Pulmonary Drainage Research Articles

Treatment of non-restrictive cor triatriatum sinister during concomitant cardiac surgery

BackgroundCor triatriatum is a rare congenital heart disease representing the 0.4% of all congenital cardiac anomalies. To date, no specific genetic alteration has been associated to cor triatriatum. The left-sided presentation (cor triatriatum sinister (CTS)) generally consists in a fibromuscular membrane that divides the left atrium into two chambers, therefore generating a varying grade of flow obstruction depending on the shape, location, and membrane fenestration size. Cor triatriatum sinister can be isolated or associated to other congenital heart defects such as ostium secundum atrial septal defect, patent foramen ovale or abnormal pulmonary veins drainage.Case presentationOur case is a 63-year-old woman who was diagnosed with a non-restrictive membrane during a hospitalization for acute heart failure. In the following 6 months, she started to become symptomatic. However, the onset of symptoms was more likely related to mitral valve regurgitation worsening and previously unknown coronary artery disease, rather than to CTS. She underwent bi-atrial surgical ablation (Cox Maze IV procedure) for atrial fibrillation (AF), surgical resection of interatrial membrane with mitral annuloplasty, and myocardial revascularization.ConclusionThe onset and severity of symptoms in patients with CTS mostly depend on membrane fenestration size, grade of stenosis generated and pulmonary veins drainage site. However, some cases may remain asymptomatic until adulthood; the degree of pulmonary hypertension and congestive heart failure is determined by the presence of additional cardiac anomalies and the fibromuscular membrane fenestration. In some cases, CTS may remain asymptomatic, thus the diagnosis can be incidental.

Imaging characteristics and associations of left atrioventricular valve atresia and patent aortic root with isometric atrial appendages on multidetector CT.

The present study sought to study the imaging associations of left atrioventricular valve (mitral) atresia and patent aortic root in patients with isomerism of atrial appendages as detected on multidetector computed tomography (CT) angiography MATERIALS AND METHODS: The CT angiography studies performed at a tertiary medical center from January 2014 to December 2021 were retrospectively evaluated to identify patients with left atrioventricular valve atresia and patent aortic root with isometric atrial chambers. The morphology of the atrial appendage and extent of pectinate muscles was used to identify the type of isomeric atrial chambers. A comprehensive assessment of discordant arrangement of organs and the variations in venoatrial connections was done. Left atrioventricular valve atresia in the presence of patent aortic root and isomeric atrial appendages was identified in eight patients (four males). The mean age at diagnosis was 7 years. Right isomerism of the atrial appendages was seen in five patients while three patients had left isomerism. Disharmonious patterns of abdominal visceral arrangement were seen in two patients. Atrial and ventricular septal defects were seen in all patients. The most common pattern of ventricular arterial connection was DORV (double outlet right ventricle) (n = 4). While fivepatients had normally related great arteries, three had aorta anterior to the pulmonary trunk. Right ventricular outflow obstruction was seen in seven patients. Right aortic arch with mirror image branching was seen in four patients. Coronary artery anomalies were seen in four patients. The presence of left atrioventricular valve atresia and patent aortic root with isomeric atrial appendages is a rare congenital anomaly frequently associated with anomalous systemic and pulmonary drainage, conotruncal anomalies, and right ventricular outflow obstruction. Hence, comprehensive CT-based evaluation is indispensable in providing detailed anatomy and aids in presurgical planning.

P649 Before and after: sinus venosus atrial septal defect

Abstract Introduction The diagnosis of sinus venosus atrial septal defect (SVASD) is complex and requires special imaging. Surgery is the conventional treatment; however, transcatheter repair may become an attractive option. Case report A 60 year-old woman was admitted to the cardiology department with several episodes of paroxysmal atrial flutter, atrial fibrillation and atrioventricular nodal reentrant tachycardia. She reported a 10-year history of occasional palpitations which had not been studied. A transthoracic echocardiography revealed severe right ventricle dilatation and moderate dysfunction. Right volume overload appeared to be secondary to a superior SVASD with partial anomalous pulmonary venous drainage. A transesophageal echocardiography confirmed the diagnosis revealing a large SVASD of 16x12 mm (Figure A) with left-right shunt (Qp/Qs 2,2) and two right pulmonary veins draining into the right superior vena cava. Additionally, it demonstrated coronary sinus dilatation secondary to persistent left superior vena cava. CMR and cardiac CT showed right superior and middle pulmonary veins draining into the right superior vena cava 18 mm above the septal defect (Figures B and C). After discussion in clinical session, a percutaneous approach was planned to correct the septal defect and anomalous pulmonary drainage. For this purpose, anatomical data obtained from CMR and CT was needed to plan the procedure. During the intervention two stents graft were deployed in the right superior vena cava. The distal stent was flared at the septal defect level so as to occlude it while redirecting the anomalous pulmonary venous flow to the left atrium (Figure D). Control CT confirmed the complete occlusion of the SVASD without residual communication from pulmonary veins to the right superior vena cava or the right atrium (Figure E). Anomalous right superior and middle pulmonary veins drained into the left atrium below the stents. Transthoracic echocardiographies showed progressive reduction of right atrium and ventricle dilatation. The patient also underwent successful ablation of atrial flutter and intranodal tachycardia. She is currently asymptomatic, without dyspnea or arrhythmic recurrences. Conclusions In this case, multimodality imaging played a key role in every stage of the clinical process. First, it provided the diagnosis and enabled an accurate understanding of the patient’s anatomy, particularly of the anomalous pulmonary venous connections. Secondly, it allowed a transcatheter approach by supplying essential information to guide the procedure. Finally, it assessed the effectiveness of the intervention and the improvement in cardiac hemodynamics during follow-up. Abstract P649 Figure.

P879 3D transoesophageal echocardiography to asses a case of a non-ebstein tricuspid valve congenital regurgitation

Abstract Introduction Due to the complexity of congenital heart disease and limitations of transthorathic echocardiogram (TTE), especially in adult patients, it is not unusual to need other image techniques to assess cardiac anatomy and function. The most common primary anomaly of tricuspid valve (TV) is Ebstein anomaly, but there are other much rarer primary anomalies of this valve consisting in prolapse, cord retraction.... without downward displacement of the leaflet, generally causing tricuspid regurgitation (TR) that can be severe and sometimes intervention is needed, preferably reparation. Due to anatomical issues, it is difficult to assess anatomy of TV in TTE, so sometimes 3D-TTE must be performed to clarify the mechanism and to measure orifice, but when transthoracic view is not enough, 3D transoesophageal echocardiogram (TOE) can be useful for this purpose. Case We report the case of a 15-year-old boy that was referred to our clinic because of shortness of breath and a systolic tricuspid murmur. TTE was performed and an image compatible with tricuspid valve prolapse with no apical displacement of any leaflets (Figure, A) causing severe TR (Figure, B) was noticed, as well as severely dilated right chambers, with good ejection fraction of both ventricles. It was not clear the mechanism so 2D TOE was done, showing a prolapse of a leaflet (Figure, C) causing severe TR (Figure, D). The mechanism was finally clarified by 3D TOE (figure E). This was a prolapse of lateral portion of posterior leaflet (asterisk) with restrictive movement of anterior (triangle) and septal (arrow) ones, causing a huge coaptation defect in systole leading to a very severe tricuspid insufficiency with signs of volume overload of right ventricle. There was no atrial septal defect and pulmonary drainage anomalies were ruled out by cardiac magnetic resonance. Patient was referred to surgery due to symptoms and great dilatation of right chambers. Conclusión: Due to anatomical complexity and limitations of echography, cross and multimodality cardiac imaging is usually needed in assessing congenital heart disease. Apart from Ebstein anomaly, other congenital entities of tricuspid valve such as prolapse and/or retraction can lead to severe tricuspid regurgitation. Due to limitations of 2D TTE in assessing tricuspid valve anatomy, 3D TTE has to be performed, but if it is not enough, 3D TOE can be an option to evaluate mechanism and directly see the orifice of regurgitation in congenital disease of tricuspid valve. Abstract P879 Figure

Thirty years and 1663 consecutive Norwood procedures: Has survival plateaued?

ObjectiveHypoplastic left heart syndrome is one of the most common and challenging lesions requiring surgical intervention in the neonatal period. The Norwood procedure for hypoplastic left heart syndrome was first reported in 1983. The objective of this study was to describe early outcomes after the Norwood procedure at a single institution over 30 years. MethodsThis retrospective cohort study included all patients with hypoplastic left heart syndrome (and variants) who underwent the Norwood procedure between January 1984 and May 2014 at a single institution. The study period was divided into 6 eras: era 1, 1984 to 1988; era 2, 1989 to 1993; era 3, 1994 to 1998; era 4, 1999 to 2003; era 5, 2004 to 2008; and era 6, 2009 to 2014. The primary outcome was in-hospital mortality after the Norwood procedure. Binomial point estimates complete with 95% confidence intervals (CL0.95) were computed for the entire cohort and by era. ResultsDuring the study period, 1663 infants underwent the Norwood procedure. Overall in-hospital mortality was 25.9% (CL0.95, 23.8-28.0). Mortality by chronologic era was 40.4% (CL0.95, 34.9-45.9), 33.6% (CL0.95, 29.2-37.9), 28.7% (CL0.95, 22.8-34.6), 14.9% (CL0.95, 10.4-19.3), 11.2% (CL0.95, 7.4-15.0), and 15.7% (CL0.95, 10.3-21.1). Survival was improved in eras 4 to 6 compared with eras 1 to 3 (P all < .03). Anomalous pulmonary drainage, moderate to severe atrioventricular valve regurgitation, lower birth weight, earlier era, younger gestational age, genetic anomaly, preterm birth, race other than white or African-American, and lower weight at the Norwood procedure were associated with increased mortality. Mortality was greatest in patients with 3 or more risk factors. In the best-fitting multiple covariate model, anomalous pulmonary venous drainage, gestational age in weeks, genetic anomaly, and race other than white and African American were statistically significant contributors, after adjusting for era. ConclusionsSurvival after the Norwood procedure has plateaued despite improvements in diagnosis, perioperative care, and surgical techniques. Nonmodifiable patient characteristics are important determinants of the risk of mortality.

Радикальная коррекция частичного аномального дренажа левых легочных вен в коронарный синус с интактной межпредсердной перегородкой

Радикальная коррекция частичного аномального дренажа левых легочных вен в коронарный синус с интактной межпредсердной перегородкой

Pneumothorax following shoulder arthroscopy under combined regional and general anaesthesia—A case report

IntroductionPneumothorax is a most rare intraoperative event but jeopardise safety. Risk factors for its occurrence should be acknowledged and it should be considered in cases of unexpected deterioration of oxygenation that not respond to standard management to improve oxygenation. Presentation of caseWe describe a patient with mild obesity and recent shoulder trauma scheduled for elective arthroscopy under combined interscalene block and general anaesthesia in the beach chair position. The block was performed with ultrasound guidance in accordance with the departmental routines and before the induction of general anaesthesia. The patient experienced low saturation shortly after administration of general anaesthesia. A thoracic ultrasound was performed in order to rule out pneumothorax and recruitment manoeuvres was done based on the suspicion of atelectasis. Surgery was commenced under pressure controlled ventilation and saturation was kept around 90 at FiO2 1.0 after recruitment manoeuvres. An initial postoperative lung X-ray on the operating table showed subcutaneous emphysema but no pneumothorax. A postoperative CT-thorax, patient still intubated, showed an extensive pneumothorax that was treated with pulmonary drainage. Patient had subsequently an uncomplicated postoperative course. DiscussionWe can not state “whom to blame”, the interscalene block, intubation and pressures assisted ventilation, recruitment manoeuvres, or surgery? In this paper we discuss possible causes that should raise the suspicion around pneumothorax in patients exhibiting unexpected low saturation perioperatively. ConclusionCompromised oxygenation during surgery that not respond to recruitment should raise suspicion about pneumothorax.

DYNAMICS OF THE MEAN PRESSURE IN THE PULMONARY ARTERY OF NEWBORNS IN NEONATAL PERIOD

Determination of mean pressure in the pulmonary artery trunk and its dynamics at the stage of neonatal hemodynamic adaptation is an urgent but insufficiently studied question. Objective. The objective of the research was the study of mean pressure dynamics in the pulmonary artery trunk in mature newborns in the early neonatal period according to Doppler echocardiography findings.Materials and methods. The research included examination of 203 “conditionally” healthy newborns (54.2% of boys and 45.8% of girls) with gestational age of 38-41 weeks. Doppler echocardiography was performed from two hours after birth and till 7 days of life. The mean pressure in the pulmonary artery trunk was determined according to A. Kitabatake et al. (1983) under physiologic sleep conditions.Results of the study. Newborns were divided into two groups such as: 1) babies born to mothers with physiological course of pregnancy and delivery; 2) babies born to mothers with extragenital pathology.General health condition of newborns from the first group was satisfactory. Apgar score was 8 and 9 points at the first and the fifth minutes of life, respectively. Adaptation period was favorable without pathologic somatic and neurologic symptoms. Postpartum adaptation of the cardiovascular system was satisfactory. Newborns were given the breast during the first two hours after birth and in the following days they were breastfed; they were discharged on the 3-5th day of their lives in satisfactory condition. General health condition of newborns from the second group was considered to be satisfactory. Apgar score was 7.7±0.2 and 8.7±0.2 points at the first and the fifth minutes of life, respectively. The early neonatal period was unremarkable, no cardiovascular pathologic symptoms were determined. All babies were given to the breast during 2-6 hours after birth and in the following days they were breastfed. Newborns were discharged in satisfactory condition on the 3-7th day of their lives due to mother’s condition.The conducted research demonstrated that 58.9% (p≤0.05) of babies from the second group were from the second and consequent pregnancies, and 4.7% – from multiple pregnancy. Pregnancy course analysis showed that 52.3% (p≤0.05) of mothers had complicated course. Anemia was reported in 13.1% of expectant mothers. 45.8% (p≤0.05) of babies were born by means of caesarean section. Exacerbation of chronic pyelonephritis during pregnancy was found in 11.2% of women, varicose veins of lower extremities and obesity – in 9.3% of expectant mothers. 58.9% (p≤0.05) of women had compromised heredity, among them 29.9% – from the side of the cardiovascular system in the form of heart rhythm and conduction disorders (AV-block of the II stage, WPW-syndrome, extrasystole), congenital heart disease (secondary defect of inter-atrial septum, anomalous pulmonary veins drainage, pulmonary artery stenosis), vegetative-vascular dysfunction, hypertensive disease, secondary cardiomyopathy, Ehlers-Danlos syndrome.Doppler echocardiography findings showed that during first 12 hours after birth 17.5% patients were registered to have high pressure in the pulmonary artery trunk up to 43.7±12.8mmHg (p≤0.05) and bidirectional shunting through open arterial duct and open oval window. By the end of the first day of life the mean pressure in the pulmonary artery trunk was 27.1±6.6mmHg; left-right shunting through open arterial duct and open oval window was consistently determined. From the second day of life there was stabilization of the mean pressure in the pulmonary artery, the average value of which was 22.8±4.1mmHg, from the third day – 22.2±2.4mmHg, from the fourth day – 23.2±3.1mmHg, and from the fifth-seventh day – 23.4±3.4mHg. The received data corresponded to physiologic time of open arterial duct closing. Indices of the mean pressure dynamics in the pulmonary artery trunk in both groups and also concerning days of life inside of groups did not have significant differences and characterized only general tendencies of intra-cardiac hemodynamics changes in newborns at the stages of hemodynamic adaptation. During individual analysis of mean pressure dynamics in the pulmonary artery trunk in 5.4% of babies (among them 54.5% (p≤0.05) of newborns born to women with extragenital pathology) on the fifth-seventh day of life a moderate increase of pressure in the pulmonary artery trunk was retained (25.5±2.0mmHg) which was connected with later period of fetal communications closing. While performing correlation analysis between level of mean pressure in the pulmonary artery trunk and floor, diameter of open oval window and width of open arterial duct no correlations were detected. Conclusions. Thus, healthy mature newborns in the first day of life are characterized by alteration of hemodynamics in the pulmonary circulation with the tendency to normalization of mean pressure in pulmonary artery trunk. In 5.4% of babies by the end of the early neonatal period increased pressure in the pulmonary artery trunk is retained which is connected with late period of fetal communications closing.

Scimitar Syndrome: The Role of Cardiac Magnetic Resonance

A 35-year-old woman with no relevant medical history presented with dyspnea on moderate exertion. Physical examination detected a mild mid-systolic murmur, and the electrocardiogram showed negative T waves in the right precordial leads. On chest radiography, the right lung was mildly hypoplastic and showed a linear opacity (Figure 1A, arrow), corresponding to a vascular structure (scimitar sign). Transthoracic echocardiography showed dilation of the right chambers with no pulmonary hypertension, and venous flow entering the inferior vena cava (Figures 1B–D). The transesophageal echocardiogram additionally revealed an ostium secundum atrial septal defect with a left-to-right shunt (Figure 1E). Magnetic resonance imaging confirmed the diagnosis of a large supradiaphragmatic right pulmonary vein draining into the left inferior vena cava adjacent to the right atrium (Figures 1F and 2A, arrow). Based on the patient’s symptoms and the significant systemic-pulmonary shunt (Qp/Qs, 1.9:1.0), a decision was made to perform corrective surgery of the partial anomalous pulmonary venous drainage. The atrial septal defect was widened and a polytetrafluoroethylene tube was placed within the right atrium, redirecting flow from the inferior vena cava to the left atrium through the defect. The patient was discharged 7 days postprocedure, with no complications. At 3 weeks, cardiac magnetic resonance showed that the tube was patent (Figure 2B, asterisk) and the size of the right ventricle had returned to normal. At 6 months, the patient was asymptomatic. In this case, cardiac magnetic resonance imaging enabled confirmation of the diagnosis of partial anomalous pulmonary drainage, selection of the best surgical technique, and precise patient follow-up. Figure 1. Figure 2.

Total pulmonary artery atresia associated with abnormal pulmonary venous drainage as a rare presentation of scimitar syndrome.

Scimitar syndrome or pulmonary venolobar syndrome is a rare, complex, and variable malformation of the right lung characterized by an abnormal right sided pulmonary drainage into the inferior vena cava, malformation of the right lung, abnormal arterial supply, and sometimes cardiac malformation. Despite the varying degrees of pulmonary hypoplasia and pulmonary artery hypertension, about half of the patients with scimitar syndrome are asymptomatic or mildly symptomatic when the diagnosis is made. Neonates have severe symptoms and worse prognosis while older children come to light because of recurrent respiratory infections, heart murmur, or an abnormal chest radiograph.

Validação técnica da drenagem pulmonar como tratamento do enfisema pulmonar avançado: estudo anatômico em cadáveres

OBJECTIVE: A cadaver-based study was carried out in order to describe the pulmonary drainage surgical technique, to determine whether the site for the insertion of the chest tube is appropriate and safe, and to determine the anatomical relationship of the chest tube with the chest wall, lungs, large blood vessels, and mediastinum. METHODS: Between May and November of 2011, 30 cadavers of both genders were dissected. The cadavers were provided by the Santa Casa de São Paulo Central Hospital Mortuary, located in the city of São Paulo, Brazil. A 7.5-cm, 24 F steel chest tube was inserted into the second intercostal space along the midclavicular line bilaterally, and we measured the distances from the tube to the main bronchi, upper lobe bronchi, subclavian vessels, pulmonary arteries, pulmonary arteries in the upper lobe, superior pulmonary vein, azygos vein, and aorta. Weight, height, and chest wall thickness, as well as laterolateral and posteroanterior diameters of the chest, were measured for each cadaver. RESULTS: Of the 30 cadavers dissected, 20 and 10 were male and female, respectively. The mean distance between the distal end of the tube and the main bronchi (right and left) was 7.2 cm (for both). CONCLUSIONS: The placement of a fixed-size chest tube in the specified position is feasible and safe, regardless of the anthropometric characteristics of the patients.

Abstract No. 63: Implementation of a low dose protocol for extra-pulmonary CT guided drainage and biopsy procedures

There is increased awareness/scrutiny regarding radiation exposure to both patients and physicians during interventional radiology (IR) procedures. The aim of this study was to evaluate the impact of a low-dose CT guidance protocol on dose metrics for extra-pulmonary abscess drainage and biopsy procedures. We hypothesize that such a protocol will decrease radiation exposure to the patient while still providing satisfactory imaging guidance. A low dose CT guidance protocol was implemented in August 2010, involving a set 120 kVp spiral acquisition with a pitch of 0.8 and 80 mAs for planning, followed by sequential 100 kVp and 80 mAs acquisitions for needle guidance. Operators determined the scanned volume and could modify the protocol. All procedures were performed on a single 16-slice CT scanner (Somatom, Siemens Medical Solutions). IRB approval was obtained. A sample of consecutive CT-guided extra-thoracic biopsy/drainage procedures before and after the implementation of the low dose protocol were identified through case log review. Dosimetry data was obtained through PACS, including the number of spiral and sequential acquisitions, the associated kVp and mAs, the total mAs, and the total dose length product (DLP). A single investigator assessed image quality. Differences in means of continuous variables were assessed with a two-tailed student's t-test. The study population consisted of 109 procedures in 106 patients. The low dose protocol reduced the average DLP for extra pulmonary procedures from 724.7 mGy*cm (range 170 - 3335) to 392.9 mGy*cm (range 150 - 1355) (p < 0.0001). There was no significant difference in the number of CT acquisitions between groups (12.8 vs 13.6 respectively) (p=0.53). Sequential scanning for needle guidance was utilized in 1.8% (1 of 55) and 89% (48 of 54) procedures respectively. Image quality was adequate for guidance in all procedures. A low dose protocol for CT guidance in extra pulmonary drainage and biopsy procedures resulted in a dose reduction of 46%, with 89% voluntary adherence to the protocol. Interventional radiologists should update CT guidance protocols to reduce patent dose to improve patient safety.

Expression of Id2 in the second heart field and cardiac defects in Id2 knock‐out mice

The inhibitor of differentiation Id2 is expressed in mesoderm of the second heart field, which contributes myocardial and mesenchymal cells to the primary heart tube. The role of Id2 in cardiac development is insufficiently known. Heart development was studied in sequential developmental stages in Id2 wildtype and knockout mouse embryos. Expression patterns of Id2, MLC-2a, Nkx2.5, HCN4, and WT-1 were analyzed. Id2 is expressed in myocardial progenitor cells at the inflow and outflow tract, in the endocardial and epicardial lineage, and in neural crest cells. Id2 knockout embryos show severe cardiac defects including abnormal orientation of systemic and pulmonary drainage, abnormal myocardialization of systemic and pulmonary veins, hypoplasia of the sinoatrial node, large interatrial communications, ventricular septal defects, double outlet right ventricle, and myocardial hypoplasia. Our results indicate a role for Id2 in the second heart field contribution at both the arterial and the venous poles of the heart.

Lumbar disc herniation in three patients with cystic fibrosis: a case series

IntroductionTo date, lumbar disc herniation has not been reported in the context of cystic fibrosis even though back pain and musculoskeletal problems are very common in patients with cystic fibrosis.Case presentationWe report on three patients with cystic fibrosis who experienced lumbar disc herniation in the course of their disease at ages 19 to 21 years (a 22-year-old Caucasian man, a 23-year-old Caucasian man, and a 21-year-old Caucasian woman). Our third patient eventually died because of her deteriorated pulmonary situation, which was influenced by the lumbar disc herniation as it was not possible for her to perform pulmonary drainage techniques properly because of the pain.ConclusionsLumbar disc herniation can lead to a vicious cycle for patients with cystic fibrosis as it may promote pulmonary infections. This report highlights the need to investigate patients correctly.

A complex coronary artery fistula with aberrant mediastinic and abdominal feeding arteries and pulmonary artery drainage

Coronary artery fistulas are rare congenital malformations that can originate from anywhere in the coronary artery system and terminate in any of the cardiac chambers, great veins or pulmonary arteries. We illustrate the unique case of a multidetector computed tomography coronary angiography scan of a young man, showing a complex coronary fistula between the left anterior descending coronary artery and a branch of the left pulmonary artery (with drainage function) with adjunctive mediastinic and abdominal aberrant feeding arteries arising, respectively, from the left internal mammary artery and the celiac trunk.

Postural drainage of respiratory tract fluid in phosgene-induced pulmonary oedema.

Abstract Cats and dogs were given phosgene by inhalation at a dose in the range of the LD50. During the hour or two before death, the volume output of respiratory tract fluid increased some 30-fold in half the animals and its lipid and sodium chloride contents were similar to those of blood plasma. Postural pulmonary drainage did not augment the volume output of respiratory tract fluid nor consistently affect chemical or histological measurements upon the lungs and chemical measurements upon respiratory tract fluid and blood. Postural pulmonary drainage did not increase the survival rate of intact rats exposed to phosgene. The ability of the animals to excrete such large volumes of respiratory tract fluid appeared to be due to a marked reserve capacity of the ciliary drainage mechanism which was evidently not affected by the dose of phosgene given to these animals.

Aplicação terapêutica da ventilação colateral com drenagem pulmonar no tratamento do enfisema pulmonar difuso: relato dos três primeiros casos

To report the results obtained in three patients with diffuse pulmonary emphysema during the pre- and post-operative periods following a new surgical technique: collateral ventilation with lung parenchyma drainage. Patients suffering from pulmonary failure and disabling dyspnea, despite having received the gold standard treatment, including pulmonary rehabilitation, were selected for the evaluation of pulmonary drainage. During the pre- and post-operative periods, patients were submitted to plethysmography and six-minute walk tests, as well as completing the following quality of life questionnaires: Medical Outcomes Study 36-item Short-Form Health Survey, Saint George's Respiratory Questionnaire, Eastern Cooperative Oncology Group Performance Status and Medical Research Council Scale. In all three cases, the postoperative follow-up period was at least 300 days. The tests were performed at the following time points: during the pre-operative period; between post-operative days 30 and 40; and on post-operative day 300. Data were analyzed using profile plots of the means. When the results obtained in the pre-operative period were compared to those obtained at the two post-operative time points evaluated, improvements were observed in all parameters studied. The results suggest that the surgical technique proposed for the treatment of patients suffering from severe diffuse emphysema successfully reduces the debilitating symptoms of these patients, improving their quality of life considerably.

Abstract 4655: Retrograde Ethanol Infusion in the Vein of Marshall for Ablation of Atrial Fibrillation: Tissue Ablation, Effects on Regional Vagal Innervation and First Human Experience

The vein of Marshall (VOM) is an attractive target during ablation of atrial fibrillation due to its autonomic innervation and its location anterior to the left pulmonary veins and drainage in the coronary sinus. We studied 14 dogs. A coronary sinus venogram showed a VOM in 10, which was successfully cannulated with an angioplasty wire and a 2 mm balloon. In 5 dogs, electroanatomical (Carto) maps of the left atrium were performed at baseline and after ethanol (100%, 4 – 8 cc) was infused in the VOM, which demonstrated the creation of a new crescent-shaped scar in the left atrium, extending from the annular left atrium towards the posterior wall and left pulmonary veins. In 4 dogs, both cervical vagal trunks were isolated in the carotid sheath and cuff stimulation electrodes were attached to them. Effective refractory periods (ERP) were measured in 3 sites of the left atrium, before and after high-frequency bilateral vagal stimulation. The baseline ERP was 113.6±35.0 ms, and decreased to 82.2±25.4 ms (p&lt;0.05) after vagal stimulation. After alcohol infusion in VOM, vagally-mediated ERP decrease was eliminated (from 108±27.2 ms to 95.6 ±16.7ms, p=NS). This elimination of vagal effects was not uniform and was limited in sites in proximity with the VOM (baseline ERP 105±18.7ms vs post vagal 98.±37.6ms, p=NS, as opposed to 106.7±27.1ms vs post vagal 73.3±19.7ms, p&lt;0.05, in sites remote to VOM). We also tested feasibility of VOM alcohol infusion in humans: 2 patients undergoing pulmonary vein antral isolation had successful VOM cannulation: left atrial voltage maps demonstrated new scar involving the infero-posterior left atrial wall extending towards the left pulmonary veins. Retrograde alcohol infusion in the VOM achieves significant left atrial tissue ablation, abolishes local vagal responses and is feasible in humans.

Anatomical study of partial anomalous pulmonary venous return with special references to the bronchial vein: Supplementary report

After the authors' previous report an additional case of partial anomalous pulmonary venous return was encountered during dissection practice for medical students. In an 87-year-old Japanese male cadaver, the anomalous vein from the right upper lobe drained into the superior vena cava at a point just below the entrance of the azygos vein. This case is similar to the first case in the authors' previous report, but the anomalous vein was recognized before dissection of the lung began. Therefore, findings were more precisely observed. The anomalous pulmonary vein was 16 mm in diameter and had three branches, which drained the regions of the apex, the anterior segment and a part of the posterior segment of the right upper lobe. The other veins from the right lung gathered into two pulmonary veins, measuring 21 mm and 18 mm in diameter, respectively, and returned to the left atrium as usual. It is noteworthy that the anomalous vein received the bronchial vein from the right upper lobe bronchus. The azygos vein also received the bronchial veins from the lower part of the trachea and from the right middle and lower lobe bronchi. The theory that the bronchial vein plays an important role in the occurrence of the anomalous pulmonary drainage is further supported by this finding.

Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia