Mediastinal Displacement Research Articles

Giant Congenital Lobar Emphysema: A Rare Cause of Persistent Respiratory Distress in Neonatal Intensive Care

Congenital lobar emphysema (CLE) is a rare congenital anomaly of the lung causing excessive aeration of one or more lobes of a histologically normal lung. It manifests in the first weeks of life and rarely in the neonatal period, with respiratory distress due to compression atelectasis and often associated with mediastinal displacement. CLE poses a challenge in terms of diagnosis and positive pressure ventilation due to air trapping. We report the case of a newborn presenting with persistent respiratory distress. A thoracic CT scan was performed, confirming the diagnosis of CLE. The definitive diagnosis is provided by histology of the operative specimen, revealing emphysematous lesions. Treatment involves lobectomy after stabilization of respiratory function. Surgical abstention is possible for asymptomatic or paucisymptomatic lesions.

Relative Mediastinal Displacement Index (RMDI): A Prenatal MRI Indicator of Adverse Events in Fetuses With Isolated Left Congenital Diaphragmatic Hernia.

Extracorporeal membrane oxygenation (ECMO), has partly improved congenital diaphragmatic hernia (CDH) outcomes, yet the overall morbidity and mortality remain high. Existing prenatal indicators for CDH fetuses are operator-dependent, time-consuming, or less accurate, a new simple and accurate indicator to indicate adverse events in CDH patients is needed. To propose and assess the association of a new MRI parameter, the relative mediastinal displacement index (RMDI), with adverse events including in-hospital deaths or the need for ECMO in fetuses with isolated left CDH (iLCDH). Retrospective analysis. One hundred thirty-nine fetuses were included in the iLCDH group (24 with adverse events and 115 without) and 257 fetuses were included in the control group from two centers in Guangzhou. 3.0 T, T2WI-TRUFI; 1.5 T, T2WI-FIESTA. Three operators independently measured the , , and DH on the axial images. The calculation formula of the RMDI was ( + )/DH. The independent sample t test, Mann-Whitney U test, Chi-square test, Chi-square test continuity correction, Fisher's test, linear regression analysis, logistic regression analysis, intraclass correlation coefficient, receiver operating characteristic curve analysis, and Delong test. A P value <0.05 was considered statistically significant. The RMDI did not change with gestational age in the iLCDH group (with [P = 0.189] and without [P = 0.567] adverse events) and the control group (P = 0.876). There were significant differences in RMDI between the iLCDH group (0.89 [0.65, 1.00]) and the control group (-0.23 [-0.34, -0.16]). In the iLCDH group, RMDI was the only indicator left for indicating adverse events, and the best cutoff value was 1.105. Moreover, there was a significant difference in diagnostic accuracy between the RMDI (AUC = 0.900) and MSA (AUC = 0.820), LHR (AUC = 0.753), o/e LHR (AUC = 0.709), and o/e TFLV (AUC = 0.728), respectively. The RMDI is expected to be a simple and accurate tool for indicating adverse events in fetuses with iLCDH. 4 TECHNICAL EFFICACY: Stage 1.

Pleuropulmonary blastoma in a child masquerading as massive pleural effusion: A case report

Pleuropulmonary blastoma (PPB) is a rare dysembryonic lung neoplasm of childhood. Its aggressive nature is demonstrated by its large size and metastasis at the time of diagnosis. Here, we present a case of a 5-year-old male with a history of sudden dyspnea who was initially referred to the primary health-care center for emergency medical services. His initial chest radiography showed massive hydropneumothorax in the right pleural cavity, with gross mediastinal displacement. These clinical findings and rapidly decreasing peripheral saturation prompted the emergency team to insert a right-sided intercostal drainage tube. Initially, this step was able to stabilize the condition, but a subsequent computed tomography scan revealed a vast cystic-solid mass in the right hemithorax. After establishing the diagnosis of PPB by means of histopathology and immunohistochemistry, he was operated on urgently for cytoreductive purposes. Despite the initial macroscopic clearance, the mass recurrence occurred after 3 months, contributing to the ultimate fatal outcome for the patient. Due to the cystic-solid nature of type II/III PPB, it could be masquerading as hydropneumothorax in the initial chest X-ray, a misleading yet the sole initial presentation of this rare entity.

A life-threatening encounter: an uncommon case of ruptured hydatid cyst presenting as anaphylactic shock and respiratory distress in a 12-year-old boy

Introduction and importance: Although rare, the spontaneous rupture of a lung hydatid cyst or its perforation into the pleural cavity can give rise to an abrupt onset of symptoms, including cough, fever, hemoptysis (coughing up blood), and hypersensitivity reactions, and can ultimately lead to respiratory failure. Case presentation: A 12-year-old boy was brought to the emergency room with a loss of consciousness. Symptoms included tachypnea, fever, low blood pressure, and overall respiratory distress. After resuscitation, a chest X-ray revealed a distinct, well-defined round opacity located in the lower region of the right lung, leading to mediastinal displacement. After confirmation of the disease, the child was hospitalized in the ICU care and consequently underwent surgery. Treatment was successful and there was no recurrence on the follow-up. Clinical discussion: Studies have demonstrated that the right lower lobe of the lung is the most frequently affected area of the lung by hydatid cysts. Symptomatic and complicated hydatid cysts are a rare concept in children, and only a small percentage, are diagnosed in patients younger than 16 years. Surgery remains the preferred treatment for the majority of patients with pulmonary hydatid disease. It is important to note that combined surgery and chemotherapy represents the current gold standard in managing pulmonary hydatid cyst. Conclusion: Although anaphylactic shock caused by a ruptured lung hydatid cyst is rare, it should be taken into consideration by physicians as a differential diagnosis in patients who also have respiratory symptoms, particularly in endemic areas.

Arrhythmogenic superior vena cava manifesting after a right-sided pneumonectomy and mediastinal lymph node dissection.

No case of AF ablation after right-sided pneumonectomy has been reported, presumably because the pneumonectomy renders the ablation procedure more difficult than lobectomy because of the marked mediastinal displacement. In the case of catheter ablation of AF after right-sided pneumonectomy, it is extremely important to insert a mapping catheter not only into the PV but also into the SVC to accurately diagnose the site of abnormal electrical activity.

Pathohistological features of mediastinal lymphoma in domestic cats

The article covers two clinical cases of domestic cats suffering from a mediastinal form of lymphoma and provides their cytological, immunohistochemical, and pathohistological verification. The lymphoma immunophenotyping method using the B-cell markers CD79a and CD3 was used to identify T-cells. The mediastinal type of lymphoma in cats is usually rarely registered and statistically, the number of cases does not exceed 20%, which is consistent with our observations. Shortness of breath, difficulty with swallowing, lack of appetite, cyanotic mucous membranes, lymphadenomegaly of the mediastinal lymph nodes and effusion in the chest cavity were found in the clinically ill cats. An X-ray examination of the chest cavity revealed an increased contrast in the mediastinal area and displacement of the lungs towards the spine. A complete blood count revealed lymphopenia. Cytological smears of the chest cavity transudates revealed mostly monomorphic lymphoblasts with large rounded hyperchromic nuclei and narrow cytoplasm stained in light blue. The karyoplasm was somewhat granular, the nucleoli were visible, and the mitoses were atypical and numerous. The cytological picture in biopsy samples of mediastinal lymph nodes was characterized by a monomorphic population of lymphoblasts with an eccentrically located nucleus and moderately basophilic karyoplasm. The cell cytoplasm was vacuolated in some places, with presence of atypical mitotic figures. Most of the cells had two nuclei. Diffuse tumoral lesions of the chest cavity tissues, focal tumorous lesions of the lung parenchyma, and lymphadenopathy of the mediastinal lymph nodes were found during the autopsy in the first case. The second clinical case demonstrated the massive lymphadenopathy of the mediastinal lymph nodes. Histologically, a diffuse lesion by a monomorphic population of lymphoblasts was revealed in preparations from the soft tissues of the chest wall. The lymphoblasts’ insignificant cytoplasm, with nuclei from round to elliptical shape, infiltrated the chest wall’s soft tissues. It was found immunohistochemically that the blast cells showed reactivity to CD79a, and were mostly negative to CD3. This indicates the development of a large diffuse B-cell lymphoma. The immunohistochemical picture of lymph node necropsies from another cat was somewhat similar. However, it was also characterized by lymphoblasts with eccentrically placed nuclei, increased number of cells with mitotic figures, somewhat intensive CD3 antibodies expression (especially in the paracortical area of lymph nodes), and significant CD79a marker expression.

Is surgical intervention routinely required for congenital lobar overinflation? A case series from a tertiary hospital in Riyadh, Saudi Arabia

IntroductionCongenital lobar overinflation (CLO) is a congenital overinflation of a pulmonary lobe. The treatment choice depends on the severity of its symptoms. Surgical intervention is indicated for patients with significant symptomatology, while a conservative approach is used to treat incidental and mildly symptomatic lesions. However, the conservative approach for children with mild symptoms is not very common among pulmonologist. Therefore, we evaluated this approach to treating mildly symptomatic children. MethodsThis retrospective study examined mildly symptomatic patients (n = 14) with a radiological diagnosis of CLO between June 2005 and August 2018 who were treated conservatively at KFSHRC in Riyadh. The participants’ ages ranged between two days and four years, with follow-up period ranged from four months to 10 years. ResultsFourteen patients with CLO—who were 2 days to four years old and comprised 10 boys (71.4%) and four girls (28.6%)—were treated conservatively. All patients were symptomatic upon presentation, and their main clinical findings were tachypnea (85.7%) and dyspnea (78.6%). A single lobe was affected for ten patients (71.4%). Congenital cardiac anomalies founded in six patients (42.9%). Radiological image showed overinflation of all patients’ affected lobes. Significant mediastinal displacement was observed among two patients (14.3%). During their follow-up periods, nine patients (64.3%) became asymptomatic, three (21.4%) showed improvement, and two (14.3%) remained symptomatic and underwent lobectomy. ConclusionsThe good outcomes for mildly symptomatic children with CLO in our series indicate that the conservative approach can be considered to treat these children at any age, along with close follow-up.

Bilateral Lung Transplantation for Patients With Destroyed Lung and Asymmetric Chest Deformity.

Background: Destroyed lung can cause mediastinal displacement and asymmetric chest deformity. Reports on bilateral lung transplantation (LT) to treat destroyed lung and asymmetric chest deformity are rare. This study presents our surgical experience of bilateral LT among patients with destroyed lung and asymmetric chest deformity.Methods: Six patients with destroyed lung and asymmetric chest deformity who underwent bilateral LT at our center from 2005 to 2020 were included in the study. Demographic data, technical data, perioperative details, and short-term follow-up data were reviewed.Results: Three patients underwent bilateral LT via anterolateral incisions in the lateral position without sternal transection, while three patients underwent bilateral LT via clam-shell incisions in the supine position with sternal transection. Only one patient required intraoperative extracorporeal membrane oxygenation. Four patients underwent size-reduced LT. In the other two patients, we restored the mediastinum by releasing mediastinal adhesions to ensure maximal preservation of the donor lung function. Patients in the lateral position group had a higher volume of blood loss, longer operation time, and longer postoperative in-hospital stay than those in the supine position group. However, these differences were not statistically significant. Postoperative computed tomography in the supine position group revealed that the donor lungs were well expanded and the mediastina were in their original positions.Conclusions: Although bilateral LT in patients with destroyed lung and asymmetric chest deformity is high risk, with sufficient preoperative preparation and evaluation, it is safe and feasible to perform bilateral LT for selected patients. For patients without severe chest adhesions, releasing the mediastinal adhesions and restoring the mediastinum through a clam-shell incision in the supine position is a simple and effective method to maximally preserve the donor lung function without pneumonectomy or lobectomy.

Overtreatment of Transient Maternal Hyperthyroidism Resulting in Fetal Goiter.

Overtreatment of Transient Maternal Hyperthyroidism Resulting in Fetal Goiter.

Ultrasound Differential Diagnosis and Prognosis of Right Main Bronchus Atresia in Fetus: Clinical Case

Background. Obstructive lesion of upper respiratory tract in fetus is extremely rare pathology with adverse perinatal outcomes.Clinical Case Description. Ultrasound examination of fetus (gestational age 21 weeks 6 days) has revealed one-sided isolated main bronchus atresia. Atresia was presented as enlargement of right lung due to mucus accumulation, its increased echogenicity, mediastinal displacement to the left and left lung size reduction. We performed differential diagnosis with cystic-adenomatous lung malformation type III, congenital lobar emphysema and pulmonary sequestration. These conditions are also characterized by lung echogenicity and volume increase but they are usually limited to one lung lobe or segment, and pulmonary sequestration has a systemic blood supply. The use of high-frequency transducers, lung vessels Doppler imaging and volume echography allow us to investigate in detail the lung structure of the fetus, correctly calculate the lungs volume and timely the main bronchus atresia at the second trimester of pregnancy.Conclusion. The ultrasound diagnosis of isolated main bronchus atresia is based on revealing of increased lung volume on ipsilateral side, its increased echogenicity, presence of hypoechogenic linear tubular structures (bronchocele), mediastinal displacement to the opposite side and extreme hypoplasia of the contralateral lung. Prognosis for the life is unfavorable.

VP10.04: Prenatal and pathological findings of fetal unilateral pulmonar agenesis

Pulmonary agenesis is a rare congenital malformation defined as the total absence of pulmonary parenchyma, bronchi and vascularisation. The diagnosis of this pathology, as well as other associated malformations, is important for the prognosis and subsequent management. Two cases diagnosed in our hospital from January 2008 to September 2019 are presented. In both cases the patients had no personal history of interest and both were diagnosed in the ultrasound scan of week 19–22. Both fetuses presented other important associated malformations: Case 1 presented associated cardiac dextroposition with mediastinal displacement, cavity discordance, mild pericardial effusion and single pulmonary artery. Case 2 also presented cardiac dextroposition, single pulmonary artery and single umbilical artery. In both fetuses the karyotype was normal. Both patients decided to terminate the pregnancy. In conclusion, pulmonary agenesis is an uncommon pathology. The key to diagnosis is the presence of an abnormal heart position without evidence of thoracic mass or diaphragmatic hernia. Supporting information can be found in the online version of this abstract Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Death due to tension gastrothorax

The term ‘tension gastrothorax’ is used to describe the rare and life-threatening complication of a diaphragmatic defect and can present with non-specific symptoms. It develops when an intra-thoracic stomach, which has herniated through a diaphragmatic defect, is distended, causing mediastinal displacement. Here, we present a case report of a previously healthy 2-year-old boy with tension gastrothorax as well as a review of the literature on this phenomenon. Although this condition is rare, it is an important differential to exclude in children presenting with non-specific symptoms.

RIGHT UNILATERAL PULMONARY APLASIA

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary agenesis is an extremely rare congenital abnormality. There is incomplete development of lung due to embryological defects. This condition is diagnosed in neonates presenting with respiratory distress. CASE PRESENTATION: A 24 year old male, asymptomatic, consulted for pre-employment clearance. Mother had episode of vaginal bleeding on 5th month of gestation but patient was carried to full term with uneventful birth history. Patient was noted frail growing up, with recurrent pulmonary infection. There was noted shallowness of right nasolabial fold, unequal shoulder height. Right hypothenar was atrophied. Trachea was shifted to the right. There was lag on right chest wall and absence of breath sounds on right lung. Chest xray showed full opacification of the right hemithorax with tracheal deviation to the right. Chest CT scan showed absence of right lung and supplying vasculature. Mediastinum was noted occupying the right hemithorax. Diagnosis was right pulmonary aplasia. DISCUSSION: Pulmonary agenesis encompasses undeveloped pulmonary parenchyma, pulmonary vasculatures, and airways. There is failure of development of the primitive lung bud. Arrest in the development of respiratory system from the foregut corresponds to these embrogenic malformations. Respiratory anlage may develop unilaterally leading to lung agenesis. Unilateral aplasia and hypoplasia are better viable with life. Functionally, unilateral agenesis and aplasia are similar. Sole functional lung is larger than normal to compensate and this enlargement is true hypertrophy and not emphysema.Primary causes include deficiency in TTF-1, HNF310, and EGFR. Secondary causes include small fetal thoracic volume, prolonged oligohydramnios, and congenital heart diseases. A third diagnosed during adulthood are asymptomatic. Recurrent childhood respiratory infections are common symptoms leading to identification. Diagnosis is suspected in patients examined with tracheal deviation, in the presence of a clinically symmetric chest and massive atelectasis in chest xray. Chest CT scan has emerged as diagnostic modality of choice in diagnosis. There is no treatment needed for asymptomatic cases. Treatment is necessary in the presence of respiratory tract infections. Prognosis of pulmonary aplasia depends on severity of co-existing congenital malformations and involvement of normal lung in infection and large vessels kink due to mediastinal displacement. Normal life span is expected for those surpassing first five years without major infection.There is higher mortality with right lung agenesis than left due to greater compression of tracheobronchial tree by shifting of midthoracic structures into the right chest. CONCLUSIONS: Pulmonary aplasia is a rare congenital abnormality characterized by absence of lung parenchyma and supporting vasculature. Patients with no other concomitant congenital anomaly survive well into adulthood. Reference #1: Mardini M K, Nyhan W L. Agenesis of lung: Report of 4 patients with unusual anomalies. Chest 1983; 87:522-7. Reference #2: Conway K, Gibson RL, Perkins J, Cunningham ML. Pulmonary agenesis: Expansion of the VCFS phenotype. Am J Med Genet. 2002:11389–92. Reference #3: Richard S. Synopsis of Diseases of the Chest. 2nd ed. Phildelphia: W. B. Saunders Company; 1994. Pulmonary Abnormalities of Developmental Origin; p. 25686. DISCLOSURES: No relevant relationships by Portia Maria Tanyag, source=Web Response

Hypoplasia of lung a rare entity mimicking as a case of tuberculosis

Pulmonary hypoplasia, a congenital malformation, is characterized by incomplete development of the lungs, leading to an abnormally less number or dimensions of bronchopulmonary segments / alveoli resulting in small fibrotic and non-functional lung. It is usually diagnosed in the neonatal period or in early childhood. Hypoplasia may be primary (idiopathic) or secondary. Primary pulmonary hypoplasia, not related to other congenital anomalies is extremely seldom diagnosed in adults. We report the case of a 32-year-old married female with two kids presented to us with chief complaints of cough and fever for past nine months. Chest radiograph showed opacification of the left hemi-thorax with decrease in its size and marked ipsilateral mediastinal displacement with an increase in volume of right lung. After investigations she was diagnosed as a case of left lung primary pulmonary hypoplasia. High level of excellent clinical judgement needed to spot and diagnose this congenital aberration, often wrongly diagnosed in adults. Hence, once confronted with an opaque hemi-thorax in a young person with ipsilateral shift of the mediastinum, differential diagnosis of “lung hypoplasia” ought to be kept in mind.

Tension gastrothorax: acute life-threatening manifestation of late onset congenital diaphragmatic hernia (CDH) in children

Tension gastrothorax in children is a life-threatening condition and presents dramatically with acute and severe respiratory distress. It develops when an intra-thoracic stomach herniated through a diaphragmatic defect is massively distended by trapped air and/or fluid causing mediastinal displacement. Tension gastrothorax is often misinterpreted as tension pneumothorax and managed as such leading to increased morbidity and mortality. We present a child with tension gastrothorax and a literature review of this phenomenon.Immediate clinical and radiographic evaluation should lead to accurate diagnosis followed by emergency decompression of the stomach before laparotomy with reduction of herniated viscera and repair of the diaphragmatic defect.

Vanishing Lung Syndrome of Uncommon Size

A 48-year-old female nonsmoker was admitted to our hospital with a 10-year history of chronic chest tightness and dyspnea. Physical examination revealed decreased breath sounds and hyperresonance to percussion in left lung. chest x-ray showed a hyperlucent left hemithorax with a severe rightward medias-tinal shift, which was suggestive of tension pneumothorax. But high-resolution computed tomography of the chest revealed that several giant bullae occupying almost the entire left hemithorax with severe mediastinal displacement to the right (Figure 1), which was consistent with vanishing lung syndrome. This patient successfully underwent video-assisted thoracoscopic resection of the left giant bullae and is currently without residual symptoms.

Airway management of a huge thyroid swelling with retrosternal extension by awake intubation using loco-sedative technique

To the Editor, The anesthesiologist approaching the patient with a difficult airway has got many techniques and instruments that can be applied for securing and maintaining oxygenation and ventilation.[1234] We report here the airway management of a patient with massive thyroid swelling accompanied by tracheal narrowing, deviation and retrosternal extension. The patient was posted for total thyroidectomy. A 43-year-old female patient presented with a history of the diffuse neck swelling since 5 years with recent onset of dyspnea. There was no suggestive history of hyper or hypothyroidism. On examination, her vital parameters were normal, and she was neither in distress nor sweating. Neck examination showed a huge swelling of around 8 cm × 4 cm on the right side and 6 cm × 4 cm on the left side. It was moving with swallowing, firm in consistency but not tender. Getting below the swelling was not possible. Cardiovascular system examination revealed no added sounds or murmurs. Chest examination showed bilateral good air entry. Laboratory investigation including thyroid function tests were within normal ranges. Radiological examination including Chest X-ray and magnetic resonance imaging (MRI) revealed diffusely enlarged thyroid gland with left lobe measuring 11.2 × 7.5 × 5.5 cms in size with retrosternal extension and right lobe measuring 8.5 × 6.2 × 4.5 cms in size with inferior margin of right lobe just above sternum associated with superior mediastinal widening, significant compression and displacement of trachea to right side. Carotid artery and jugular vein were displaced laterally on both sides of neck. There was no tracheal erosion or infiltration [Figure 1]. On IDL, larynx was not seen and with 70 degree scope, larynx was pushed to right with normal and mobile bilateral vocal cords. Fine-needle aspiration cytology showed possibility of benign follicular lesion. Airway assessment revealed adequate mouth opening with Mallampati Grade II, but limited neck movement. The plan was to perform awake endotracheal intubation through direct laryngoscopy.Figure 1: Magnetic resonance imaging plate showing huge swelling with retrosternal extensionPremedication was achieved with injection glycopyrrolate 0.2 mg intramuscular and injection midazolam 1 mg intravenous (iv) followed by nebulization with lignocaine (2%) solution and lignocaine (2%) viscus gargles. In the operation theater, the difficult airway cart was arranged and noninvasive blood pressure cuff, SpO2 and electrocardiogram were attached to the patient. Injection dexmedetomidine bolus was started at 1 mcg/kg over 10 min, followed by infusion at 0.6 mcg/kg/h along with which preoxygenation was done with 100% oxygen. When the sedation score was Ramsay score 3, direct laryngoscopy was performed and lignocaine (5%) spray was puffed and after 5 min trachea was intubated successfully with 7.5 mm size armored tube with external manipulation of larynx. Intubation was confirmed by attaching EtCO2 monitor, which was followed by IV injection of propofol and injection vecuronium. Anesthesia was maintained with incremental doses of vecuronium and sevoflurane. Total thyroidectomy was uneventful. On completion of surgery, neuromuscular blockade was reversed and trachea was extubated after performing leak test to rule out any possibility of tracheomalacia. The problems anticipated during induction were difficult mask ventilation after induction of general anesthesia and muscle relaxation secondary to partial or complete airway collapse by huge thyroid swelling, which can cause severe hypoxia and warrants urgent tracheal intubation which may be difficult and time consuming due to distorted anatomy.[234] In this situation, it was prudent to secure the airway before induction of anesthesia. Awake fiberoptic intubation is ideal gold standard technique in such situation where intubation is done under direct visualization of the glottis.[1] Fiberoptic bronchoscope was not available in our institute so awake oral intubation with direct laryngoscopy was planned. Dexmedetomidine is selective ά2 agonist with pharmacological actions like analgesia, anxiolysis, sedation, reduction in the secretion, sympatholytic action, minimal respiratory depression, decreased stress response to intubation and attenuation of airway reflexes making it promising agent in this situation.[5] Hence dexmedetomidine in bolus and infusion was used during induction to enhance patient comfort and cooperation, which is essential for the success of awake intubation using direct laryngoscopy. In conclusion, awake intubation using topical anesthesia and sedation with dexmedetomidine infusion is a viable option in case of huge thyroid swelling. Acknowledgments A deep regards and my profound gratitude to Department of Otorhinolaryngology, New Civil Hospital, Surat for providing all help with patient's details and MRI picture of the patient.

Endoscopic treatment of native lung hyperinflation using endobronchial valves in single‐lung transplant patients: a multinational experience

Hyperinflation of the native lung (NLH) is a known complication to single-lung transplantation for emphysema. The hyperinflation can lead to compression of the graft and cause respiratory failure. Endobronchial valves have been used to block airflow in specific parts of the native lung, reducing the native lung volume and relieving the graft. We report short-term follow-up and safety from 14 single-lung transplant patients with NLH treated with bronchoscopic lung volume reduction using endobronchial valves. Retrospective clinical information related to endobronchial valve treatment was obtained from four centres. All patients were treated with IBV(TM) Valve System (Spiration, Olympus Respiratory America, Redmond, WA, USA). All patients had evidence of severe NLH with mediastinal displacement. A total of 74 IBV valves were placed in 14 patients, with an average of 5.3 (range 2-10). Five patients had two procedures with staged treatment. Eleven patients reported symptom relief, and nine had lung function improvements. There was a significant increase in forced expiratory volume in 1 s of 9% (P = 0.013) and forced vital capacity of 15% (P = 0.034) within the first months after treatment. There were no reported device-related adverse events nor reports of migration. Two patients had pneumothorax. One patient had pneumonia in the location of the valve placement, and another had infection within days. Three other patients were hospitalised with infection 2 months after treatment. Treating NLH with IBV endobronchial valves leads to clinical improvement in the majority of patients, and the treatment has an acceptable safety.

Differential Lead Component Pulling as a Possible Mechanism of Inside‐Out Abrasion and Conductor Cable Externalization

Conductor cable externalization with protrusion (CCE*) is highly prevalent among the Riata 8F and ST 7F defibrillation (DF) leads and infrequently present in the QuickSite and the QuickFlex coronary sinus (CS) leads (St. Jude Medical, Sylmar, CA, USA). A model for CCE* based on differential lead component pulling and conjugate extension with reciprocal compression-bending was developed. Extension of a proximal lead body segment by pectoral or cardiac movements causes reciprocal compression-bending of a distal lead body segment mediated by inextensible conductor cables running down a lead body fixed at various points by fibrous adhesions. The "sawing" action of these cables under tension causes inside-out abrasion of insulation leading to CCE*. DF leads from different manufacturers and the QuickFlex and QuickFlex μ CS leads were subjected to simulated differential pulling. Restitution from differential pulling followed three patterns: complete, partial without escalation, and incomplete with escalation. Only the last pattern (only shown by the Riata 8F and ST 7F leads) was associated with an increased risk to CCE*. For CS leads, deformation concentrated on the more flexible segment when the lead body did not have a uniform construction. The Durata, Riata ST Optim, QuickFlex μ, and Quartet leads should be relatively immune to CCE*. The Durata leads are extremely resistant to longitudinal deformation and probably cause mediastinal displacement rather than differential pulling in response to pectoral movements in vivo. Implantation techniques and lead designs can be used to minimize the risk of CCE*. A bench test for CCE* can be constructed.

An unusual cause of haemoptysis in a smoker

A 33-year-old Caucasian male smoker presented to our rapid access lung cancer clinic with a single episode of moderate haemoptysis and no other respiratory or systemic symptoms. There was no...