group), the diagnostic sensitivity metric of the first classifier was 88%, its specificity metric -86% and accuracy metric -87%. The metrics for the classifier "asthmatic patient/non-asthmatic patient and healthy" were 92%, 82%, and 87%, respectively. The last model applied to analyze 941 records in asthmatic patients indicated the correct asthma diagnosis in 93% of cases. The proposed method is distinguished by the fact that the trained model enables diagnostics of bronchial asthma (including differential diagnostics) with high accuracy irrespective of the patient gender and age, stage of the disease, as well as the point of sound recording. The proposed method can be used as an additional screening method for preclinical bronchial asthma diagnostics and serve as a basis for developing methods of computer assisted patient condition monitoring including remote monitoring and real-time estimation of treatment effectiveness.

Right anterolateral thoracotomy with partial sternotomy for chronic type B aortic dissection with right aortic arch and Kommerell's diverticulum.

Chronic type B aortic dissection with the right aortic arch was rare. We present the case of a 59-year-old man with a right aortic arch and chronic type B aortic dissection, with a maximum size of 80 mm. Graft replacement was successfully performed through right anterolateral thoracotomy with partial sternotomy through the fourth intercostal space. The patient's postoperative course was uneventful. He had no paralysis and was extubated on postoperative day 2 and discharged from the hospital on postoperative day 15. Anterolateral thoracotomy with partial sternotomy could be a suitable approach for right-sided aortic aneurysms.

Intraoperative prophylactic right ventricular assist device in prevention of postcardiotomy failure.

In patients at risk of developing right ventricular failure after cardiac surgery, right ventricular support with a ventricular assist device may be a promising strategy to reduce mortality. We present our experience with intraoperative right ventricular assist device implantation as a prevention strategy of right ventricular failure after cardiac surgery. Between 2016 and 2022, we implanted four right ventricular assist devices prophylactically in a series of patients with surgical indication for valvular heart disease and high risk of postoperative right ventricular failure. Indications for the right ventricular assist device were suprasystemic pulmonary hypertension or severe right ventricular dysfunction. Externalization of the device cannulas through intercostal spaces was performed in three patients, allowing early mobilization and withdrawal without resternotomy. Removal of the device ocurred on the eighth postoperative day. ICU and hospital length of stay was 12 (±1.6) and 23 days (±4.2) respectively. Hospital mortality was null. No patient died during follow-up, mean follow-up was 32.5months [1-72]. Patients improved their NYHA functional class up to grade II during follow-up. Acute right ventricular failure after cardiac surgery remains a significant cause of morbidity and mortality. Prophylactic strategies to prevent postoperative right ventricular dysfunction may decrease the incidence of refractory postoperative right ventricular failure. We propose a novel approach to prevent right failure after cardiac surgery with prophylactic intraoperative ventricular assist device implantation.

Usefulness of supplemental parasternal block for sternal keloid excision under general anesthesia in a child status post multiple cardiac surgeries

Sir A 12-year-old boy weighing 60 kg, with history of tricuspid atresia, had undergone right modified Blalock–Thomas–Taussig shunt, and patent ductus arteriosus ligation on day 1 of life. One year later he underwent bidirectional Glenn shunt, and extra cardiac Fontan surgery was done at 6 years. He presented now with a thick keloid in the midline sternotomy scar for keloid excision. Current screening echo showed tricuspid atresia, normally related great arteries with normal ventricular flow and unobstructed Glenn and Fontan flow profiles. Intravenous midazolam 1 mg, fentanyl 100 mcg and ketamin 60 mg were given and incremental bolus of propofol 10 mg (total 20 mg) was given till loss of response to verbal commands and relaxation of jaw. Airway was then secured with size 3 proseal laryngeal mask airway (PLMA) and correct placement was ensured with regular endtidal carbon dioxide (ETCO2) waveforms. Parasternal block was then given under ultrasound guidance at third and fifth intercostal spaces 2 cm lateral to midline bilaterally. Spread of injected solution causing separation of pectoralis major muscle from the rib and external intercostal muscle confirmed deposition of drug in the correct plane (Fig. 1). Ten milliliter of 0.25% bupivacaine was injected at each site.Figure 1: Superficial parasternal-intercostal plane block.Anesthesia was maintained with sevoflurane (1.5–2%) in air oxygen mixture under spontaneous ventilation. Intraoperatively patient remained stable with heart rate 86-98/min, systolic blood pressure 90–100 mmHg, oxygen saturation 96–98% and ETCO2 32-40 mmHg and had received 500 ml of Ringer lactate. At the end of surgery, which lasted for 2 h, PLMA was removed when patient was awake. He had good postoperative analgesia. Anesthetic goals in a child post-Fontan surgery include adequate hydration, avoidance of hypoxia, hypercabia, and acidosis and preservation of spontaneous ventilation whenever possible. If general anesthesia is mandated, low inspiratory pressures and minimal positive end expiratory pressures are to be used [1,2]. Sternotomy produces considerable pain which increases with chest wall movement and reduces pulmonary function with higher risk of development of postoperative hypoxia, atelectasis, and pneumonia [3]. Parasternal block is commonly advocated to provide supplemental anaesthesia intraoperatively and for postoperative analgesia following median sternotomy, breast surgery and cardioverter-defibrillator implantation [4,5]. The nerve targeted is the anterior branches of intercostal nerves which enters intercostal and pectoralis major muscles and innervates the antero-medial region of chest wall. Local anesthetic is injected deep to pectoralis major muscle and superficial to intercostal muscles or between internal thoracic muscle and transverses thoracis muscle. Therefore, these blocks are essentially described as superficial or deep parasternal-intercostal plane blocks, depending on where the target nerves are blocked. The anatomical injection site differentiates these techniques though both techniques provide analgesia to the antero-medial chest wall [5]. Supplemental regional block helps to reduce dose requirement of anesthetic agents intraoperatively. Use of supplemental parasternal block enabled us to keep the child spontaneously breathing under general anaesthesia using PLMA with use of lesser doses of anesthetic agents, thereby minimising drug adverse effects which could be deleterious in the presence of cardiac diseases. It is concluded that supplemental parasternal block provides good intraoperative and postoperative analgesia following anterior midline chest wall surgeries.

Ventricular Tachycardia in an Elderly Male With Brugada Syndrome.

We present a case of Brugada syndrome in a 74-year-old patient who presented with urine retention and incidentally found to have non-sustained ventricular tachycardia (NSVT) on electrocardiogram (ECG) and telemetry. To reveal characteristic type 1 Brugada pattern, right-pericardial lead was placed in the third right intercostal space. No antiarrhythmics were started, a loop recorder was implanted, and on follow-up episodes of self-terminating sustained ventricular tachycardia (VT) were noted. The patient was started on quinidine with resolution of VT.

Risk of Harm in Needle Decompression for Tension Pneumothorax.

Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Echocardiographic characterization of cardiac chambers and vasculatures in buffaloes (Bubalus bubalis) during diastolic and systolic phases.

Ultrasonography had diagnostic importance in the evaluation of different diseases in buffaloes, including cardiovascular diseases. The current work describes the normal echocardiographic findings in healthy buffaloes, along with establishing reference values for echocardiographic dimensions for both sides of the heart, i.e., left and right ones. About 30 healthy adult buffaloes that belonged to private farms in Assiut, Egypt, were included in this study. Each animal underwent a complete clinical evaluation as well as hematological analyses, lipid profile indices, liver functions, cardio-thoracic radiography, and echocardiography to confirm no diseased conditions were detected. The study was conducted on healthy buffaloes (n = 30) in Assiut Governorate, Egypt. The obtained results reported healthy buffaloes with normal clinical findings as well as indices of blood pictures and serum biochemicals that were within the reference intervals. Radiography revealed a free reticulum and a well-defined diaphragm. The heart was seen as a typical radio-opaque organ. Ultrasonographically, using grayscale B-mode and M-mode, the heart was commonly imaged from the left fourth intercostal space. Different echocardiographic views were described, including the four chamber view, i.e., right atrium (RA), right ventricle (RV), tricuspid valve (TCV), left atrium, left ventricle, mitral valve, and interventricular septum (IVS), and the right ventricular outflow tract, i.e., RA, TCV, RV, pulmonary artery (PA), and pulmonary valve. Cross sections in each of the apex and base of the heart were described. Echocardiographic dimensions during cardiac diastole and systole, including diameters and wall thickness of each of the atria and ventricles, were demonstrated. Interventricular septal thickness wall thickness as well as diameters of the aorta and PA, were stated. The work tried to put reference values on the normal echocardiographic dimensions using 2-D B-mode gray scale ultrasonography in healthy adult buffaloes. These echocardiographic reference dimensions with normal echocardiographic imaging will be very helpful in enhancing the diagnostic efficacy of ultrasounds for recognizing abnormal findings related to cardiac disorders.

Co-activation of the diaphragm and external intercostal muscles through an adaptive closed-loop respiratory pacing controller.

Respiratory pacing is a promising alternative to traditional mechanical ventilation that has been shown to significantly increase the survival and quality of life after the neural control of the respiratory system has been compromised. However, current pacing approaches to achieve adequate ventilation tend to target only the diaphragm without pacing external intercostal muscles that are also activated during normal inspiration. Furthermore, the pacing paradigms do not allow for intermittent sighing, which carries an important physiological role. We hypothesized that simultaneous activation of the diaphragm and external intercostal muscles would improve the efficiency of respiratory pacing compared to diaphragm stimulation alone. We expanded an adaptive, closed-loop diaphragm pacing paradigm we had previously developed to include external intercostal muscle activation and sigh generation. We then investigated, using a rodent model for respiratory pacing, if simultaneous activation would delay the fatigability of the diaphragm during pacing and allow induction of appropriate sigh-like behavior in spontaneously breathing un-injured anesthetized rats (n = 8) with pacing electrodes implanted bilaterally in the diaphragm and external intercostal muscles, between 2nd and 3rd intercostal spaces. With this novel pacing system, we show that fatigability of the diaphragm was lower when using combined muscle stimulation than diaphragm stimulation alone (p = 0.014) and that combined muscle stimulation was able to induce sighs with significantly higher tidal volumes compared to diaphragm stimulation alone (p = 0.014). Our findings demonstrate that simultaneous activation of the inspiratory muscles could be used as a suitable strategy to delay stimulation-induced diaphragmatic fatigue and to induce a sigh-like behavior that could improve respiratory health.

A modified method for measuring the length of peripherally inserted central catheters to reduce the risk of malposition during catheter insertion.

Malposition may occur during peripherally inserted central catheter insertion. Accurately measuring the length of a peripherally inserted central catheter is crucial to preventing malposition, including "long peripherally inserted central catheter placement," in which the tip of a peripherally inserted central catheter is deeper than the target position. The traditional method of measuring peripherally inserted central catheter length involves measuring from the insertion site to the parasternal notch and down to the third or fourth intercostal space, which may result in overestimation because of the thickness of the pectoralis major and anterior chest wall. To avoid this overestimation, the authors developed and tested a modified method for reducing long peripherally inserted central catheter placement. This study employed a retrospective design. Chest X-rays were used to examine the peripherally inserted central catheter tip positions in 48 patients in the medical intensive care unit who had undergone peripherally inserted central catheter insertion. The traditional and modified measurement methods were used to measure the peripherally inserted central catheter length in 17 and 31 patients, respectively. Fisher's exact test was used to examine between-group differences in the incidence of different types of peripherally inserted central catheter malposition. The peripherally inserted central catheter tip position was near the target position in five patients (29.41%) in the traditional measurement group and 17 patients (54.84%) in the modified measurement group (p = 0.132), whereas long peripherally inserted central catheter placement occurred in six patients (35.29%) in the traditional measurement group and one patient (3.23%) in the modified measurement group (p = 0.006). However, the incidence of other types of peripherally inserted central catheter malposition did not differ significantly between the groups. The results of this study that the proposed modified measurement method may be able to reduce the incidence of long peripherally inserted central catheter placement among medical intensive care unit patients. The method must be further evaluated in prospective studies and studies with larger sample sizes in the future.

Modified pericostal suture technique to reduce postoperative pain and provide optimum anatomic restoration after conversion of minimally invasive thoracic surgery to thoracotomy.

Minimally invasive thoracic techniques often need to be converted to open thoracotomy. Thoracotomy is associated with severe postoperative pain in 50% of the patients, and this situation can be maintained for a prolonged period. Many efforts have been made to avoid this complication. We propose an easy and fast thoracotomy closure technique to avoid nerve entrapment at the time of chest closure suitable for cases of conversion to thoracotomy after a minimally invasive attempt. The proposed method effectively avoids interference with the intercostal nerve, which remains intact and restores the anatomy of the intercostal space. Efforts to decrease postoperative pain are vital. Thoracic surgeons are the principal health professionals able to deal with operative factors and postoperative pain management. We believe that the use of this easy and fast technique can facilitate excellent anatomic repositioning of the ribs alongside nerve sparing.

A novel simulation model for tube thoracostomy.

Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine. This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues. The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt. We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.

Totally Endoscopic Constrictive Pericarditis Treatment: A Case Series.

Minimally invasive cardiac surgery has increased in popularity to reduce the morbidity associated with open heart surgery. In this article, a totally endoscopic case series is presented in which anterior pericardiectomy is performed by peripheral femoral arterial and venous cannulation. Right periareoal incision and right submammary incision were used for male and female patients, respectively, to access the heart by the fourth intercostal space.

Altering magnetic field strength impacts the assessment of diaphragmatic function using cervical magnetic stimulation

Quantifying diaphragm neuromuscular function using cervical magnetic stimulation (CMS) typically uses only a single stimulator (1-Stim) which may be inadequate to maximally stimulate the phrenic nerves. We questioned if using two stimulators (2-Stim) together alters diaphragm neuromuscular function at baseline and following inspiratory pressure threshold loading. Six (n = 3 female) healthy young participants were instrumented with esophageal and gastric balloon tipped catheters and electrodes over the 7–8th intercostal space. With either 1-Stim or 2-Stim an incremental protocol, where the stimulator intensity was progressively increased was completed prior to a series of potentiated twitches. The inspiratory threshold loading test consisted of loaded breathing to failure. Compared to 1-Stim, 2-Stim resulted in significantly greater unpotentiated Pditw and M-waves during the incremental protocol (both p < 0.01). Similarly, 2-Stim resulted in greater potentiated Pditw (31 ± 8 vs. 41 ± 9 cmH2O; p = 0.02) and M-waves (6.4 ± 2.9 vs. 8.6 ± 2.4 V; p = 0.02). Our findings suggest that CMS using 1-Stim is unlikely to generate a sufficient magnetic field to maximally stimulate the phrenic nerves and may underestimate diaphragm function.