Left Intercostal Space Research Articles

Appropriate body position and site for diaphragm ultrasound: Comparison with inspiratory mouth pressure

ObjectiveThis study aimed to examine the appropriate body position and anatomical site for DUS through comparisons with maximal inspiratory pressure (MIP). MethodsThirty healthy adults were included in the study. MIP was measured using a spirometer. DUS was performed in both the right and left intercostal spaces in both sitting and supine positions. The diaphragm thickness at functional residual volume (TDFRC) and total lung capacity (TDTLC) were measured, and the fractional change in diaphragm thickness (TF) was calculated under each condition. To assess interobserver reproducibility, DUS was performed by an experienced examiner and a novice examiner. ResultsAmong the DUS parameters, the TDFRC measured at the right intercostal space in the sitting position showed the strongest correlation with MIP (r = 0.68, p < 0.001). The correlations of TDTLC with MIP tended to be inferior to those of TDFRC with MIP, and the TF parameters did not correlate significantly with MIP. DUS measurements in the supine position demonstrated greater reproducibility than those in the sitting position, and those at the right intercostal space tended to be better than those at the left intercostal space. ConclusionWhen evaluating respiratory muscle function during inspiration using DUS, TDFRC at the right zone of the apposition in the sitting position was found to be appropriate. DUS measurements at the right zone of apposition in the supine position were considered adequate for clinical use because the influence of examiner experience was small.

Successful management of pneumonia and pyogranulomatous cranial mediastinitis due to Coccidioides species infection with fluconazole in a 3‐year‐old horse

SummaryA 3‐year‐old Quarter Horse gelding originating from Texas presented for fever and inappetence. An encapsulated, mixed echogenic cranial mediastinal mass visible ultrasonographically in the left and right fourth intercostal space that displaced the heart caudally was identified. Histological evaluation of needle biopsies obtained under general anaesthesia revealed a severe pyogranulomatous inflammatory process associated with intralesional round, 15–25 μm in diameter, thick double‐contoured cell wall fungal structures. Sequencing of products obtained from DNA extracted from the paraffin‐embedded biopsy sample and a panfungal PCR assay targeting the large ribosomal unit region had a 99.1% identity to either Coccidioides immitis or C. posadessii. Bronchoscopy revealed purulent exudate in the right primary bronchus. Cytological evaluation of bronchial alveolar lavage fluid (BALF) contained 96% moderately degenerative neutrophils and 4% macrophages. Fungal structures were not appreciated in the BALF. However, the mediastinitis could have resulted from inhalation and dissemination of arthroconidia through lymphatics or directly from the lung parenchyma. Quantitative immunodiffusion of serum for the presence of coccidioidal IgG antibodies yielded a titre of 1:256 suggestive of disseminated coccidioidomycosis. After oral fluconazole for 24 months, the horse's general health and athletic performance had returned to normal and the mediastinal mass was not appreciated sonographically.

Morphological identification of brugada type 1 pattern using loop recorder: a feasibility study

Abstract Introduction The presence of spontaneous type 1 Brugada pattern (BP1) is associated with an elevated risk of arrhythmic events. Diagnosis of this condition is often underestimated due to its intermittent nature. While periodic ambulatory ECG monitoring can distinguish patients with pharmacologically induced patterns from those with spontaneous patterns, the diagnostic capabilities of this method are limited. Implantable cardiac monitors (ICM), designed to continuously record heart rhythm, may offer higher sensitivity in detecting patients with intermittent patterns. However, the ICM's ability to morphologically identify the ST segment elevation associated with BP1 remains uncharted. Purpose This study aimed to assess the ICM's capacity to morphologically identify the ST segment elevation associated with BP1. Methods We enrolled all patients who underwent ajmaline testing (AT) between November 2022 and September 2023 in our centre. For positive patients, the external simulator of a loop recorder was utilized to evaluate four positions (I-II left intercostal space at a 45° tilt, II-III left intercostal space at a 45° tilt, II-III right parasternal intercostal space, and II-III left parasternal intercostal space). These positions were selected to capture the trace with the most significant ST segment elevation at the J point during the peak positivity of the ECG during the ajmaline test. Measurements from the recorded traces were acquired using dedicated software. Results Out of 50 patients, 21 (male-to-female ratio 1.62:1, mean age 43.4±13.1 years) had a positive AT result. Seventeen patients exhibited ST segment elevation in the simulator trace during the highest ajmaline dose. Among these patients, the optimal recording position was in the I-II left intercostal space at a 45° tilt in 66.7% of cases. The median ST segment elevation recorded by the simulator was 0.9 mm (interquartile range 0.6-1.1 mm). Notably, there was no observed correlation between the extent of ST segment elevation in the ECG and that recorded by the simulator trace (Pearson linear coefficient = 0.09). Conclusions ICM may offer the potential to record BP1, a finding that holds significant diagnostic and prognostic implications for asymptomatic patients with pharmacologically induced BP1. Further research is needed to develop useful programming algorithms for the automatic recording of this pattern.

Utilization of implantable cardiac monitors in detecting type 1 patterns in brugada syndrome

Abstract Introduction In individuals with Brugada syndrome, the presence of the type 1 pattern (BP1) is linked to an elevated risk of severe arrhythmias. However, the identification and measurement of BP1 can be challenging due to its intermittent nature. Implantable cardiac monitors (ICMs) provide extended continuous monitoring, potentially overcoming the limitations of intermittent ambulatory ECG monitoring in detecting spontaneous BP1. Nevertheless, their specific application for this purpose remains unevaluated. Methods From November 2022 to September 2023, all patients presenting with pharmacologically induced BP1 were enrolled at our centre. An ICM was surgically placed in the left second intercostal space at a 45° angle, enabling readings with a morphology similar to the right precordial ECG leads during ajmaline testing (AT). Patients were remotely monitored, and in addition to routine automatic transmissions, each patient was provided with a remote control to transmit in case of fever or symptomatic events. Transmissions were scrutinized to detect: 1) ST-segment elevation; 2) ventricular arrhythmias; 3) burden of ventricular extrasystoles (PVC). A reading was classified as positive for BP1 if it bore a similar morphology to that recorded during AT. The frequency of BP1-positive transmissions was evaluated across four hourly intervals. Results The ICM was successfully implanted in 21 patients (male-to-female ratio 1.62:1, mean age 43.9±13.1 years). Over an average follow-up of 168±70.6 days, a total of 7818 transmissions were received, evenly spread across hourly intervals (minimum of 1296 transmissions per interval). Among these, 173 transmissions were identified as BP1 positive (2.2%), originating from 6 patients (28.6% of the total, all newly diagnosed with spontaneous BP1). The median duration between implantation and the diagnosis of spontaneous BP1 was 16.5 days (range 2-23). The median number of days with at least one positive transmission was 30.2 (range 13.4-73.9). The evening period (6 pm to midnight) displayed a significantly higher rate of positive transmissions compared to the morning (p=0.04) and afternoon (p=0.01); however, not in contrast to the nighttime (p=0.8). No sustained ventricular arrhythmias were observed, and there were no significant differences in PVC burden among patients. Conclusions The utilization of ICM for continuous monitoring in patients with pharmacologically induced BP1 led to the identification of spontaneous BP1 patterns in almost 30% of cases during an approximately 6-month follow-up. Evening and nighttime periods exhibited the highest incidence of BP1. This methodology shows promise in quantifying BP1 incidence and could serve as a tool for stratifying arrhythmic risk in individuals with Brugada syndrome.

Radiographic and echocardiographic evaluation in rescued Korean raccoon dogs (Nyctereutes procyonoides koreensis).

Nyctereutes procyonoides koreensis (Korean raccoon dog), a member of the Canidae family, is anatomically similar to dogs. Previous studies have used vertebral heart scale measurements to measure the cardiac size of Korean raccoon dogs on thoracic radiographs; however, the use of additional cardiac size indices, such as vertebral left arial score, intercostal space, cardiothoracic ratio, and echocardiographic indices, has not been reported. Therefore, this study aimed to establish normal reference ranges for various thoracic radiographic and echocardiographic indices in normal Korean raccoon dogs. Twenty-six Korean raccoon dogs (11 males and 15 females) were included in this study. The thoracic radiographic indices, vertebral heart scale score, and vertebral left atrial score were measured in the right lateral view. The intercostal space and cardiothoracic ratio were measured in the ventrodorsal view. The echocardiograms were evaluated in the right parasternal long and short axis view and left parasternal apical view. The mean values for the thoracic radiographic and echocardiographic indices were as follows: vertebral heart scale, 9.12 ± 0.74; vertebral left atrial score, 1.5 ± 0.31; intercostal spaces, 3.17 ± 0.34; cardiothoracic ratio, 0.69 ± 0.07; left atrial to aortic root ratio, 1.22 ± 0.14; main pulmonary artery to aorta ratio, 1.22 ± 0.14; left ventricular end-diastolic internal diameter normalized for body weight, 1.36 ± 0.19; end-diastolic volume index, 51.07 ± 19.6; end-systolic volume index, 16.54 ± 7.45; the peak velocity of early diastolic transmitral flow, 73.13 ± 15.46 cm/s; and the ratio between the transmitral flow velocities and the peak early diastolic velocity, 1.77 ± 0.47. Only percent increase in the left ventricular end-systolic internal diameter was negatively correlated with body weight. The remaining indices showed no correlations with body weight. To the best of our knowledge, this is the first case report covering both thoracic radiographic and endocardiographic indices for Korean raccoon dogs. Thus, the thoracic radiographic and echocardiographic indices established in this study may be used to evaluate the cardiac condition of Korean raccoon dogs.

Ruptured Pulmonary Hydatid Cyst with Multiple Small Bronchopleural Fistula Formations: A Case Report

Hydatid disease is a zoonosis caused by Echinococcus granulosus. It manifests as cystic lesions, most commonly found in the liver and lungs, and rarely in other parts of the body. The disease occurs when a human host accidentally ingests contaminated food containing eggs from canine waste products. Since the clinical characteristics of this disease are nonspecific, radiological investigations play a crucial role in diagnosis. Diagnostic challenges arise due to atypical imaging features of complicated hydatid cysts. A 40-year-old female patient presented with fever, breathlessness, chest pain, and an unproductive cough persisting for eight days. Upon examination, she was in hypovolaemic shock, and an intercostal drainage tube had been inserted in the left sixth intercostal space. The chest radiograph revealed a dense, homogeneous opacity in the left hemithorax, partially compressing the left lung medially. An High-resolution Computed Tomography (HRCT) thorax showed a thick-walled cavity with an air-fluid level and layered membranes in the dependent part of the cavity, indicating a water lily sign in the left lower lobe of the lung, suggesting a ruptured hydatid cyst. The patient underwent cystectomy with suturing of a small bronchopleural fistula. Computed Tomography (CT) is the preferred imaging modality, especially for assessing associated complications and ruling out differentials in cases of ruptured pulmonary hydatid cysts.

Epidural Anesthesia in Management of Pregnant Eissenmenger’s Syndrome Patient Undergoing Caesarean Section

Background: Eisenmenger syndrome is very rare in pregnant women. Debates remain concerning the management of Eisenmenger syndrome in this patient population, and the prognosis is unclear in terms of maternal and fetoneonatal outcomes. Managing anesthesia in maternal patients with a cardiac abnormality might be particularly difficult because these individuals have inadequate circulatory reserves and altered maternal cardiovascular physiology.&#x0D; Case presentation: We present a 26-year-old 34 weeks pregnant woman with Eisenmenger’s syndrome (ES) scheduled for an elective caesarean section. The clinical findings reveal slight tachypnea with peripheral oxygen saturation of 82% with oxygen supplementation using a cannula at 3 lpm. The patient's baseline hemodynamics are stable, but a third-degree murmur is heard in the 3rd and 4th left intercostal space. The patient was managed with epidural anesthesia using bupivacaine 0.5% 20 ml without adjuvant. The epidural catheter was inserted in an interspinous process between L3-L4. The surgery was done in 90 minutes with stable hemodynamics, and postoperatively, the patient was monitored in the intensive cardiac care unit (ICCU).&#x0D; Conclusion: Epidural anesthesia has been shown to provide favorable outcomes due to its slow onset and reducing the likelihood of abrupt hemodynamic changes.

New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures

ObjectiveWe have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting. MethodsFrom October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed. ResultsThe mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures. ConclusionsMitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.

Giant benign intrathoracic schwannoma: a decade-long progression towards fatality

BackgroundIntrathoracic neurogenic tumors arise from sympathetic nerve trunks and intercostal nerves; more than 90% are benign. Schwannomas are the most common histological variety, but fatalities due to giant schwannomas are rare.Case presentationWe report a case of a 65-year-old woman who presented with chest pain and cough. Computed tomography (CT) revealed a large left chest wall mass of 130-mm in size, and the patient was referred to our department. Tumor biopsy was performed under local anesthesia, and a diagnosis of schwannoma was made. Ten years previously, a 30-mm tumor had been noted in the left third intercostal space by a previous doctor, but follow-up had been interrupted owing to depressive disorder. Although we planned to perform intercostal artery embolization followed by chest wall tumor resection, the patient did not consent to surgery due to uncontrolled depression. After four months, she developed respiratory failure caused by compression due to an enlarged tumor and died. Autopsy also revealed a benign schwannoma with no malignant findings.ConclusionsAlthough schwannomas are benign tumors, there are some very rare cases in which they can become huge and life-threatening. Therefore, a benign tumor should not be neglected, and if surgery is not possible at the time of diagnosis, a regular follow up is necessary, in order not to miss the right timing for surgery.

Comparing perioperative outcomes following off-pump multi-vessel minimally invasive via a single left intercostal space incision with median sternotomy coronary artery bypass grafting: A single-center retrospective cohort study.

The perioperative outcomes following off-pump multi-vessel minimally invasive surgery (MICS) coronary artery bypass grafting (CABG) via a single left intercostal space incision has not been well evaluated. From July 2019 to January 2022, a total of 444 patients with multi-vessel coronary artery disease (CAD) were enrolled and divided into MICS (n = 179) and sternotomy CABG (n = 265). Perioperative outcomes were compared between these two groups, including intraoperative blood loss, postoperative first 24h drainage, ventilation duration, length of stay (LOS) in ICU and total LOS in hospital. Intraoperative blood flow of graft vessels were measured by transit-time flow measurement after vascular anastomosis and mean flow (MF) and pulsatile index (PI) were compared. There were no significant differences in preoperative profiles between these two groups except younger and lower proportion of female in MICS. No significant difference in the number of graft vessels was observed between MICS (3.18 ± 0.74) and sternotomy CABG (3.28 ± 0.86). Compared to sternotomy CABG, patients with MICS showed longer operation duration [(4.33 ± 0.86)h versus (5.10 ± 1.09)h], fewer intraoperative blood loss [700 (600, 900)mL versus 500 (200, 700)mL], fewer postoperative first 24h drainage [400 (250, 500)mL versus 300 (200, 400)mL], shorter postoperative ventilation duration [16.5 (12.5, 19.0)h versus 15.0 (12.0, 17.0)h], LOS in ICU [20.0 (16.0, 23.0)h versus 18.0 (15.0, 20.0)h] and total LOS in hospital [(14.5 ± 3.9)d versus (12.6 ± 2.7)d] (all p < .001). MI and PI of graft vessels were similar and no significant differences in major perioperative complications and mortality were observed between MICS and sternotomy CABG (all p > .05). Off-pump multi-vessel MICS may be an alternative treatment for patients with multi-vessel CAD with better perioperative outcomes than sternotomy CABG.

Efficacy of off-pump minimally invasive via a single left intercostal space incision compared with median sternotomy multi-vesselcoronary artery bypass grafting

Objective: To compare the efficacy of off-pump minimally invasive cardiac surgery (MICS) via a single left intercostal space incision with median sternotomy multi-vesselcoronary artery bypass grafting (CABG). Methods: Patients who were diagnosed with multi-artery coronary artery disease (CAD) in the Ward 10 of the Department of Cardiac Surgery, Beijing Anzhen Hospital Affiliated to Capital Medical University and underwent CABG from July 2019 to January 2022 were retrospectively collected. All the patients were divided into MICS group and conventional CABG group according to the surgical methods. The perioperative outcomes were compared between thetwo groups, including intraoperative blood loss, postoperative 24 h thoracic drainage volume, ventilation duration, length of stay (LOS) in intensive care unit (ICU) and total LOS in hospital. Intraoperative blood flow of graft vesselswas measured by transit-time flow measurement (TTFM) after vascular anastomosis, and mean flow (MF) and pulsatile index (PI) were compared between the two groups. Results: A total of 444 patients were in the final analysis, with 351 males and 93 females, and the mean age of (62.0±8.9) years. There were 179 patients in MICS group and 265 cases in conventional CABG group, respectively. There were no statistically significant differences in the preoperative profiles between the two groups (all P>0.05) except that younger age [(60.7±9.3) years vs (62.8±8.5) years, P=0.017] and lower proportion of female [10.1% (18/179) vs 28.3% (75/265), P<0.001] were detected in MICS group. Likewise, there was no significant difference in the number of graft vessels between MICS group (3.18±0.74) and conventional CABG group (3.28±0.86) (P=0.234). Compared with those in conventional CABG group, patients in MICS group showed longer operation duration [ (5.10±1.09) h vs (4.33±0.86) h], fewer intraoperative blood loss [500 (200, 700) ml vs 700 (600, 900) ml], fewer postoperative 24 h thoracic drainage volume [300 (200, 400) ml vs 400 (250, 500) ml], shorter postoperative ventilation duration [15.0 (12.0, 17.0) h vs 16.5 (12.5, 19.0) h, P<0.001], LOS in ICU [18.0 (15.0, 20.0) h vs 20.0 (16.0, 23.0) h, P<0.001] and total LOS in hospital [(12.6±2.7) d vs (14.5±3.9) d, P<0.001]. MI and PI of graft vessels were similar between the two groups (both P>0.05). Moreover, there were no significant differences in major perioperative complications (i.e., repeat thoracotomy, incision infection, stroke) and mortality between the two groups (all P>0.05). Conclusion: MICS is an alternative treatment for patients with multi-vessel CAD with better perioperative outcomes compared with conventional CABG.

Percutaneous management of complicated empyema thoracis using pigtail, report of a case from University Hospital of Nepal: a case report.

A 66-year-old female presented with complaints of cough, fever, and chest pain. A clinical examination was done and relevant investigations were sent. She was then treated in the line of left-sided empyema thoracis. A pigtail catheter was inserted into the loculated empyema via the left 9th intercostal space through a posterolateral approach with ultrasonography guidance. The main aim of this article is to provide an overview of a rare management approach for empyema, a condition characterized by the accumulation of pus in the pleural cavity of the lungs. In this case report, the authors have focused on pigtail catheter drainage over traditionally performed chest tube drainage, and image-guided drainage has been performed over blind drainage ensuring accurate placement and reducing the risk of damage to surrounding tissues. Another notable change in empyema management is the shift in drainage sites from the safety triangle to other sites based on the site of loculations under ultrasonography guidance.

PO-03-082 EFFECT OF IMPLANTABLE LOOP RECORDER INSERTION SITE ON P WAVE AMPLITUDE

Implantable loop recorders (ILRs) are increasingly utilised for rhythm monitoring, including in the diagnosis of atrial fibrillation and other atrial arrhythmias. A larger P wave amplitude may assist in improving arrhythmia diagnosis. Current manufacturer guidelines for ILR insertion suggest a left 4th intercostal space (ICS) insertion, without prior mapping of R waves or P waves. However, recent data using surface mapping suggests that P wave sensing may be improved by altering the implant site to a higher ICS. To determine the effect of ILR insertion in the 3rd or 4th ICS on ILR sensing parameters. We reviewed the medical records and remote monitoring transmissions of 117 patients who underwent Medtronic ILR insertion at our institution. Both LINQ I and LINQ II devices were included. All devices were implanted in the left parasternal 3rd or 4th ICS using surface anatomical landmarks, at a 45-60 degree angle to the sternum. The choice of ICS was at the discretion of the implanting physician. P wave, T wave, R wave (base to positive peak), S wave (base to negative peak) and peak-to-peak QRS amplitudes were measured on the using electronic calipers, which were calibrated using the included voltage marker. Patients were excluded if the presenting electrocardiogram showed atrial fibrillation. Of the 117 patients, 77 (66%) had LINQ II and 40 (34%) had LINQ I devices. The median age was 65 years (IQR 43-75 years) and 63 (54%) were male. Sixty-nine (59%) devices were inserted in the 3rd ICS. The majority of devices were inserted for investigation of syncope (61%). A 3rd ICS implant location was associated with a higher mean P wave amplitude (0.037±0.016 vs 0.026±0.012mV, p<0.001). Mean R wave amplitude was smaller (0.24±0.24 vs 0.38±0.37mV, p=0.009) but there was no difference in mean peak-to-peak QRS amplitude (0.58±0.35vs 0.60+0.39mV, p=0.74) or mean T wave amplitude (0.12±0.08 vs 0.12±0.10mV, p=0.82). The mean QRS / P amplitude ratio was significantly lower with 3rd ICS implants (16±8.5 vs 24±13.9, p<0.001). Two patients had undetectable P waves and both had devices in the 4th ICS. One patient with a 3rd ICS device had peak-to-peak QRS amplitude of 0.09mV and intermittent T wave oversensing was noted. Insertion of ILRs in the 3rd ICS as opposed to the 4th ICS resulted in significantly higher P wave amplitude without a reduction of overall QRS amplitude.

Minimally invasive cardiac surgery via bilateral thoracotomy in treatment of left ventricle aneurysm: a case report

BackgroundLeft ventricle aneurysm (LVA) as a sequela to myocardial infarction or iatrogenic injury is required surgical treatment with full median sternotomy. Herein, we report a case of successful surgical treatment of left ventricle aneurysm performed by minimally invasive cardiac surgery (MICS).Case presentationWe describe a case of a LVA treated by minimally invasive cardiac surgery in an 82-year-old woman who reported to the hospital with the complaint of chest pains at rest. Computed tomography (CT) coronary angiography revealed a left ventricle apical aneurysm. The aneurysm was suspected to be a pseudoaneurysm caused by a previous myocardial infarction. Surgery was performed under general anesthesia, with the patient in a supine position. A small incision was made in the 3rd intercostal space through which an aortic root vent cannula and aortic clamp were inserted, followed by exposing the aneurysm via incision of the left 6th intercostal space. The aneurysm was resected and pathologically examined, revealing it to be a “true” aneurysm. The left ventricle wall was closed using polypropene mattress sutures. Postoperative CT scan revealed successful resection of the aneurysm. Usually, a surgical treatment with full median sternotomy and left ventriculostomy is indicated for LVA. We decided to treat the LVA with bilateral thoracotomy MICS. We preferred to perform this procedure under cardiac arrest to ensure safe and secure closure of the aneurysm. The right small thoracotomy was necessary for aortic cross-clamping and aortic root venting.ConclusionsThe procedure was safe and simple and yielded excellent postoperative outcomes. Therefore, we speculate that this method can be applied to the management of larger aneurysms.

Schwannoma with an unusual anterior chest wall location: A rare case report

Chest wall schwannoma is a rare intercostal nerve tumor originating from Schwann cells. Here, we present a case of a 44-year-old woman who presented with symptoms of cough, fever, and left-sided chest pain. A plain chest radiograph was unremarkable and was further evaluated with a contrast-enhanced chest computed tomography (CECT) scan, which showed a well-defined, encapsulated soft-tissue mass in the left anterior first intercostal space. The diagnosis of schwannoma was based on histopathological and immunohistochemical studies of tissue biopsies taken from the lesion. The patient was referred to a higher oncology center for further treatment where he received symptomatic treatment for the pain and cough after which he improved. The patient was discharged and followed up in the clinic. Six months later, the patient underwent another chest CECT, which revealed no growth in size from the first one. Therefore, it was decided to keep the patient in regular follow-up since the lesion remained stable in size.

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.

482 A CASE OF RIGHT SIDE INFECTIVE ENDOCARDITIS IN PATIENT WITH VENTRICULAR SEPTAL DEFECT

Abstract A 25-years old white female was admitted to our emergency department presenting with dyspnea, fever, cough and nausea. Her medical background included a small ventricular septal defect (VSD) (congenital) with a left to right shunt, micropolicistic ovary syndrome, Sars Cov 2 infection on January 2022, history of cutaneous infection after sternal piercing in the last three years. Patient showed onset of fever, headache and nausea since 20 days and had a history of ampicillin and cephalosporin usage for 15 days for comunitary pneumonia. Upon arrival in the emergency room, physical examination revealed temperature 38°C, crackles on down right lung fields, regular but tachycardic rhythm, 3/6 holosystolic murmur in the third left intercostal space, also skin redness around the piercing zone. Laboratory test showed increasing of WB (white blood cells), C-reactive protein (CPR) and procalcitonin. Because of worsening of respiratory conditions, CT chest was performed, showing tree in bud sign, with pulmonary pattern suggestive of staphylococcal “emboligenous-like” infectious state. According to patient's clinical history and CT results, she was referred to transthoracic echocardiogram (TTE) demonstrating the presence, on the right side of the small VSD, of a isoechoic large mass (20x 13 mm) with irregular margins attached to the right ventricular wall near the ostium of the VSD, compatible with vegetation; septal tricuspid valve leaflet involvement could not be ruled out. Methicillin-susceptible Staphylococcus aureus (MSSA) was detected six times from blood cultures; therapy with oxacillin 2 gr every 4 hours combined with daptomycin 750 mg daily was started. Cardiac MRI performed after few days, documented the infective involvement of the ventricular and atrial side of the septal leaflet with moderate tricuspid regurgitation (TR). Congenital heart disease (especially Tetralogy of Fallot, bicuspid aortic valve, aortic coarctation, ventricular septal defect) is a lifelong risk factor for infective endocarditis (IE). Size of VSD is generally not correlated with IE that is directly correlated with turbulent flow; tricuspid valve involvement is mostly seen in VSD, often complicated by pulmonary embolism. In this predisposing situation, skin infection of the piercing zone could have caused transient bacteremia which led to the formation of vegetations in the highest turbulence flow zone.

Abstract 14923: A Special Type Aortic Left Ventricular Tunnel With Bicuspid Aortic Valve: A Case Report

Introduction: Aortic-left ventricular tunnel (ALVT) is an extremely rare congenital cardiac lesion that is an abnormal passage connecting the ascending aorta to the left ventricle. ALVT can be diagnosed by the use of real-time two-dimensional and continuous-wave Doppler echocardiography. Case presentation: A two-year and seven-month-old boy with recently diagnosed influenza presented to the hospital because of severe tachypnea and fatigue after running. Physical examination revealed a grade 3/6 systolic and diastolic murmur at the second and third left intercostal space. Transthoracic echocardiography (GE E95 with a 5-MHz scanning head) demonstrated that the aortic valve was a bicuspid aortic valve (BAV) with mild-moderate insufficiency during diastole, the peak systolic velocity (PSV) and gradient of aortic valve were 1.9m/s and 14mmHg, respectively; The aortic sinotubular junction (ASJ) was stenotic, the PSV and gradient of ASJ were 2.7m/s and 29mmHg, respectively; A tubular-like structure originated in the outlet septum beneath the right coronary cusp and terminated in the ascending aorta superior to the right coronary aortic sinus (Fig. A, B), CDFI and continuous-wave Doppler showed unobstructed to-and-fro (systolic and diastolic) flow in the tunnel with a high-velocity color signal that aliased during systole (Fig. C-E). Clinical considerations for congenital heart disease: ALVT combines BAV with aortic insufficiency and supravalvar aortic stenosis. The patient was referred for possible surgical correction. Discussion: In this patient, the type of ALVT does not belong to any one of Hovaguimian’s classifications. Two-dimensional echocardiography can display the tunnel-like structure of ALVT in real-time, and CDFI can identify that two-stage bidirectional shunted blood flow, systolic ventricular ejection occurs through both the tunnel and the semilunar valve, and the diastolic flow reverses from the aorta to ventricle via ALVT.

Abstract 14714: Marked Gradient Reduction Through a Transcoronary Alcohol Ablation of Septal Hypertrophy in a Patient With Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

A 66-year-old male with a history of carpal tunnel syndrome and hypertension presented with dyspnea (NYHA III), angina pectoris, and sinus bradycardia. On clinical examination, the patient was stable and euvolemic. A systolic murmur (III/VI) was audible in the 4th left intercostal space laterally, augmented after a Valsalva maneuver. An electrocardiogram revealed normal sinus rhythm, heart rate of 81 bpm, normal voltage, and non-specific ST-changes in I, II, III, aVF, V5, and V6. The patient underwent a transthoracic echocardiography, which revealed thickened ventricular walls (IVSd 23 mm, PWd 20 mm), hyperdynamic left ventricular ejection fraction (LVEF 75%), LVOT gradient of 150 mmHg maximum (after Valsalva maneuver), apical sparing on strain analysis, and a dilated atria. A coronary angiography ruled out coronary artery disease. A endomyocardial biopsy revealed hypertrophic cardiomyopathy combined with focal cardiac amyloidosis (Figure 1). Subtyping and genetic analysis revealed transthyretin (ATTR) wild-type amyloidosis. Accordingly, therapy with Tafamidis 61 mg daily was initiated. Given the relevant amount of hypertrophy depicted on the biopsy samples, the high LVOT gradient, and the patient’s debilitating symptoms despite maximal medical therapy, the decision was made to attempt a transcoronary alcohol ablation of the septal hypertrophy (TASH). The TASH reduced the LVOT gradient from 150 mmHg to 35 mmHg. After the procedure, the patient experienced significant symptom improvement (NYHA II) and was discharged the next day. This case illustrates the feasibility of marked LVOT gradient reduction in patients with amyloidosis and hypertrophic cardiomyopathy through a TASH procedure. Figure 1: Histology reveals hypertrophic cardiomyocytes and cardiac amyloidosis on Congo red staining.

Surgical Treatment of a Late Post-Coarctation Aortic Aneurysm

A 55 year old man treated when aged 12 with a Dacron patch aortoplasty for coarctation, presented with hoarseness. (A) Computed tomography angiography showed a 67 mm post-coarctation aneurysm, angulated hypoplastic aortic arch (AA), ectatic proximal left subclavian artery (LSA), thickened ligamentum arteriosus (LA), and bicuspid aortic valve (posterior view). Re-thoracotomy was performed through the left fourth intercostal space with lysis of tight adhesions. Aneurysmectomy with graft interposition (14 mm Dacron) and LSA revascularisation was performed (B). Banding of the proximal anastomosis was added owing to the very fragile AA wall. Post-operative hospitalisation was uneventful.Image 1