Limited Thoracotomy Research Articles

P62: A Unique case of Transcatheter aortic valve replacement dislodgement in the presence of a durable left ventricular assist device

Background: Transcatheter aortic valve replacement [TAVR] for severe pure aortic insufficiency [AI] in the presence of a durable left ventricular assist device [LVAD] is fraught with challenges. We report an interesting case of TAVR valve dislodgement by the LVAD that was treated with redeployment of another TAVR valve, and redo surgery for extraction of the intraventricular TAVR valve. Methods and Results: A 46-year-old man presented to our unit in cardiogenic shock [CS] and severe pulmonary hypertension [PH] of 72/45mmHg. He underwent placement of an Impella 5.5 [Abiomed, Danvers, MA] as a bridging strategy to treat his CS and PH while transplant candidacy was being assessed. However, he remained pulmonary hypertensive with a trans-pulmonary gradient 26mmHg and pulmonary vascular resistance 5.3 wood units, despite 14 days of impella 5.5 therapy combined with aggressive management with milrinone 0.25 mcg/kg/min and bumetanide infusion 1mg/hr. He therefore underwent implantation of heart mate 3 [HM3] LVAD [Abbott Laboratories, Chicago, IL] by a limited left thoracotomy in the 5th intercostal space and upper ‘inverse-T’ hemi-sternotomy into the fourth intercostal space. His postoperative course was complicated by requirement for 31mm percutaneous Protek Duo [LivaNova, London, UK] Right VAD [RVAD] for 32 days, and gastrointestinal bleeding requiring cessation of heparin therapy, which prompted formation of thrombus in the left coronary cusp of the aortic valve. Organization of this thrombus and consequent retraction of the left coronary leaflet led to severe AI and consequent CS, requiring inotropic support and discussion on optimal management strategy. He underwent TAVR with a 29mm Edwards Sapien 3 valve [Edwards Lifesciences, Irvine, CA] with 20% over-sizing, which got dislodged and migrated into the LV. Another 29mm Edwards Sapien 3 TAVR valve was successfully deployed. The patient was then placed on cardiopulmonary bypass via the femoral vessels, and the left thoracotomy was reopened. The LVAD was temporarily stopped, and the latch mechanism on the HM3 was opened. The HM3 was removed from the sewing cuff, and the TAVR valve was ‘fished-out’ from the cavity of the LV. The HM3 was reinserted and restarted after thorough de-airing through the outflow graft. The incisions were closed in a standard manner and the patient was discharged home on the 20th postoperative day. Conclusions: TAVR for severe AI in the presence of a durable LVAD is fraught with challenges due to the constant suction action of the LVAD, and the absence of calcium in the native annulus to anchor the prosthesis. Our case highlights the feasibility of extricating a dislodged TAVR valve through simple redo-surgery. With this approach, we managed to avoid a more conventional redo procedure involving administration of cardioplegia for a surgical AVR or for extricating the prosthesis, with its inherent risk of right ventricular failure requiring RVAD. Figure showing dislodged TAVR on the left and redeployment on the right

Left ventricular assist device exchange from HeartMate II to HeartMate 3 in an Asian patient—a case report and literature review

BackgroundPump exchange surgery of left ventricular assist device (LVAD) has been demonstrated in several studies; however, information for Asian patients was limited.Case presentationA 63-year-old man underwent a pump upgrade from HeartMate II to HeartMate 3 for driveline damage through limited left anterior thoracotomy and lower partial sternotomy. He did not experience any hemodynamic adverse events or device malfunction during postoperative follow-ups of 12 months. We also reviewed all published cases with HeartMate II exchange to HeartMate 3.ConclusionsThe case demonstrated that it was safe and feasible to perform HMII LVAD exchange to HM3 through a limited approach for Asian patients.

MANAGEMENT AND IDENTIFICATION OF RARE COINFECTIONS

MANAGEMENT AND IDENTIFICATION OF RARE COINFECTIONS

Strategies to decrease morbidity in surgical management of esophageal cancer: a single center experience.

In this study we described our experience in decreasing morbidity by performing a few changes during and after the Ivor Lewis esophagectomy. This is a retrospective single center experience comparing a control period (group A) and a study period (group B) in patients who underwent esophagectomy for esophageal cancer (control group: 23; study group: 17). Control group had postero-lateral thoracotomy and a gastric tube without aspiration during postoperative period. Study group had limited lateral muscle sparing thoracotomy and postoperatively the gastric tube was routinely left for 1 week with intermittent aspiration (10 times every two hours for 1 week). Average operation time was 312±56 minutes in control period, in study period 189±36 min. Average ICU stay was 10 (7-32) days in the control group, in study group 4 (1-8) days. Anastomotic leak rate was significantly higher in control vs. study group (53.3% vs. 16.6%; P<0.05). Respiratory complications were significantly lower in the study group (47.8% vs. 17.6%). The combination of a limited lateral thoracotomy and postoperative intermittent aspiration seem to reduce the rate of respiratory and anastomotic complication after Ivor-Lewis' procedure.

A Simplified Approach Step-by-Step with Pearls and Pitfalls for Minimally Invasive Mitral Valve Surgery (Non-redo)

Minimally invasive mitral valve surgery was introduced in Europe and the United States in the late 1990's. There has been a low, but increasing adoption rate in the United States. The low adoption rate is likely secondary to the lack of formalized training during cardiothoracic surgery residency and a culture that has failed to accept the procedure. In this manuscript, we provide a detailed, step-by-step guide to minimally invasive mitral valve surgery via a limited right thoracotomy.

A CASE OF NON-RESOLVING PNEUMONIA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Non-resolving pneumonia is defined as pneumonia with slow or incomplete resolution despite adequate appropriate antibiotic treatment. It is a common reason for pulmonary consultations & bronchoscopies in the hospital. Though occurrence is relatively rare, there are many reasons non-resolving pneumonia may develop. Often, they are caused by resistant organisms, mechanical airway obstructions, inappropriate antibiotic treatment, & inadequate duration of treatment. We present a rare case of non-resolving pneumonia, which led to irreversible respiratory failure. CASE PRESENTATION: A 68-year-old male with no significant past medical history presented with worsening dyspnea on exertion & cough productive of yellowish sputum for 5 weeks. In the ER, he reported fevers, night sweats, & unintentional 10-lb weight loss. Vitals showed tachycardia & hypoxia. Physical exam was positive for decreased breath sounds on the right with rhonchi. The patient had not seen a physician for many years. He reported smoking 1 pack per day for 50 years. Chest X-ray showed extensive opacification of the right hemithorax with a small pleural effusion, which suggested multi-lobar right lung pneumonia. The patient was started on empiric piperacillin-tazobactam & vancomycin. Sputum culture grew normal respiratory flora. Blood cultures remained negative. Extensive infectious workup was performed with all tests being negative. CTPA revealed airspace opacities within the right lung & fluid density within the right lung apex which is consistent with early lung necrosis. Bronchoscopy showed a normal bronchial tree. Bronchoalveolar lavage cytology showed no malignant cells. After 10 days of no clinical improvement, a repeat CT chest showed worsening right lung opacification, ground-glass opacities within the left upper lobe, & enlarged mediastinal lymph nodes. The patient continued to worsen clinically therefore underwent right limited thoracotomy & lung biopsy, which showed extensive adhesions with pleural & lung implants. Pathology revealed lung adenocarcinoma. The patient declined therapeutic chemotherapy treatment & opted to go home with hospice. DISCUSSION: This case emphasizes the importance of early recognition of non-resolving pneumonia, the proper diagnostic approach, & when to initiate further invasive workup. Evaluation of a patient with a slowly or incompletely resolved pneumonia starts with a careful history, physical examination, & review of the medical record CONCLUSIONS: Consideration of risk factors for delayed resolution should include age, comorbidities, the severity of pneumonia, & specific pathogens. If indicated, further evaluation should include CT chest to assess for findings suggestive of an alternative diagnosis. When pneumonia fails to resolve, bronchoscopy should be considered. Patients with a negative bronchoscopy examination should undergo further evaluation with lung biopsy to assess for malignancy REFERENCE #1: Jameson, J. L., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., & Loscalzo, J. (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. DISCLOSURES: No relevant relationships by Luqman Baloch, source=Web Response No relevant relationships by Luqman Baloch, source=Web Response No relevant relationships by Adrienne DaGue, source=Web Response No relevant relationships by ayobami olaleye, source=Web Response

Bronchogenic Cyst Associated with an Ostium Secundum Atrial Septal Defect in a One and Half Month Infant: Is it the Youngest Patient Yet

ABSTRACT We report an extremely rare case of a Bronchogenic Cyst incidentally identified via contrast enhanced computed tomography in a one and half-month-old male infant, a known case of Ostium Secundum Atrial Septal Defect and mild pulmonary hypertension. The patient was evaluated in detail and cystic mass resembling a Bronchogenic Cyst was found over lower paratracheal mediastinal space. The patient was planned for excision of the posterior mediastinal lesion using a right limited postero-lateral thoracotomy incision and complete excision was done and the mass was pathologically confirmed to be a Bronchogenic Cyst. This case is one of the few rare cases of infants with acyanotic congenital heart defectd that were incidentally found to have a Bronchogenic Cyst. This case to our knowledge is one of the youngest patient yet and also highlights the importance of identifying rare causes like these amongst differentials of cough and wheeze responding poorly to regular treatment.

Morbidity and mortality of surgical lung biopsy in the diagnosis of usual interstitial pneumonia.

Histology represents the major source of information to define a usual interstitial pneumonia (UIP) pattern. However, the procedure is associated with significant morbidity and mortality. The aim of this study was to evaluate morbidity and mortality of surgical lung biopsy (SLB) in diagnosing UIP. Patients undergoing SLB with the ultimate diagnosis of UIP were studied. Clinical data concerning medical history, histology, pulmonary functions, radiology, length of hospital stay (LOS), morbidity and mortality status were retrospectively recruited from four hospitals. The study included consecutive 93 patients with a SLB diagnosis of UIP. Mean age was 61 ± 8 years, with one third of the patients were ≥65 years. In 58 cases (62.4%), the biopsy was performed by video-assisted thoracoscopic surgery, in 35 (37.7%) by limited thoracotomy. Eighty patients (86%) had possible UIP, 12 (12.9%) had inconsistent with UIP and one (1.1%) had UIP pattern on high-resolution computed tomography. The mean LOS was 5.47 ± 3.16 days. LOS was associated with smoking status (P = 0.024), type of biopsy (P = 0.00), 6-min walk test (P = 0.00) and number of biopsy (P = 0.00). There was no in-hospital and 30-day mortality in our cohort, and 90-day mortality rate was 1.1%. In seven patients (7.5%), we observed postoperative morbidities, predominantly prolonged air leakage (7.5% of all cases). Postoperative morbidity was only associated with the type of SLB. Patients with limited thoracotomy showed greater morbidity rates (17.1% versus 1.7%, P = 0.011). SLB is a relatively safe procedure in the diagnosis of UIP and can be performed in suitable patients with suspected UIP/idiopathic pulmonary fibrosis.

Retrolaminar Block Versus Paravertebral Block for Pain Relief After Less-Invasive Lung Surgery: A Randomized, Non-Inferiority Controlled Trial.

IntroductionA retrolaminar block (RLB) is a modified paravertebral technique with a local anesthetic injected at the retrolaminar site. The aim of this non-inferiority, parallel-group, prospective, and randomized study was to compare the analgesic efficacy of the paravertebral block (PVB) and RLB after lung surgery.MethodsEligible subjects were patients aged more than 20 years, with American Society of Anesthesiologists physical status Ⅰ or II, who were scheduled to undergo video-assisted thoracoscopic surgery (VATS) or limited thoracotomy because of lung disease. Patients were randomly allocated to receive either a PVB or RLB using a computer-generated sequence and sealed opaque envelopes. The PVB and RLB were induced by injecting 20 mL of 0.50% ropivacaine and 40 mL 0.25% ropivacaine, respectively. As the primary outcome variable, we considered the area under the curve (AUC) of the postoperative pain intensity using the trapezoidal method. Pain intensity was assessed using an 11-point numerical rating scale (NRS). We converted the NRS (0-10) into the visual analog scale (VAS) (0-100 mm) proportionally. We compared the AUC of the converted NRS (AUC-cNRS) on coughing between one and two hours after the operation. The non-inferiority margin was set at 25 mm × h in the AUC-cNRS. Patients and nurses were blinded to group assignments. Secondary outcomes included time to perform the block, NRS for pain intensity at rest and on coughing at one, two, four, 24, and 48 hours after the operation, the incidence of postoperative nausea and vomiting, time to first morphine use after the operation, and cumulative morphine consumption at 24 and 48 hours after the operation.ResultsIn each group, 25 patients were randomized and analyzed. No significant difference in the AUC-cNRS was noted between the groups (P = 0.117). The mean difference in the AUC-cNRS (group RLB minus group PVB) was 13.42 mm × h, 95% confidence interval, −3.48 to 30.32 mm × h. However, when patients with unexpectedly extended skin incision were excluded from the analysis, the AUC-cNRS of group RLB was significantly higher as compared to group PVB (P = 0.0388). The time to perform the block was longer in PVB as compared to the RLB group (P < 0.0001). No significant differences were noted in the remaining secondary outcomes.ConclusionThe non-inferiority of RLB as compared to PVB was not confirmed. Though RLB has the advantage of a shorter time to perform, RLB is not recommended for patients undergoing VATS or limited thoracotomy because of lack of efficacy as compared to PVB.

Comparison of VATS and limited axillary thoracotomy in the treatment of spontaneous pneumothorax: A cross-sectional study.

To compare the results of conventional mini axillary thoracotomy with video-assisted thoracic surgery in the treatment of spontaneous pneumothorax. The retrospective study was conducted at Izmit Seka State Hospital, Kocaeli, Turkey, and Canakkale Onsekiz Mart University Teaching Hospital, Çanakkale, Turkey, and comprised data from November 2011 to May 2019 of patients who underwent surgery for spontaneous pneumothorax either with video-assisted thoracic surgery, who were placed in Group A, or axillary thoracotomy, who were placed in Group B. Data gathered related to age, gender, operation side, smoking status, postoperative hospital stay, recurrence rates, and postoperative complications. Data was analysed using SPSS 25. Of the 75 patients, 60(80%) were male and 15(20%) were female. The overall mean age was 29.37±11.60 years. Group A had 41(54.7%) patients, while Group B had 34(45.3%). Postoperative recurrence was not encountered in any patient in Group B, while 2(5.4%) patients in Group A had a recurrence (p>0.05) who both continued smoking. Hospital stay was significantly higher in Group B (p<0.001). Video-assisted thoracic surgery in the treatment of spontaneous pneumothorax was found to shorten hospital stay, and can be used more widely.

Pulmonary valve replacement via left anterior minithoracotomy: Lessons learned and early experience.

Median sternotomy has been the standard for pulmonary valve replacement (PVR) in patients with free pulmonary regurgitation (PR) and right ventricular enlargement. With the introduction of transcatheter therapy, the search for an alternate to sternotomy is mandated. We present our early experience with a limited anterior left thoracotomy approach. We used a left anterior mini-thoracotomy in six male patients (15 ± 1.94 years of age) who developed progressive right ventricular enlargement due to chronic PR. Primary diagnoses were tetralogy of Fallot in five patients and pulmonary atresia with an intact septum in another. Four patients had previous median sternotomy with transannular patch repair. The mean right ventricular end-diastolic volume index was 189 ± 27.13 ml/m2 . The procedure was feasible in all patients. All patients had satisfactory adult size pulmonary bioprosthesis (25 or 27 mm valve), with a mean peak gradient of 18 ± 2.40 mmHg across the prosthesis at discharge. All patients were extubated intraoperatively at the end of the procedure and required no intraoperative transfusions. There were no early or late mortalities. Early morbidities included left hemidiaphragm paralysis in one patient, and re-sternotomy for prosthetic valve endocarditis in one. One patient required late reoperation for a common femoral artery pseudoaneurysm. Minimally invasive access for PVR is feasible in both primary and repeat settings, through a limited anterior left minithoracotomy in the absence of intracardiac shunts and the need for other concomitant cardiac procedures. Longer-term studies with a larger number of patients are needed to compare the efficacy of this approach to standard sternotomy.

Video-Assisted Thoracoscopic Surgery Versus Limited Posterolateral Thoracotomy for Management of Post Traumatic Clotted Hemothorax

Background: Hemothorax is collection of blood in pleural cavity caused by blunt or sharp trauma.Retained hemothorax is an undrained collection in pleura that can lead to fibro-thorax or empyema. Chest tube placement is described as a method of management. Now, videoassisted thoracoscopic surgery (VATS) has evolved to become a gold standard in the management of retained hemothorax. Our objective is to compare VATS with limited thoracotomy in treatment of traumatic retained hemothorax. Patients and Methods: A prospective comparative study conducted on 60 patients with traumatic clotted hemothorax studied between January 2016 and December 2019. Patients were selected and classified into two groups each included 30 patients, Group I managed by open thoracotomy and group II managed by VATS. Results: Our study revealed no difference between both groups regarding age, gender, side of affection or preoperative ICT period. There were a significant reduction in operative time (55.67 Vs 101.3; P = 0.001), post-operative pain (P = 0.001) and postoperative period of ICT insertion (1.2 vs 1.2 day, P = 0.021) and postoperative total hospital stay (3.03 vs. 5.53 day; P = 0.001) and the period needed for return to normal activity (1.03 vs. 2.2 days; P = 0.01) in VATS group versus open thoracotomy group. Conclusion: We concluded that thoracoscopy is feasible, safe and tolerable method for management of retained traumatic hemothorax and so, we recommended it as a suitable method for this type of hemothorax. Key words: VATS; retained hemothorax; limited thoracotomy

A woman with knife In situ of chest

The violence can be physical, psychological or sexual. Physical violence can be by the use of sharp objects. Chest stab wounds with retained penetrating objects are rare. Here, we have reported a case with a knife impaled in her upper back who was treated successfully without any complications. A 35-year-old woman presented to our emergency department with an in situ knife at T4–T5 level. Neurologic examination revealed normal and bed side sonography reveals no free fluid in the abdomen, but lung sliding was disrupted on the left hemithorax without evidence of tamponade. A portable chest-x ray showed that the knife passes through an oblique track from right to left. The patient transferred to the operating room and the 50 cm knife removed without traumatic force. Limited thoracotomy with chest tube placement was done. We have reported a case report of an in situ knife at the upper back of a young woman who was successfully treated. The patient was stabbed in the upper back due to her husband's violence and the knife passes through an oblique track from right to left without any vascular injury. We stabilized the patient and used bedside sonography as a modality for diagnosis and decision making.

Left Thoracotomy Upper Hemisternotomy Left Ventricular Assist Device (LVAD) Implantation Offers Safe, Durable Option for Patients with Prior Sternotomy Undergoing LVAD Implantation

Purpose Increasingly, patients undergoing LVAD implantation have had previous cardiac surgery, and re-operative sternotomy LVAD implantation can pose certain technical challenges. The approval of the thoracotomy approach for LVAD implantation potentially offers increased flexibility of access and may mitigate some of these technical challenges. Thus we reviewed our series of patients with previous sternotomy and who underwent left thoracotomy and upper hemisternotomy LVAD implantation. Methods Data were compiled on all patients who had consented to be included in the Advanced Heart Failure Registry, at Vanderbilt University Medical Center, between January 2013 and October 2018. Patients who had had previous sternotomy and thoracotomy HeartWareTM HVAD LVAD implantation were included in the analysis. Patients who had undergone thoracotomy HeartMate II (N=3), or off-pump thoracotomy HVAD implantation (N = 9) were excluded from the analysis. The operative technique for all patients involved a limited left anterolateral thoracotomy with an upper hemi-sternotomy anastomosis to the ascending aorta . Preoperative, Intra-operative and post-operative clinical and VAD specific variables were reported. Data regarding clinical end points were analyzed at 30 days and one year following implant. Results 19 patients satisfied the inclusion criteria, and their characteristics are described in Table 1. One patient died 11 days post LVAD implantation due to multi-system organ failure . This patient was INTERMACS 1 at implant with multi-organ failure pre-operatively. All other patients were either transplanted or still on LVAD support one year following implant. Conclusion The use of the left thoracotomy upper hemisternotomy approach for LVAD implantation in patients with previous sternotomy is a safe alternative to re-operative sternotomy.

Unusual case of primary spontaneous hemopneumothorax in a young man with atypical tension pneumothorax: a case report

BackgroundSpontaneous life-threatening hemopneumothorax is an atypical but treatable entity of unexpected circulatory collapse in young patients, affecting 0.5–11.6% of patients with primary spontaneous pneumothorax. Spontaneous pneumothorax is a well-documented disorder with a classic clinical presentation of acute onset chest pain and shortness of breath. This disorder might be complicated by the development of hemopneumothorax or tension pneumothorax.Case presentationA 23-year-old Asian man was referred to the emergency room of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. A physical examination revealed a young man who was awake and alert but in mild to moderate painful distress. His vital parameters were relatively stable at first. The examining physician noted slight tenderness along the right posterolateral chest wall along the eighth and tenth ribs. Primary spontaneous pneumothorax was considered, and a standing chest X-ray confirmed the diagnosis. A right thoracostomy tube was immediately placed under sterile conditions, and he was referred to the respiratory service. While in the respiratory department, approximately 420 mL of blood was drained from the thoracostomy tube over 15 minutes. Our patient developed obvious hemodynamic instability with hypovolemic shock and was subsequently admitted to the cardiothoracic surgical ward after fluid resuscitation. During the ensuing 4 hours after admission, 750 mL of blood was drained through the thoracostomy tube. A bedside chest X-ray was requested after he was temporarily hemodynamically stabilized. Primary spontaneous hemopneumothorax associated with right tension pneumothorax was considered based on the radiological impression and clinical signs. An emergency limited posterolateral thoracotomy was performed. A standing chest X-ray performed on day 6 of admission after the removal of the thoracostomy tube showed a complete re-expansion of his right lung. He remained stable and was discharged within 1 week.ConclusionsThe successful treatment of a large spontaneous hemopneumothorax depends on early recognition, proactive intervention, and early consideration by a cardiothoracic surgeon. Once the diagnosis is confirmed, early thoracotomy should be considered. Such an aggressive surgery not only leads to shorter hospitalization but also confers better long-term outcomes.

Surgical Technique for Redo-Sternotomy Sparing Heartware HVAD Exchanges

Prolonged support times in bridge to transplant patients, as well as the growing number of destination patients lead to increased rates of LVAD pump exchanges for pump thrombosis, pump infections, and other device problems. We describe our surgical approach for pump exchanges in patients supported with the Heartware HVAD ventricular assist device. Pump exchanges are performed via a limited thoracotomy in the fourth, fifth, or sixth left intercostal space with cardiopulmonary bypass support. The apical sewing ring as well as the outflow graft are reused in order to limit the complexity of the procedure and minimize the need for extensive dissections. Given the significant reduction in surgical complexity and invasiveness, the described technique should be considered the standard approach for Heartware HVAD patients with device complications necessitating isolated pump exchanges.

VATS Plication of the Diaphragm: A Descriptive Observational 10-Year Southampton Experience.

The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016. Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12 mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively. Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23-76 years). The mean body mass index was 32.1 (range = 22.2-45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty two were performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1-18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. There were no deaths, no 30-day readmissions, and no long-term neuralgia in this series. We found minimal access VATS plication of the diaphragm to be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.

Pleurodesis: Which of which in management of recurrent primary spontaneous pneumothorax

ObjectivePrimary spontaneous pneumothorax is a common health problem with predominance in males than in females and have high tendency for recurrence. While management of primary spontaneous pneumothorax is conservative issue varying from observation to ICT insertion, the recurrent cases are a surgical problem. Pleurodesis is an adjuvant to surgical resection of source of air leakage. Chemical or mechanical form of pleurodesis is still a matter of debate between surgeons. Patients and methodsPatients are divided into three groups, Group A, pleurodesis done by pleurectomy, Group B pleurodesis done by pleural abrasion and Group C, pleurodesis done by chemical insulation of minocycline into chest with complete lung expansion. All cases operated through 4th space, limited thoracotomy according to the affected side. ResultsData are recorded and analyzed. Pleurectomy group is superior to Groups B and C regarding recurrence and reported complications while no deference regarding the side of recurrence and demographic data and indication of surgery in the three groups. ConclusionPleurectomy pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after surgical treatment for primary spontaneous pneumothorax.

Minithoracotomy as the primary alternative for left ventricular lead implantation during cardiac resynchronization therapy: Can the cardiac surgeon reduce the number of nonresponders

Introduction/Objective. Numerous anomalies of the cardiac venous system prevent the optimal endovascular implantation of the left ventricular (LV) lead in more than 15% of patients with indication for cardiac resynchronization therapy (CRT). The endovenous approach in these patients can be one of the potential reasons for the large number of nonresponders reported in the literature. The purpose of this study was to analyze the results of an alternative myoepicardial approach to the stimulation of the left ventricle in CRT. Methods. From June 2014 to December 2015 at the Department of Cardiac Surgery of the Clinical Centre of Serbia, 15 myoepicardial LV leads for CRT were implanted. Coronary sinus venography revealed thrombosis of the coronary sinus in nine patients, and unfavorable anatomy of the coronary venous system in six patients. In all patients, limited left thoracotomy was used as an approach to the lateral wall of the heart. Results. There were no major surgical complications and no lethal hospital outcomes. In a six-month follow-up period we registered a significant increase in the length of the six-minute walk test (for an average of 57.9 m), reduction of the QRS complex width (to 26.25 ms), increase in left ventricular ejection fraction (12.2%), and reduction of mitral regurgitation for 1+. Based on all the parameters, it was concluded that all patients responded favorably to the applied CRT. Conclusion. Closer cooperation between cardiologists and cardiac surgeons in identifying patients who would benefit the most from a myoepicardial approach for LV stimulation is necessary in order to attempt to reduce the nonresponder rate.

Right Posterior Thoracotomy for Open-Heart Surgery in a Rare Morphology

The closure of atrial septal defects through right-sided limited posterior thoracotomy has been well established in selected subsets. We present a case of large ostium secundum atrial septal defect, pulmonary valvar stenosis, absent right superior vena cava, and isolated left superior vena cava draining to right atrium via coronary sinus. The child successfully underwent total correction through limited posterior thoracotomy with necessary modifications of intraoperative steps.