Left Parasternal Approach Research Articles

Redo aortic arch replacement through a second transcostal approach for closure of type 1A endoleak after endovascular treatment of type B aortic dissection in Marfan syndrome

A 41-year-old woman with Marfan syndrome suffering from chronic expanding type A dissection of the distal aortic arch and pectus excavatum underwent aortic arch replacement through a left parasternal approach. We demonstrate that this approach is also feasible in complex redo surgery on the aortic arch in selected patients.

Two-dimensional and M-mode echocardiographic parameters in Ghezel sheep.

Echocardiography is a non-invasive method of cardiac evaluation in most species. Echocardiographic reference parameters are poorly documented in sheep and not documented in Ghezel sheep. The purpose of this study was to determine reference ranges of normal echocardiographic parameters using two-dimensional and M-mode techniques in Ghezel sheep. In 15 healthy female Ghezel sheep aged between 15 and 18 months, echocardiography was performed in standing position from left and right parasternal approach focused at 3rd - 5th intercostal spaces using a 2.50 - 5.00 MHz phased array transducer. The following parameters were measured in two-dimensional echocardiography: left atrial diameter (LAD), mitral valve annulus (MVA), aortic sinus (AoS), aortic valve (AoV), pulmonary sinus (PuS), and pulmonary valve (PuV); and in M-mode echocardiography: interventricular septum (IVS), left ventricular internal diameter (LVID), left ventricular free wall (LVFW), right ventricle free wall (RVFW), right ventricle internal diameter (RVID). Calculated variables included the ratios LAD/Ao and Pu/AoS, and the fractional shortening (FS), end diastolic volume (EDV), end systolic volume (ESV), ejection fraction (EF), stroke volume (SV) and cardiac output (CO) of the left ventricle. In conclusion, echocardiographic parameters could be reliably assessed in Ghezel sheep and our study provided some normal echocardiographic reference ranges that might be useful in proper identification, visualization, and measurements of cardiac structures. Such findings could be useful to assess and to diagnose the specific heart diseases in sheep practice and also for experimental studies in sheep as an animal model used for research purposes in cardiovascular studies of human.

Incremental value of right parasternal transthoracic echocardiographic examination over the left parasternal approach in assessing ascending aorta size: Additional benefit of three-dimensional echocardiography.

The ascending aorta (AA) has not been well studied using two-dimensional right parasternal transthoracic echocardiographic examination (2DRPE). The aim of the present study was to assess the incremental value of 2DRPE over two-dimensional left parasternal transthoracic echocardiographic examination (2DLPE) in evaluating the size of AA in adult patients (pts) and, secondly, to determine whether live/real time three-dimensional (3D) RPE provided any additional benefit over 2DRPE. The AA was successfully imaged by 2DLPE, 2DRPE, and 3D RPE in 87 of 141 (61.7%) pts which comprised of two groups of consecutive pts separated by an interval of 2 weeks. The maximum length of AA visualized by 2DRPE (4.98 ± 0.89) was larger than 2DLPE in 76/87(87%) pts (P < 0.001). Both the maximum systolic AA inner luminal width and leading edge-to-leading edge width by 2DRPE were greater than 2DLPE (P < 0.001). Similar to other noninvasive imaging modalities where mid-AA width is taken at level of right pulmonary artery, mid-AA width could also be taken at this level by 2DRPE in 79/87(91%) pts since this landmark was visualized during 2DRPE. However, this vessel could be visualized in only 2/87 (2%) pts with 2DLPE. 3DRPE conferred additional benefit over 2DRPE. The maximal AA length by 3DRPE was larger than 2DRPE in 60/87(69%) pts, and the maximal inner lumen and leading edge to leading edge widths were larger in 54/87(62%) and 66/87(76%) pts, respectively. Our preliminary study demonstrates significant incremental value of 2DRPE over 2DLPE in the assessment of AA. 3DRPE confers an additional advantage over 2DRPE.

Development of a new model for acute myocardial infarction in rabbits.

The rabbit left anterior descending coronary artery is not macroscopically apparent; this often leads to failure in creation of an acute myocardial infarction (AMI) model. In order to devise a simple method with good reproducibility and high success rate for use as a rabbit AMI model, a new surgical technique was developed, in which the obtuse marginal (OM) branch of the left circumflex coronary artery was coagulated with an electric knife using a left parasternal approach. Four weeks after OM branch coagulation, an electrocardiogram (ECG), blood biochemistry analysis, echocardiographic measurements and pathologic analysis were performed. The left parasternal approach provided the surgeon clear visualization of the targeted blood vessel to accurately identify the proper site to occlude. The successful development of AMI was confirmed by ST segment elevation on the ECG, by high levels of AMI-related markers in blood samples, by cardiac functional damage reflected on echocardiographic images and by changes in pathological sections. Furthermore, an acceptable success rate and low mortality were achieved. Hence, this surgical technique was suggested to be a highly reliable and reproducible method to induce AMI in rabbits for the assessment of new therapeutic interventions or regenerative approaches.

Perventricular device closure of a doubly committed juxtaarterial ventricular septal defect through a left parasternal approach: midterm follow-up results.

BackgroundIt is infeasible to occlude a doubly committed juxtaarterial ventricular septal defect (DCVSD) percutaneously. The previous perventricular device closure technique was performed through an inferior median sternotomy approach. The purpose of this study is to evaluate the feasibility, safety and efficacy of perventricular device closure of DCVSDs through a left parasternal approach.MethodsSixty-two patients, with the DCVSD of less than 6 mm in diameter, were enrolled in this study. The pericardial space was approached through a left parasternal mini-incision without entering into the pleural space. Two parallel pursestring sutures were placed on the right ventricular outflow tract for puncture. Under transesophageal echocardiographic guidance, a new delivery sheath loaded with the device was inserted into the right ventricle and advanced through the defect into the left ventricle. The device, connected with a device stay suture, was deployed subsequently.ResultsSuccessful device closure of the defects was achieved in 58/62 patients (94 %). The DCVSD failed to close in 4 (6 %) patients due to device-related aortic regurgitation and device migration. The mean DCVSD diameter was 3.4 ± 1.0 mm (range, 2.0 to 6.0 mm). The implanted device size was 5.2 ± 1.3 mm (range, 4 to 8 mm). Forty-four out of 58 patients (76 %) was implanted with an eccentric occluder. The mean intracardiac manipulation time was 14 ± 13 min (range, 2 to 60 min). The procedure time was 66 ± 15 min (range, 42 to 98 min). During the follow-up period of 180 to 1860 (median 880) days, new mild pulmonary regurgitation occurred in 2 patients. No other device-related complications were found. The complete closure rate was 95 % at discharge, 98 % at 1-, 6- and 12-month, 96 % at 2-year, and 100 % at 3-year follow-up.ConclusionsPerventricular device closure of a DCVSD through a left parasternal approach is feasible, safe, and efficacious in selected patients. This minimally invasive technique permits easy defect crossing and accurate device positioning.

Simultaneous examination of the aorta in echocardiography of patients with coronary artery disease

The majority of aortic aneurysms are asymptomatic and are discovered incidentally on routine physical examination or on imaging studies for other indications [1], although the rupture of the aortic aneurysm can cause uncontrolled hemorrhage and rapid circulatory collapse. Atherosclerosis has been considered the underlying cause of aortic aneurysms, and the concomitant disorder of aortic aneurysm and coronary artery disease can be frequently observed [2]. Echocardiography is a basic modality to assess patients with coronary artery disease and can be used for the screening of aortic aneurysm. I would like to recommend the simultaneous examination of the aorta in the echocardiography of patients with coronary artery disease and propose the following screening method for aortic aneurysms. (1) Superior intercostal view (Fig. 1): left parasternal approach is a standard method for the long-axis view of the left ventricle, atrium, and proximal ascending aorta. The approach from the superior intercostal space can visualize the proximal to mid-portion of the ascending aorta. (2) Small-scale longaxis view (Fig. 2): the descending aorta can be seen behind the left atrium in the parasternal view of echocardiography by adjusting the window depth. (3) Subxiphoid view: abdominal aorta can be seen from subxiphoid and abdominal approaches. (4) Suprasternal view (Fig. 3): aortic arch to proximal descending aorta can be illuminated from the suprasternal approach on the ‘‘sniff’’ and supine position. These approaches may be recalled as the ‘‘four Ss’’. The routine evaluation of the aorta in echocardiography must make the time required for aortic echo shorter. Quick aortic echo using the four S approaches will be able to play an important role not only in the search for aortic aneurysm, but also in the evaluation of acute aortic dissection in the emergency room.

Echocardiography Part 2: Left parasternal approach

Companion AnimalVolume 13, Issue 4 p. 48-51 Echocardiography Part 2: Left parasternal approach Paddy Mannion BVMS DVR MRCVS DipECVDI, Paddy Mannion BVMS DVR MRCVS DipECVDI RCVS & EUROPEAN SPECIALIST IN VET. DIAGNOSTIC IMAGING CAMBRIDGE RADIOLOGY REFERRALS, 12–20 VICTORIA ROAD, CAMBRIDGE. CB4 3DUSearch for more papers by this author Paddy Mannion BVMS DVR MRCVS DipECVDI, Paddy Mannion BVMS DVR MRCVS DipECVDI RCVS & EUROPEAN SPECIALIST IN VET. DIAGNOSTIC IMAGING CAMBRIDGE RADIOLOGY REFERRALS, 12–20 VICTORIA ROAD, CAMBRIDGE. CB4 3DUSearch for more papers by this author First published: 30 September 2010 https://doi.org/10.1111/j.2044-3862.2008.tb00271.xAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume13, Issue4May 2008Pages 48-51 RelatedInformation

Combined Severe Pectus Excavatum Correction and Aortic Root Replacement in Marfan’s Syndrome

A 23-year-old man with Marfan's syndrome was admitted for repair of annulo-aortic ectasia and severe pectus excavatum. A submammary skin incision approach followed by bilateral subperichondrial resection of abnormal costal cartilages was performed. The left intercostal muscles and perichondrial sheaths were divided 2 inches lateral to the sternum in a parasternal fashion to place the retractor. The aortic root was replaced with a 23-mm St. Jude's composite graft (St. Jude Medical, Inc, St. Paul, MN). Chest wall reconstruction was completed with a high sternal osteotomy and support of the sternum was made with Gortex strips (W.L. Gore & Associates, Inc, Flagstaff, AZ). The patient made an uneventful recovery.

Usefulness of Left Parasternal Approach for the Continuous-Wave Doppler Measurement of Left Ventricular Outflow Tract Pressure Gradient in Patients With Hypertrophic Cardiomyopathy

Usefulness of Left Parasternal Approach for the Continuous-Wave Doppler Measurement of Left Ventricular Outflow Tract Pressure Gradient in Patients With Hypertrophic Cardiomyopathy

Echocardiographic Diagnosis of Pulmonary Arterial Hypertension in Chronic Lung Disease with Hypoxemia

Background : Secondary pulmonary hypertension is an important final endpoint in patients with chronic hypoxic lung disease, accompanied by deterioration of pulmonary hemodynamics. The clinical diagnosis of pulmonary hypertension and/or cor pulmonale could be difficult, and simple noninvasive evaluation of pulmonary artery pressures has been an relevant clinical challenge for many years. Doppler echocardiography might to be a more reliable method for evaluating pulmonary hemodynamics in such patients in terms of the accuracy, reproducibility and easiness for obtaining an appropriate echocardiographic window than M-mode echocardiography. The aim of this study was to assess echocardiographic parameters associated with pulmonary arterial hypertension, defined by increasing right ventricular systolic pressure(RVSP), calculated from trans-tricuspid gradient in patients with chronic hypoxic lungs. Method : We examined 19 patients with chronic hypoxic lung disease, suspected pulmonary hypertension under the clinical guidelines by two dimensional echocardiography via the left parasternal and subcostal approach in a supine position. Doppler echocardiography measured RVSP from tricuspid regurgitant velocity in continuous wave with 2.5MHz transducer and acceleration time(AT) on right ventricular outflow tract in pulsed wave for the estimation of pulmonary arterial pressure. Results : On echocardiography, moderate to severe degree of pulmonary arterial hypertension was defined as RVSP more than 40mmHg, presenting tricuspid regurgitation. Increased right ventricular endsystolic diameter and shortened AT were noted in the increased RVSP group. Increased RVSP was correlated negatively with the shortening of AT. Other clinical data, including pulmonary functional parameters, arterial blood gas analysis and M mode echocardiographic parameters were not changed significantly with the increased RVSP. Conclusion : These findings suggest that shortened AT on pulsed doppler can be useful when quantifying pulmonary arterial pressure with increased RVSP in patients with chronic lung disease with hypoxemia. Doppler echocardiography in pulmonary hypertension of chronic hypoxic lungs is an useful option, based on noninvasiveness under routine clinical practice.

Diagnosis of right ventricular outflow obstruction in infants by cross sectional echocardiography.

Cross sectional echocardiographic studies were assessed prospectively in 58 infants in whom right ventricular outflow obstruction was subsequently shown angiographically. A subcostal cut was used to display simultaneously the short axis of the aortic root and the long axis of the right ventricular outflow tract. This facilitated the differentiation of the common right ventricular outflow tract obstructive lesions. Tetralogy of Fallot was diagnosed correctly in 22 of 26 infants; pulmonary atresia with intact septum in all of 14 neonates; isolated severe pulmonary valve stenosis in all of nine infants; and pulmonary atresia with ventricular septal defect in eight of nine infants. The subcostal approach is the technique of choice for evaluating right ventricular outflow tract obstruction as it is more reliable than the left parasternal approach.