Left Midaxillary Line Research Articles

Ten years of subcutaneous defibrillator therapy: Consolidated clinical evidence and future perspectives.

The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative to the traditional transvenous implantable cardioverter defibrillator (TV-ICD), aiming to provide easier implantation, simplified detection algorithm of malignant ventricular arrhythmias and prevention from placing components in the cardiovascular system. The S-ICD is implanted subcutaneously or intramuscularly with the generator placed in the left midaxillary line and the lead tunneled subcutaneously in the left para-sternal region. Preimplant electrocardiogram screening is recommended to prevent implantation in patients at high risk of T wave over-sensing. Currently, the S-ICD is unsuitable for patients requiring pacing or cardiac resynchronization. Since the beginning, the S-ICD underwent extensive preclinical investigation until the first prospective multicentre trial demonstrating high efficacy and safety led to market release. While earlier studies focused on younger patients with higher ejection fraction, more recent studies showed favorable outcomes even in patients with comorbidities similar to those typically observed in patients receiving TV-ICD. The development of second and third generation devices has contributed to reduce inappropriate shocks and overcome previous limitations. The aim of this paper is to review the evidence in the literature over the past decade supporting S-ICD as a valid alternative to TV-ICD in terms of safety and efficacy, highlighting the improvements in technology, as well as outcomes.

Intermuscular placement and defibrillation with the extravascular ICD: a single-centre experience

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICD), owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. The proposed implantation technique for EV-ICDs is a subcutaneous pocket along the mid axillary line, although an intermuscular ICD placement can potentially reduce the risk of pocket complications, device migration and improve patient comfort and aesthetic outcomes. Purpose exploring the safety and feasibility of extravascular ICDs implantation with a substernal coil and an intermuscular generator placement. Methods Seventeen patients with a class I or IIa ICD indication either for primary (14/17) or secondary (3/17) prevention underwent EV-ICD implantation in our centre as part of the EV ICD Pivotal Study from May 2021 to November 2022. Access and tunnelling along the retrosternal space were performed based on current standard recommendations for EV-ICDs implantation. An intermuscular pocket for generator placement was obtained between the latissimus dorsi and the serratus anterior muscles beyond the left mid-axillary line. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients, with one implant failure due to inadequate sensing (0,5 mV); the median sensing amplitude was 2,3 mV (min = 1,3 mV; max = 5,8 mV), with R1R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16. Defibrillation Testing (DFT) was performed in all patients: a 15 J shock terminated induced ventricular fibrillation (VF) in 12/16 patients, 20 J terminated VF in 3, a single patient had VF terminated at 30 J. No patient had infection or skin erosion or complained pain/discomfort at the pocket site along an 18±4 months follow-up. Only 1/16 patients had ventricular tachycardia at follow-up, successfully treated by the device. Conclusions Intermuscular placement of the EV ICD may be a feasible and reliable alternative to a subcutaneous one in terms of defibrillation efficacy, enabling patient comfort and aesthetic acceptance in thin-habit or young patients. Additional long-term data and larger patient cohorts are required to confirm its advantage compared to the subcutaneous placement.

Feasibility and reliability of whintings scanwatch to record 4-lead Electrocardiogram: A comparative analysis with a standard ECG

The recent technological advances allowed us to produce some new wearable devices, such as smartphones and smartwatches (SW). These devices provide different services to their users through different software applications installed even in the SW or smartphones. Health monitoring functionalities, among these services, are nowadays the new technological fashion. In fact, the monitoring is ensured by the sensor incorporated in the SW. The SW allows the record of only one single lead Electrocardiogram (ECG), which is sufficient to screen or diagnosis of rhythm and conduction disorders, especially during the onset of cardiac symptoms, but insufficient for the detection of ischemic disease and cardiomyopathies. In this context, this paper aims to evaluate the feasibility, and reliability of a SW to obtain ECG recordings in comparison with a standard ECG. For that purpose, 140 patients were recruited for this analysis. At the first step, the 12 lead ECG followed with four lead SW-ECG; using the Withings Scanwatch device, were recorded in the same resting conditions. The four lead SW-ECG consists of Einthoven DI lead recorded with the SW, where the SW was on the left wrist and the right index finger on the crown, and three Wilson-type leads, in the which the V1 was recorded in the fourth right parasternal intercostal space, V3 was recorded in the fifth intercostal space on the midclavicular line, and V6 was recorded in the fifth intercostal space on the left midaxillary line with the right index finger placed on the crown and the left hand encompassing the right wrist. 700 ECGs recordings were collected and statistically analyzed in this study. In total, 97 % of the patients were able to obtain an ECG through the SW. A strong correlation was observed between the two recording methods concerning the duration of the studied parameters (r >90 %). The correlation coefficient showed that 33 out of 44 parameters have a strong correlation with the standard ECG. The similarity of the combined leads in the 4 established subgroups was significantly higher, meaning that increasing the number of leads would improve the detection of electrical anomalies. Our findings confirm the existing data on the high similarity between SW and standard 12-leads ECG. Despite SW not having the accuracy and utility of the standard ECG machine, they should be considered as an interesting screening tool for cardiac rhythm disorders, and a compelling solution to electrical documentation of general cardiac symptoms.

Optimal Place for Precordial Stethoscope Attachment in Nonintubated Children under Two Years of Age: An Observational Trial

Background: The precordial stethoscope is a non-invasive monitoring method in pediatric anesthesia. We previously investigated optimal place for its attachment among intubated children under two years old. Now we also did in nonintubated children under two years old.
 Methods: Twenty-five patients who underwent general anesthesia in our institution were involved in this study. Lung and heart sounds via precordial stethoscope were recorded (MP3 format) at the six places: Site A (paratracheal region), B (suprasternal notch), C (between place of the nipple and clavicle on the left midclavicular line), D (between place of the costal arch and nipple on the left midclavicular line), E (horizontal level of Site D on the left midaxillary line), and F (epigastric fossa). Two blinded evaluators scored random sorted lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly) individually.
 Results: Statistically significant differences were observed between Sites A: 10.0 (8.5–10.0), B: 9.0 (2.5–9.5), C: 8.0 (6.5-9.0) and D: 1.5 (1.0–6.5), E: 4.5 (1.5–7.0), F: 1.0 (0.0–4.5) for lung sounds and between Sites B: 9.0 (5.0–10.0), C: 9.5 (8.0–10.0), D: 9.0 (4.5–9.5) and A: 0.0 (0.0–0.0), E: 0.5 (0.0–2.5), F: 0.5 (0.0–0.5) for heart sounds.
 Conclusion: Site C is the optimal place for precordial stethoscope attachment for children under two years of age during general anesthesia

Uniport video-assisted thoracoscopic surgery for thoracic Eden type IV dumbbell tumor.

Uniport video-assisted thoracoscopic surgery for thoracic Eden type IV dumbbell tumor.

VP026 LIRA-TAPE TECHNIQUE. A NEW PROCEDURE FOR RESTORING THE MIDLINE BY MIS IN SUPRAPUBIC AND MIDDLE SIZE MIDLINE HERNIAS

Abstract Aim LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) was described in 2018 in order to reduce the tension in the midline as an alternative for Closing the defect (CD) during Laparoscopic Ventral Hernia Repair. TAPE (Transabdominal Partial Extraperitoneal) was described in 2011 in order to repair complex suprapubic hernias to reduce the recurrence rate. We present a case of suprapubic hernia associated to a medium-size midline hernia using LIRA combined with TAPE as a new procedure for abdominal wall reconstruction Material and Methods 50 years old female affected with a M5 W2 hernia associated to a M2-3 W2. (EHS Classification). Preoperative scan was performed. Results 3 Ports (2 of 5 mm, 1 of 12 mm) in the left mid axillary line for LIRA and supraumbilical (10 mm) and right paraumbilical (5mm) to assist TAPE were placed. A peritoneal flap is created to expose de pubic arch and the Coopeŕs Ligament. CD was performed in suprapubic defect using a barbed suture and continued for LIRA procedure in the posterior rectus sheath. An intraabdominal mesh was placed (Polyvinylidene fluoride (PVDF) mesh, Dynamesh (®)-IPOM (FEG Textiltechnik mbH, Aachen, Germany. The mesh overlapped the suprapubic arch and was fixed using helicoidal sutures and covered the whole incision in the midline. Pelvic flap covered partially the mesh. Patient was discharge in 72 h Conclusions Complex hernias close to bones, as suprapubic hernias, can be restored using a minimal invasive approach, even those associated to mid-line defects. LIRA-TAPE is a safe and reproducible association for restoring the midline with a low rate of complications.

Optimal Site for Precordial Stethoscope Placement in Pediatric Patients Younger than Two Years: A Preliminary Cross-sectional Study

Background: The precordial stethoscope is a traditional and non-invasive monitoring method during pediatric general anesthesia. In this preliminary cross-sectional study, we aimed to investigate the characteristics of lung and heart sounds via precordial stethoscope and determine the optimal site for auscultation in children below 2 years of age. Methods: This study involved 68 patients who underwent general anesthesia with tracheal intubation. Auscultation sounds via precordial stethoscope were recorded in MP3 format at the following three sites: Site A-region between the clavicle and nipple on the left midclavicular line; Site B-region between the nipple and costal arch on the left midclavicular line; and Site C-point on the left midaxillary line that was horizontally leveled with Site B. Eight blinded evaluators individually and randomly scored lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly). Results: Lung sound scores at Sites A, B, and C were 8.0 (7.0–9.0), 4.5 (2.9–6.0), and 7.0 (5.5–8.5), respectively, while heart sound scores at Sites A, B, and C were 3.5 (2.0–6.0), 6.5 (4.0–8.0), and 1.0 (0.4–2.0), respectively. Statistically significant differences were found in all pairs of sites. Conclusion: We suggest that Site A, where anesthesiologists can hear both the lung and heart sounds, is the optimal site of precordial stethoscope attachment during general anesthesia for intubated children below 2 years of age.

Patient comfort factors associated with the chronically implanted extravascular ICD (EV ICD): retrospective analysis of the first-in-human EV ICD trial

Abstract Background The extravascular ICD (EV ICD) utilizes a lead positioned within the substernal space and a device placed along the left midaxillary line to provide pacing and defibrillation therapies. Since substernal implantation positions the lead close to the heart, a lower energy for defibrillation is needed for the EV ICD relative to an ICD with subcutaneous lead placement. With lower energy requirements, the EV ICD system requires only a 33 cubic centimeter (cc) device, whereas the commercially available subcutaneous ICD utilizes a ∼60 cc device. The smaller form factor for EV ICD may require a smaller device incision site with smaller pocket, potentially resulting in less post-operative pain. Figure 1 illustrates the comparative sizes of the EV ICD and a subcutaneous device. While issues related to patient comfort have been published for the subcutaneous ICD, patient comfort factors associated with the EV ICD system have not been described previously. Purpose To characterize post-operative factors related to patient comfort associated with the EV ICD system. Methods The EV ICD first-in-human study was conducted at four sites in Australia and New Zealand. Data from chronically implanted patients were retrospectively analyzed for changes in analgesics in the post-operative window between implant and the two-week follow-up. Adverse events were collected between implant and six months related to patient-reported pain/discomfort, need for system revision based on discomfort, impaired wound healing and seroma formation. Results In total, 21 patients underwent implantation of the EV ICD system. Three patients had initiated pain control medications prior to enrollment, including one patient with fractured ribs. Overall, 12 patients (57.1%) received no anesthetic or analgesic medications besides acetaminophen beyond the day of implant. For the remainder of patients, post-operative medications included fentanyl (1), discontinued after two days; morphine (4), discontinued the day of implant (1) or after ≤2 days (3); or oxycodone (10), discontinued after ≤1 day (7) or ≤1 week (3). There were no intraprocedural complications. There were four non-serious, early-onset (≤1 week post-implant) adverse events identified, which included swelling (1), impaired healing at the xiphoid incision site (1), and two instances of inspiratory pain ≤1 day post-implant, all of which resolved without sequelae. There were no system revisions or removals associated with incision sites or pocket discomfort, and there were no reports of seroma formation through six months of follow-up. Conclusions Analysis of factors related to patient comfort indicate that the EV ICD system has generally been well tolerated across patients. A larger data set is needed to more fully characterize whether the smaller device size of the EV ICD relative to the subcutaneous defibrillator results in improved patient comfort. Sizes of extravascular devices Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic plc

Chronic follow-up from the pilot study of a novel substernal extravascular implantable cardioverter-defibrillator

Abstract Background The investigational Extravascular Implantable Cardioverter Defibrillator (EV ICD) is an implantable defibrillator with defibrillation and pacing therapies, including the potential for antitachycardia pacing (ATP). Purpose To characterize chronic EV ICD system performance through 12 months of follow-up. Methods The first-in-human EV ICD Pilot study was prospectively conducted at four centers in Australia and New Zealand. Patients with Class I or IIa indications for ICD were enrolled between July and December of 2018. A defibrillation lead was inserted into the substernal space under radiologic guidance and a device was positioned close to the left midaxillary line. Figure 1 illustrates the implanted EV ICD. Defibrillation testing was conducted at implant and chronically in 5 patients. Follow-ups were conducted at pre-hospital discharge, 2 weeks, 4–6 weeks and 3 months post-implant, and every 6 months thereafter. Results A total of 26 patients were enrolled and 21 underwent the EV ICD implant procedure with no intraprocedural complications. Median energy for defibrillation at implant was 15 J; mean R-wave amplitude was 3.4±2.0 mV; mean pacing capture threshold was 5.1±2.0 volts. Seventeen of 21 implanted patients entered into chronic follow-up after successful system placement and implant testing, and 14 patients continue to be followed, representing >180 patient-months of total follow-up. Multiple episodes of spontaneous ventricular tachycardia (VT) were detected in one patient and either self-terminated or successfully cardioverted following unsuccessful ATP. One patient received an inappropriate shock secondary to lead tip displacement with subsequent P-wave oversensing. Elective chronic defibrillation testing was performed at physician discretion and converted 5 of 5 patients with ≤40 J (maximum energy of device). Three patients had the system electively removed due to 1) inappropriate shock after lead displacement, 2) recurrent VT without ATP termination, and 3) inadequate chronic safety margin for defibrillation. Conclusions The EV ICD is a novel platform for delivering high voltage therapy. Chronic system performance has generally remained stable during 12 months of follow-up and the device has demonstrated the ability to detect and treat VT. Fluoro images of implanted system Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic plc

Multiple CNS Tumors in a Patient With Neurofibromatosis Type 2: Classical Presentation of a Rare Disease

Neurofibromatosis type 2 is a genetic autosomal dominant disorder caused by a spontaneous mutation in the gene located on chromosome 22 q11-13.1, which usually emerges in adolescence or early adulthood and is characterized by the development of bilateral vestibular schwannoma. We hereby report the classical case of Neurofibromatosis type 2 in a 25-year-old young male with multiple tumors associated with the disease. This patient presented to us with 3 years history of multiple painless nodules on his skin, facial weakness, left-sided progressive hearing loss, and 20 days history of weakness in the left lower limb. On Examination, he was vital with a GCS of 15/15. He was anemic with no jaundice. He had left inguinal lymphadenopathy along with multiple subcutaneous nodules on different areas, including the scalp, face, left mid-axillary line over the abdomen. He also had Right-sided facial palsy and horizontal nystagmus. CNS examination revealed an upgoing plantar on the left side, right facial nerve palsy, and bilateral vestibulocochlear nerve paralysis. Spine examination revealed spinal tenderness in the lower lumbar region. Superficial abdominal reflexes were absent. Upper limb and right lower limb power, tone, and reflexes were normal while the tone and power in the left lower limb were reduced power being ⅗. Reflexes were also exaggerated in the left lower limb. The right ankle showed swelling, most probably a plexiform neuroma. On investigations, he had normochromic normocytic anemia with mild leucocytosis. Platelets were normal. The rest of the biochemical investigations, including serum electrolytes, liver function tests, and renal function tests, were also normal.MRI brain and spine confirmed bilateral acoustic neuroma and multiple cranial and peripheral nerve tumors i.e., classical presentation of a rare disease neurofibromatosis. He was referred to the neurology unit for further assessment and treatment.

Validation of radiofrequency determined lung fluid using thoracic CT: Findings in acute decompensated heart failure patients.

BackgroundNoninvasive outpatient monitoring for heart failure (HF) has significant opportunity to reduce patient morbidity and the costs associated with recurrent hospitalization. The purpose of this study was to validate the ability of radiofrequency (RF) to assess lung fluid via a wearable patch device compared to thoracic CT in order to characterize volume overload.Methods120 subjects were studied: 66 acute heart failure (AHF) inpatients and 54 subjects without AHF (Control – 44 healthy and 10 stable HF). All underwent supine thoracic CT scans and supine RF readings from the wearable patch device placed on the left mid-axillary line (age = 74 ± 16 vs. 57 ± 15 yrs.; female = 38 vs. 44%; BMI = 33.2 ± 9.0 vs. 27.3 ± 5.1, AHF vs. Control respectively). Reflected RF signals and subject-specific anthropometric data were used to calculate the RF-determined lung fluid content. CT Lung fluid was reported as percentage of lung volume. Classification analyses were used to compare RF and CT performance.ResultsAHF presented with higher lung fluid than controls by both CT and RF (CT: 20.1 ± 4.2% vs. 15.4 ± 2.4%; RF: 20.7 ± 5.6% vs. 15.6 ± 3.3%; p < 0.05 for all). The correlation between lung fluid measured by CT vs. RF was r = 0.7 (p < 0.001). RF determined lung fluid performed as well as CT in distinguishing AHF from control subjects: Sensitivity: 70% vs. 86%; Specificity: 82% vs. 83%; Positive Predictive Value: 82% vs. 86%; Negative Predictive Value: 69% vs. 83%, CT vs. RF respectively.ConclusionsNoninvasive nonionizing RF determined lung fluid provides a potential alternative to other measures for diagnosing and monitoring pulmonary fluid overload.

Most Effective Pad Placement in Elective Cardioversion.

Most Effective Pad Placement in Elective Cardioversion.

Single-Lead ECG Recordings Including Einthoven and Wilson Leads by a Smartwatch: A New Era of Patient Directed Early ECG Differential Diagnosis of Cardiac Diseases?

Background: Smartwatches that are able to record a bipolar ECG and Einthoven leads were recently described. Nevertheless, for detection of ischemia or other cardiac diseases more leads are required, especially Wilson’s chest leads. Objectives: Feasibility study of six single-lead smartwatch (Apple Watch Series 4) ECG recordings including Einthoven (I, II, III) and Wilson-like pseudo-unipolar chest leads (Wr, Wm, Wl). Methods: In 50 healthy subjects (16 males; age: 36 ± 11 years, mean ± SD) without known cardiac disorders, a standard 12-lead ECG and a six single-lead ECG using an Apple Watch Series 4 were performed under resting conditions. Recording of Einthoven I was performed with the watch on the left wrist and the right index finger on the crown, Einthoven II was recorded with the watch on the left lower abdomen and the right index finger on the crown, Einthoven III was recorded with the watch on the left lower abdomen and the left index finger on the crown. Wilson-like chest leads were recorded corresponding to the locations of V1 (Wr), V4 (Wm) and V6 (Wl) in the standard 12-lead ECG. Wr was recorded in the fourth intercostal space right parasternal, Wm was recorded in the fifth intercostal space on the midclavicular line, and Wl was recorded in the fifth intercostal space in left midaxillary line. For all Wilson-like chest lead recordings, the smartwatch was placed on the described three locations on the chest, the right index finger was placed on the crown and the left hand encompassed the right wrist. Both hands and forearms also had contact to the chest. Three experienced cardiologists were independently asked to allocate three bipolar limb smartwatch ECGs to Einthoven I–III leads, and three smartwatch Wilson-like chest ECGs (Wr, Wm, Wl) to V1, V4 and V6 in the standard 12-lead ECG for each subject. Results: All 300 smartwatch ECGs showed a signal quality useable for diagnostics with 281 ECGs of good signal quality (143 limb lead ECGs (95%), 138 chest lead ECGs (92%). Nineteen ECGs had a moderate signal quality (7 limb lead ECGs (5%), 12 chest lead ECGs (8%)). One-hundred percent of all Einthoven and 92% of all Wilson-like smartwatch ECGs were allocated correctly to corresponding leads from 12-lead ECG. Forty-six subjects (92%) were assigned correctly by all cardiologists. Allocation errors were due to similar morphologies and amplitudes in at least two of the three recorded Wilson-like leads. Despite recording with a bipolar smartwatch device, morphology of all six leads was identical to standard 12-lead ECG. In two patients with acute anterior myocardial infarction, all three cardiologists recognized the ST-elevations in Wilson-like leads and assumed an occluded left anterior descending coronary artery correctly. Conclusion: Consecutive recording of six single-lead ECGs including Einthoven and Wilson-like leads by a smartwatch is feasible with good ECG signal quality. Thus, this simulated six-lead smartwatch ECG may be useable for the detection of cardiac diseases necessitating more than one ECG lead like myocardial ischemia or more complex cardia arrhythmias.

Therapy From a Novel Substernal Lead

The ASD2 (Acute Extravascular Defibrillation, Pacing, and Electrogram) study evaluated the ability to adequately sense, pace, and defibrillate patients with a novel implantable cardioverter-defibrillator (ICD) lead implanted in the substernal space.Subcutaneous ICDs are an alternative to a transvenous defibrillator system when transvenous implantation is not possible or desired. An alternative extravascular system placing a lead under the sternum has the potential to reduce defibrillation energy and the ability to deliver pacing therapies.An investigational lead was inserted into the substernal space via a minimally invasive subxiphoid access, and a cutaneous defibrillation patch or subcutaneous active can emulator was placed on the left mid-axillary line. Pacing thresholds and extracardiac stimulation were evaluated. Up to 2 episodes of ventricular fibrillation were induced to test defibrillation efficacy.The substernal lead was implanted in 79 patients, with a median implantation time of 12.0 ± 9.0 min. Ventricular pacing was successful in at least 1 vector in 76 of 78 patients (97.4%), and 72 of 78 (92.3%) patients had capture in ≥1 vector with no extracardiac stimulation. A 30-J shock successfully terminated 104 of 128 episodes (81.3%) of ventricular fibrillation in 69 patients. There were 7 adverse events in 6 patients causally (n = 5) or possibly (n = 2) related to the ASD2 procedure.The ASD2 study demonstrated the ability to pace, sense, and defibrillate using a lead designed specifically for the substernal space.

The importance of computer tomography-imaging in a case of a gunshot wound with an atypical entrance wound

Abstract This paper is intended to demonstrate the importance of collaboration between the Radiologist and the Medical Examiner, especially in cases of firearms injuries; Computer Tomography (CT) is the method normally used, thanks to its high anatomical definition and potential for three-dimensional reconstruction and multiplanar visualisation. The case considered here concerns a shooting victim. Upon his arrival at the emergency ward two injuries were observed, one in the lower back region and a second one in the left front mid axillary line; CT-scans were taken. The entrance wound was identified as the lower back wound, which was surrounded by a margin of abrasion of eccentric shape, with burr at the bottom and on the left: this suggested that the path of the projectile was from left to right and from below upwards. The exit wound, however, was located on the left side of the front of the torso: this could be compatible with deviation of the bullet's path within the victim's body caused by having hit bones. Only analysis of CT images and three-dimensional reconstruction could permit to define the correct path of the bullet and to exclude the possibility of deviation within this path; the atypical nature of the entrance wound was therefore the consequence of a bullet which had been deformed previously. The case described demonstrates how, in presence of non-typical entrance wounds, external examination of the victim can lead to misleading conclusions, so that, even in apparently simple cases, it is essential to work with a multidisciplinary team.

A rare gigantic primary epithelial cyst of spleen in an adolescent boy

Cysts arising from spleen are a rare clinical entity, with their discovery usually being incidental. We present a case of the largest reported primary epithelial cyst of spleen. In present study a 16-year-old child presented with abdominal distension for 1 month associated with abdominal pain for 2 weeks. On examination, a mass was felt in the epigastrium, left hypochondrium and left flank, extending across from the right midclavicular line to the left midaxillary line, and extended inferiorly till 6cm caudal to umbilicus. CT abdomen revealed a unilocular cyst of 17x20x24cm arising from the spleen with a volume of 3700ml. Splenectomy was performed; intra-operatively there was a huge splenic cyst measuring 30x30x30cm. Histopathological examination was diagnostic of Primary congenital epithelial cyst of the spleen. Till date the largest congenital splenic cyst documented in literature is 20 cm × 13 cm × 21 cm, as reported by Valentina et al, in 2014. Present specimen bests this previous case considerably.

59-02: Ventricular Pacing from the Substernal Space in Humans

Introduction: Transvenous lead failure remains an important drawback of transvenous implantable cardioverter-defibrillators (ICD). The subcutaneous ICD overcomes this issue, but lacks pacing capabilities. The objective of this study was to assess feasibility of ventricular pacing and thresholds from within the substernal space to examine a new extravascular ICD configuration with pacing capabilities. Methods: Patients with midline sternotomy for coronary arterial bypass grafting (CABG) or aortic valve replacement (AVR) were enrolled. After the sternum was opened, a duodecapolar diagnostic pacing catheter was positioned in the substernal space anterior to the pericardium, and a cutaneous patch in the left midaxillary line, after which the chest was closed. Different pacing configurations were assessed: bipolar between the catheter electrodes (inter electrode spacing 2mm, 30mm, or 60mm) and unipolar between the catheter electrodes and the patch. A downwards stepwise pacing protocol was used to identify the best configuration, starting at 25mA with a pulse width (PW) of 10ms. Results: Eight patients, (6 males), with mean age 69 ± 9 years, of whom 7 underwent AVR and one CABG, were included. In five out of eight patients ventricular capture was achieved in ≥1 configuration. The mean bipolar pacing thresholds at PW 10ms, 5ms, 3ms, 1ms were 12.4 ± 3.7mA (5 pts), 13.3 ± 5.8mA (3 pts), 18.3 ± 5.7mA (3 pts) and 25 ± 0mA (2 pts) respectively. The 60mm electrode spacing was the most successful bipolar configuration. Unipolar pacing was attempted in 4 pts and successful in 3 pts with mean thresholds of 10 ± 0mA at 10ms (3 pts), 15 ± 0mA at 5ms (3 pts), 16.7 ± 2.9mA at 3ms (3 pts) and 20 ± 7.1mA at 1ms (2 pts). The optimal unipolar vector was from the catheter electrodes over the right ventricle to the patch.

Abstract 19549: Automated External Defibrillation: Not That Easy! Untrained Laypeople Place AED Pads Poorly

Introduction: Public access defibrillation is recommended to increase survival. Automated external defibrillators (AED) have therefore been widely deployed and are available in public places. AEDs are claimed to be easy to use without requirements for training. The aim of this study was to investigate the ability of untrained laypersons to correctly place AED pads. Methods: Untrained laypeople were invited to participate. Participants were asked to operate a training AED (Lifepak® CR-T AED Trainer, PhysioControl) and place pads according to instructions fra the AED. Pads were placed on an anatomically realistic male resuscitation torso with arms (AMBU® Man, AMBU). Positioning of pads was digitally photographed and compared to the recommended pad position i.e. left apical pad in the left mid-axillary line, approximately level with the V6 ECG electrode and right sternal pad to the right of the sternum, below the clavicle. Digital data analysis was performed using ImageJ (version 1.46r) and distance from the center of the AED pads to the recommended pad position was calculated. Results: In total 40 volunteers (female: 60%, mean age 48.6 years) participated. The distance from the recommended left apical pad position was (median; 25% and 75% percentile) 8.6 (6.5; 10.4) cm while distance from the recommended right sternal pad position was (median; 25% and 75% percentile) 2.4 (1.6; 3.7) cm. In total, 95% of participants placed the left apical pad more than 5 cm from the recommended position. The right sternal pad was less often (12.5%, p&lt;0.0001) placed more than 5 cm away from recommended position. The left apical electrode was often placed too medial (Figure 1). Only, 12.5% of participants moved the left arm of the manikin to help place the left apical pad correctly. Conclusions: Untrained laypeople place AED pads poorly. The left apical pad is often misplaced medially. AED voice prompts and pad design should be further developed to guide untrained users to correct pad placement.

Abstract 19582: Placement of the Left Side AED Pad is Poor: Training on the Left Compared to the Right Side of a Manikin Does Not Improve Pad Placement

Introduction: Placement of automated external defibrillators (AED) pads is poor, especially placement of the left apical pad is rarely achieved. Sitting on the right side of a victim in cardiac arrest may interfere with correct left side pad placement because the rescuer has to bend over the victim to reach the left mid-axillary line. In addition, the left arm of the victim may hamper access to the left lateral side of the thorax. Hypothesis: Training automated external defibrillation sitting on the left side of a manikin improves AED pad placement compared to sitting to the right. Methods: Laypeople participating in a first aid course were randomized to learn automated external defibrillation sitting on the left or right side of a manikin during AED training. After course completion participants operated a training AED (Lifepak® CR-T AED Trainer, PhysioControl) and placed AED pads according to instructions from the AED. Pads were placed on an anatomically realistic male resuscitation torso with arms (AMBU® Man, AMBU). Participants were instructed to sit on the same side of the manikin as trained. The distance from the center of AED pads to the recommended pad position was measured. Results: In total, 30 volunteers were included and randomized to AED training on the left (n=14, 43% male, age: 47.9 years) and right (n=16, 25% male, age: 46.7 years) side of a manikin. There was no difference in left pad placement when trained on the left or right side (distance to recommended left apical pad position (mean±sd): 5.8±2.1 cm vs 7.0±2.4, p=0.15). The left apical electrode was in all cases placed too medial. Only a minor part of participants (left trained (36%); right trained (31%)) moved the left arm of the manikin to place the left apical pad. No difference was observed with respect to right pad placement when trained on the left or right side respectively (distance to recommended right sternal pad position (mean±sd): 2.7±1.7 cm vs 1.8±0.8 cm, p=0.10). Conclusion: Training automated external defibrillation on the left side of a manikin does not improve pad placement compared to training on the right side. Placement of the left apical pad is poor and future training should emphasize correct left lateral pad placement.

Robot-Assisted Resection of a Large Posterior Mediastinal Mass

Introduction: Ganglioneuromas are rare, typically benign, tumors that arise from tissues that have a neural crest cell origin. They typically occur in patients ranging in age from 10 to 40 years and are classically found in the adrenal glands. Ganglioneuromas are frequently asymptomatic and discovered incidentally while another condition is being investigated. The video demonstrates a difficult dissection that offers technical advantages over traditional thoracoscopy instruments by the articulating instruments of the robot with run time of 4 minutes 31 seconds. Background: An 18-year-old woman who was being followed for scoliosis was found to have a large left chest mass on a chest x-ray. A chest CT scan revealed a 10×7.5×6.5-cm mass in the left upper chest, consistent with a bronchogenic cyst. She had no reports of fever, shortness of breath, or chest pain, although she did endorse frequent feelings of left chest/shoulder tightness. In an attempt to avoid a large thoracotomy or sternotomy, we proceeded with a robot-assisted resection of the large mass. Methods: The patient was laid supine with the left chest slightly elevated and her left arm extended above her head. She was intubated with a Carlens tube for single lung ventilation. With the left lung deflated, an 8-mm robotic trocar was placed in the left midaxillary line (sixth intercostal space), an 8-mm robotic trocar was placed in left anterior axillary line (fifth intercostal space), and an 8-mm trocar was placed posterior to scapula (fourth intercostal space). An additional 5-mm step trocar was placed as an assistant port, lower left midchest in the posterior axillary line. Using hook cautery and graspers with bipolar cautery, the tumor was dissected free from the surrounding tissues and the blood vessels cauterized. The mass seemed to arise from the left sympathetic ganglia chain, which had to be sacrificed for tumor removal. The tumor extended into the apex of the left chest and into the lower part of the left neck just behind the head of the clavicle. The tumor was resected free and placed into an endocatch bag, where it was cut to facilitate its removal. The anterior axillary line trocar was removed and widened to ∼5 cm to allow specimen removal. A 28F chest tube was used because the larger tube was less likely to clog, and the chest hole was already large enough to accommodate it. The operative time was 5.5 hours, with 5 to 10 minutes of setup for the robot. Final pathology revealed a ganglioneuroma. Results: She was admitted to the step down unit postoperatively with patient-controlled anesthesia pain control. She was transitioned to oral pain medicine with a general diet on postoperative day 1. Her chest tube was removed and she was discharged on postoperative day 2. She was seen in clinic the following month with some left arm numbness and slight symptoms of Horner's syndrome (left eye ptosis and miosis when tired). Twelve months later, she reports being asymptomatic from her Horner's syndrome. Conclusions: Robot-assisted thoracic surgery provides great 3D visualization and articulating instruments that can be used to dissect large intrathoracic tumors and possibly avoid a large thoracotomy or sternotomy. No competing financial interests exist. Runtime of video: 4 mins 31 secs This work was presented as a poster at the 2014 IPEG conference in Scotland.