Subxiphoid Incision Research Articles

Air under pressure: a case report on tension pneumomediastinum arising from traumatic injury

Abstract Background Tension pneumomediastinum (TPM) is a rare but critical condition characterized by the accumulation of air in the mediastinum, leading to increased intrathoracic pressure and cardiovascular compromise. This case report is novel due to the rarity of TPM arising from blunt chest trauma and the necessity for emergent surgical intervention after initial conservative management failed. Case presentation A 63-year-old male presented with severe chest pain and dyspnea following a high-impact motor vehicle collision. Initial assessment revealed tachypnea, tachycardia, and hypotension, along with extensive subcutaneous emphysema over the chest and neck. Imaging confirmed pneumomediastinum and bilateral pneumothoraxes, consistent with TPM. Despite initial management with high-flow oxygen and bilateral chest tube insertion, the patient’s condition deteriorated, necessitating emergent mediastinal decompression via an anterior subxiphoid incision. This intervention resulted in immediate hemodynamic improvement. Conclusions This case underscores the importance of recognizing TPM in patients with chest trauma and highlights the need for prompt surgical intervention in cases of hemodynamic instability. Early and accurate diagnosis and timely surgical management are crucial for improving patient outcomes in TPM.

Association between speckle tracking echocardiography and pressure-volume loop derived parameters at increasing levels of myocardial damage in a porcine model of acute cardiogenic shock

Abstract Background Echocardiography is a diagnostic cornerstone in acute cardiovascular care. However, the relationship between speckle tracking assessed global longitudinal strain (LS) and Doppler-based echocardiography with basic physiological markers of cardiac function derived from pressure-volume loops remains poorly elucidated, especially with increasing levels of myocardial damage. Objectives We aimed to describe the association between LS and Doppler-based echocardiography and direct measurements of central hemodynamic parameters from conductance catheter-based pressure-volume loops in an animal model with increasing left ventricular (LV) dysfunction. Methods Twelve Danish landrace pigs weighing 75-80 kg were used. All instrumentations were performed percutaneously, including placement of a conductance catheter in the LV. Progressive LV dysfunction was induced by stepwise embolization trough the left main coronary artery every three minutes until a 50% reduction in cardiac output or mixed venous saturation, compared to baseline, or a mixed venous saturation <30%. Echocardiography was performed through a subxiphoid midline incision, and was done at baseline and 90 seconds after each injection. Results With progressive LV dysfunction, mean cardiac output decreased from 5.6 l/min (SD: 0.9) to 2.1 l/min (SD: 0.9) and mean mixed venous saturation deteriorated from 61.1%(SD: 7.9) to 35.3% (SD: 6.1). Mean LS and LV outflow tract velocity time integral (LVOT VTI) declined from -13.8% (SD 3.0) to -6.1% (SD: 2.0) and 16.9 cm (SD: 2.6) to 7.8 cm (SD: 1.8), respectively (Figure 1). LS and LVOT VTI showed the strongest correlation to stroke work in unadjusted univariate regression (r2=0.53 and r2=0.49, respectively. p<0.01 for both). LS correlated significantly, but modest, with stroke volume (r2=0.46, p<0.01), end-systolic elastance (r2=0.32, p<0.01), systolic blood pressure (r2=0.37, p<0.01), ventriculo-arterial coupling(r2=0.34, p<0.01), and arterial elastance (r2=0.23, p<0.01) (Figure 2). In a multivariate regression analysis, LS showed significant correlation with stroke work, systolic blood pressure, and end-diastolic wall stress (r2=0.60, p<0.01). Conclusion In an animal model of acute progressive LV dysfunction, echocardiographic and conductance catheter-based measurements changed significantly. LS and LVOT VTI displayed the earliest and the largest alterations with increased myocardial damage and LS showed moderate correlations with contractility, arterial elastance and ventriculo-arterial coupling. This indicates that LS is a marker of overall ventricular performance.Echocardiographic changes from baselineScatter plot of LS and hemodynamics

Hybrid convergent ablation: an evaluation of left atrial electroanatomical voltage maps

Abstract Background Hybrid convergent ablation is an effective, emerging treatment for persistent atrial fibrillation (AF) (1). Minimally invasive surgical epicardial left atrial (LA) ablation is performed via a subxiphoid incision to ablate the posterior wall, within the limits of the pericardial reflections, before endocardial catheter ablation is performed primarily to complete pulmonary vein isolation. The overall aim is to create durable, transmural posterior wall ablation to target potential drivers that may sustain persistent AF. Purpose We evaluated electroanatomical maps obtained during endocardial ablation to determine the site and extent of LA posterior wall scar following epicardial ablation and whether this determines outcome in patients undergoing convergent ablation. Methods Patients who underwent Convergent ablation at a single UK cardiac centre (2012-2019) using CARTO-3 mapping system for endocardial ablation were included. Patients who had previous AF ablation were excluded. Low-voltage areas (LVAs) were manually measured using the CARTO-3 system and defined as areas <0.5mV on bipolar voltage maps (pulmonary veins were excluded). Scar location was classified by evaluating for presence and amount of LVA in each quadrant of the posterior LA wall. AF recurrence was evaluated at 12 months post-procedure. SPSS (v. 27) was used for statistical analysis. Results Of the 32 patients included, 7 patients experienced AF recurrence within 12 months post-procedure (21.9%). The average amount of posterior wall LVA following convergent ablation was 54.1% of posterior wall area and 5.8% of total left atrial area, neither of which were associated with 12-month AF recurrence (see Table 1). The presence and extent of LVAs in the upper quadrants were heterogeneous amongst patients and did not relate to AF recurrence. All patients displayed LVAs in the lower quadrants post-epicardial ablation, with the majority having LVAs occupying more than 50% of these quadrants. 96.8% had LVA on the inferior LA surface. In total, 75% of patients had a significant amount of LVA (defined as LVA occupying >50% of the quadrant area) in both lower posterior wall quadrants (see Figure 1) and this feature was associated with lower AF recurrence on multivariable Cox regression analysis (see Table 1). Conclusions Extensive scar was observed in the LA posterior wall in patients following epicardial convergent ablation. The presence of such scar, particularly in the lower regions of the posterior wall, may influence outcomes and be associated with reduced AF recurrence.Table 1Figure 1

Advances in robotic lung transplantation: development and validation of a new surgical technique in animal models.

The objective of this study was to describe a novel minimally invasive robotic video-assisted approach for lung transplantation, utilizing a minimally invasive technique with a subxiphoid incision, in an animal experimentation model. Two left robotic-assisted single lung transplants were performed in sheep using a robotic surgical system. A subxiphoid incision was made, and robotic ports were inserted into the thoracic cavity for dissection and anastomoses of the bronchus, artery, and pulmonary veins. The integrity of anastomoses was evaluated, and procedural details were recorded. Both animals survived the procedure, with a mean duration of 255 min and a mean console time of 201 min. Anastomoses were performed without complications, and the closed-chest approach with a subxiphoid incision proved successful in preventing gas leakage. The novel approach demonstrated improved exposure and workflow compared to existing techniques. The minimally invasive robotic video-assisted approach for lung transplantation utilizing a closed-chest technique with a subxiphoid incision appears safe and feasible in an animal experimentation model. Further studies in the clinical setting are warranted to establish its feasibility and safety in human lung transplantation. This approach has the potential to offer benefits over the traditional Clamshell incision in lung transplantation procedures.

A uniport subxiphoid approach with a modified sternum retractor is safe and feasible for anterior mediastinal tumors.

Minimally invasive surgery has been used to treat anterior mediastinal tumors. This study sought to describe a single team's experience of uniport subxiphoid mediastinal surgery using a modified sternum retractor. Patients who underwent uniport subxiphoid video-assisted thoracoscopic surgery (USVATS) or unilateral video-assisted thoracoscopic surgery (LVATS) from September 2018 to December 2021 were retrospectively enrolled in this study. A 5-cm vertical incision approximately 1-cm caudal to the xiphoid process was usually made followed by the installment of a modified retractor, which was able to raise the sternum by 6-8 cm. Next, the USVATS was performed. In the unilateral group, 3 1-cm incisions were usually made, among which, 2 are made in the 2nd or 3rd and 5th intercostal anterior axillary line, and the 3rd was made in the 5th intercostal midclavicular line. In some instances, an additional subxiphoid incision was made to remove the large tumors. All the clinical and perioperative data, including the prospectively recorded visual analogue scale (VAS) score, were analyzed. In total, 16 patients who underwent USVATS and 28 patients who underwent LVATS were enrolled in this study. With the exception of tumor size (USVATS 7.9±1.6 cm vs. LVATS 5.1±2.4 cm, P<0.001), the baseline data of the patients in the 2 groups were comparative. Blood loss in surgery, conversion, draining duration, postoperative stay, postoperative complications, pathology and tumor invasion were similar between the 2 groups. Although the operation time was significantly longer in the USVATS group than the LVATS group (115±19 vs. 83±30 min, P<0.001), the VAS score at 1st postoperative day (1.9±1.1 vs. 3.1±1.1, P<0.001) and moderate pain level (a VAS score >3) (6.3% vs. 32.1%, P=0.049) were better in the USVATS group than the LVATS group. Uniport subxiphoid mediastinal surgery is a feasible and safe procedure, especially for large tumors. Our modified sternum retractor is especially helpful during uniport subxiphoid surgery. Compared to lateral thoracic surgery, this approach has the advantages of less injury and lower postoperative pain, which may lead to a faster recovery. However, its long-term follow-up outcomes need to be observed.

Robot-assisted resection of multiple lung nodules through combination of intercostal incisions and a subxiphoid incision as a utility port.

Robotic-assisted thoracic surgery (RATS) via subxiphoid incision may be superior in resection of multiple lung nodules. Outcomes of robot-assisted one-stage bilateral lobectomy or segmentectomy via intercostal and subxiphoid incisions for multiple ground-glass opacities were analysed. Total 36 cases were analysed in this study. Thirteen cases had bilateral lobectomy+segmentectomy, 15 cases underwent bilateral segmentectomies, and 8 cases underwent lobectomy+segmentectomy+wedge resection. The average intraoperative blood loss was 110.2±57.8mL, operation time was 154±64.2min, thoracic draining time was 2.6±3.2days, and postoperative hospital stay was 4.8±3.3days. Three patients had atrial fibrillation and 3 patients had continuous air leakage for over 3days, but there was no death or postoperative pain. Robot-assisted one-stage bilateral resection of multiple lung nodules through combination of intercostal and subxiphoid incision as a utility port is safe and reliable.

Discussion

Discussion

Subxiphoid Mediastinoscopic Autonomous Double Fenestration.

The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that has a minor impact on the patient's general status and allows for fast fluid evacuation and biopsy sampling if necessary. We present a subxiphoid mediastinoscopic autonomous (simultaneous noncommunicating) double fenestration approach for these patients with both diagnostic and therapeutic advantages in selected cases. Using the mediastinoscope alone through the subxiphoid incision can considerably reduce the duration of operation, allow for fluid evacuation, and significantly alleviate the patient's symptoms. This method enables the sampling of pleural and pericardial fluids and targeted tissue, if necessary.

Surgical treatment of tension pneumomediastinum in patients with covid-19 at the field hospital: a case series

BackgroundTension pneumomediastinum is one of the most serious complications in COVID-19 patients with respiratory distress requiring invasive mechanical ventilation. This complication can lead to rapid hemodynamic instability and death if it is not recognized in a timely manner and intervenes promptly.Case presentationWe reported 7 COVID-19 patients with tension pneumomediastinum at a field hospital. All patients were critically ill with ARDS. These 7 patients, including 3 females and 4 males in this series, were aged between 39 and 70 years. Tension pneumomediastinum occurred on the first day of mechanical ventilation in 3 patients and later in the course of hospital stay, even 10 days after being intubated and ventilated. The tension pneumomediastinum caused hemodynamic instability and worsened respiratory mechanics with imminent cardiopulmonary collapse. In this series, we used two surgical techniques: (i) mediastinal decompression by suprasternal drainage with or without simultaneous pleural drainage in the first two cases and (ii) mediastinal drainage via suprasternal and subxiphoid incisions in 5 patients. The surgical procedures were feasible and reversed the pending cardiopulmonary collapse. Four patients had a favorable postprocedural period and were discharged from the intensive care center. Both patients undergoing suprasternal drainage died of failed/recurrent tension pneumomediastinum and nosocomial infection. Only one in five patients who underwent mediastinal drainage via suprasternal and subxiphoid incisions died of septic shock secondary to ventilator-associated pneumonia.ConclusionTension pneumomediastinum was a life-threatening complication in critically ill COVID-19 patients requiring mechanical ventilation. Surgical mediastinal decompression was the salvage procedure. The surgical technique of mediastinal drainage via suprasternal and subxiphoid incisions proved an advantage in tension relief, hemodynamic improvement and mortality reduction.

Successful resolution of ectopic Cushing syndrome by minimally invasive thoracoscopic resection of the neuroendocrine tumor of the thymus: a rare case report

BackgroundEctopic Cushing syndrome (ECS) is a sporadic condition. Even uncommon is an ECS that derives from a carcinoid tumor of the thymus. These tumors may pose several diagnostic and therapeutic conundrums. This report discusses the differential diagnosis, clinicopathological findings, and effective treatment of a rare case of ECS using a minimally invasive approach.Case presentationA 29-year-old woman with Cushing syndrome presented with facial flushing. Physical examination revealed hypertension (blood pressure: 141/100 mmHg). A mediastinal tumor was discovered to be the cause of the patient’s chronic hypokalemia and hypercortisolemia. Cortisol levels increased in the morning, reaching 47.7 ug/dL. The levels of the hormones ACTH, aldosterone, and renin were determined to be 281 pg/mL, 3.0 ng/dL, and 2.1 pg/mL, respectively. The presence of hypertension, hypokalemia, and alkalinity suggested Cushing’s syndrome, which was proven to be ACTH-dependent ECS by a dexamethasone suppression test. A chest CT scan revealed inflammation in the posterior basal region of the right lower lobe. The superior anterior mediastinum was characterized by round-shaped isodensity lesions with distinct borders. She underwent thoracoscopic anterior mediastinal tumor excision via the subxiphoid technique (R0 resection); following surgery, her blood pressure returned to normal, and the hypernatremia/hypopotassemia resolved. The tumor was determined to be a thymic carcinoid. Most notably, cortisol levels fell to half of their presurgical levels after one hour of surgery, and other abnormalities corrected substantially postoperatively.ConclusionThoracoscopic excision of thymic tumors by subxiphoid incision may be a useful treatment option for ECS caused by neuroendocrine tumors of the thymus

Simultaneous Comparison of Subxiphoid and Intercostal Wound Pain in the Same Patients Following Thoracoscopic Surgery.

There is a lack of data comparing postoperative pain after subxiphoid and intercostal video-assisted thoracoscopic surgery (VATS). Pain is an individual’s subjective experience and, therefore, difficult to compare between different individuals subjected to either procedure. This study assessed reported pain at six postoperative time points in the same patients receiving both subxiphoid and intercostal incisions for thoracic disease. Data from 44 patients who received simultaneous combined intercostal and subxiphoid VATS were retrospectively analyzed from August 2019 to July 2021. All patients received the same length of subxiphoid and intercostal incisions with or without drain placements. A numerical pain rating scale was administered on postoperative days (POD)-1, POD-2, POD-Discharge, POD-30, POD-90, and POD-180. Bilateral uniportal VATS was performed in 11 patients, and unilateral multiportal VATS was performed in 33 patients. In the unilateral VATS group, there were no differences in pain reported for both incisions in the early postoperative period. However, in the bilateral VATS group, subxiphoid wounds resulted in significantly higher pain scores on POD-1, POD-2, and POD-Discharge (p = 0.0003, 0.001, and 0.03, respectively). Higher late (3 and 6 months) postoperative pain was associated with intercostal incisions in both groups, as previously reported, whereas higher early (day 1, 2, and discharge) postoperative pain was more associated with subxiphoid incisions than intercostal incisions in the bilateral VATS group.

A Modfied Nuss Procedure for Recurrent Pectus Excavatum of Adults.

BackgroundLimited data exist for adults with recurrent pectus excavatum (PE) treated with minimally invasive surgical repair.MethodsBetween July 2008 and December 2020, forty-two adult patients with recurrent PE underwent a modified Nuss procedure with a newly designed bar in our center. A small vertical subxiphoid incision was used to separate severe adhesions when necessary. Multiple steel wires were sutured, and the rib space was narrowed to firmly fix the bar. The primary end point was Haller index change after operation. The secondary end points included length of stay after operation, short-term and long-term complications.ResultsThe mean patient age was 22.02 ± 3.49 years. The mean Haller index was 4.59 ± 1.09. A subxiphoid incision was performed in 12 patients. Thirty-nine patients had one bar placed, and 3 patients required two bars. Sixteen patients had 3 or more wires fixation, and 4 patients needed to have their intercostal space narrowed. There was no perioperative death, and the mean hospitalization was 5.57 ± 2.47 days. The Haller index reduced to 3.03 ± 0.41 after the operation (t = 11.85, p < 0.001). During the follow-up, there were 3 patients who developed non-infective wound effusion; bar rotations occurred in 3 patients. Twenty patients had the bar removed, post-bar removal Haller index was significantly reduced compared to the preoperative Haller index (2.89 ± 0.37 vs. 4.72 ± 1.05, t = 8.96, p < 0.001).ConclusionsThe modified Nuss procedure with a new titanium alloy bar can achieve good results for adult patients with recurrent PE.

Surgical treatment of descending necrotising mediastinitis caused by odontogenic infection: aretrospective analysis of 20 patients.

Analysing the results of patients with odontogenic descending necrotising mediastinitis (DNM) treated predominantly by transcervical approach. Odontogenic DNM is a rare but serious complication of dental disease and dental procedures. Retrospective evaluation of 20 patients who underwent surgery for odontogenic DNM. The mean age was 33.95±12.24 years, and 18 patients (90 %) were men. Type I and diffuse form of DNM were identified in 8 (40 %) and 12 (60 %) patients, respectively. The mean time between the onset of symptoms and surgery was 7.16±4.23 days. The transcervical approach was used in 16 patients, combined cervicotomy and subxiphoid incision in three patients, and cervicotomy and posterolateral thoracotomy was used in one patient. Four patients were reoperated. The mean mediastinal drainage duration and postoperative length of stay (LOS) were 17.05±10.27 days and 20.70±10.87 days, respectively. Fourteen (70 %) patients received mechanical ventilation with a mean duration of 8.86±9.55 days. Comorbidities were present in five (26 %) patients; there were complications in 17 (85 %) patients. In-hospital mortality reached 5 % (1 patient). Thirty-five teeth were extracted. Lower mandibular molars represented 21 (62 %) of extracted teeth. Submandibular and submental spaces were the most affected by the presence of deep neck infection (five and four cases, respectively). This study supports the role of transcervical mediastinal drainage as an alternative approach in the surgical treatment of odontogenic DNM (Tab. 4, Fig. 2, Ref. 30).

Non-intubated uniportal subxiphoid thoracoscopic extended thymectomy for thymoma associated with myasthenia gravis

BackgroundTo describe a technique of non-intubated uniportal subxiphoid thoracoscopic extended thymectomy.MethodsData were collected retrospectively. A single 3-cm transverse incision was made below the xiphoid process. This method for extended thymectomy entails adoption of uniportal subxiphoid VATS combined with using of non-intubated anesthesia for thymoma associated with myasthenia gravis.ResultsTen consecutive patients underwent this procedure successfully. Mean operative time was 102.5 min. Conversion to intubated ventilation or thoracotomy was not required.Mean chest tube duration was 3.5 days. Mean postoperative hospital stay was 4.7 days. Histologic examination showed early-stage thymomas. Side effects were rare. Quantitative MG scores decreased during follow-up.ConclusionsPatients were uneventfully discharged with fast recovery. This technique may merge the potential benefits of a subxiphoid incision and the non-intubated anesthesia protocol.

Nuss procedure without videothoracoscopy.

Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in patients with previous thoracic and/or cardiac surgical interventions, due to severe intrathoracic fibrous adhesions. Herein, we describe an original modification technique in a patient with bilateral apical wedge resection and total pleurectomy due to recurrent spontaneous pneumothorax episodes within the past two years. Correction was performed by opening the pleura bilaterally and retrosternal release with digital palpation via a subxiphoid incision, to help to guide the introducer and the pectus bar, without a videothoracoscopic visualization.

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery.

OBJECTIVESPectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar.METHODSA retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary.RESULTSThere were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome.CONCLUSIONSThe novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.

Single-Incision Laparoscopic Intragastric Surgery for Gastric Submucosal Tumors Located Near the Esophagogastric Junction.

Background: Laparoscopic local resection of the stomach for gastric submucosal tumors (SMTs) is widely accepted by surgeons. For SMTs located near the esophagogastric junction (EGJ), simple laparoscopic wedge resection is rarely performed owing to concerns of causing cardia deformities or stenosis. Single-incision laparoscopic intragastric surgery (sLIGS) has been used to treat SMTs located near the EGJ in carefully selected cases. Methods: We modified sLIGS using a subxiphoid incision. Thirteen consecutive patients with intraluminal or intramural growth type gastric SMTs located near the EGJ underwent sLIGS at our institution from July 2018 to April 2020. Results: Thirteen operations were successfully performed using sLIGS, including eight full-thickness resections and five submucosal resections. There were no conversions to an open procedure and all tumors were confirmed to have negative margins on pathology. The mean operation time was 100 ± 10 minutes (range, 85-160 minutes). The mean blood loss was 50 ± 10 mL (range, 50-100 mL). The mean length of postoperative hospital stay was 7 ± 1.5 days (6-10 days). One patient was found to have oozing of blood confirmed by gastroscopy postoperatively and recovered after stopping antiplatelet therapy. Ten cases were gastrointestinal stromal tumor (GIST), two cases were leiomyoma, and one case was neuroendocrine neoplasm. Of the 10 GISTs, 9 were classified as low risk; 1 showed medium risk and the patient received adjuvant imatinib therapy. There were no tumor recurrences during a mean follow-up of 14 ± 4 months (range, 5-25 months). Conclusions: This modified sLIGS for the treatment of the gastric SMTs located near the EGJ is simple and safe. This can be used as an alternative treatment for gastric SMTs near the EGJ.

Three-Field LVAD Implantation Completely Avoids Dissection of the Heart in Patients with Previous Sternotomy

<h3>Introduction</h3> Less invasive techniques to implant a left ventricular assist device (LVAD) reduce perioperative complications, length of stay, right heart failure, and perhaps even mortality. In this case series we describe a novel three-field implant technique (3FIT) for LVAD for patients with previous sternotomies. This technique employs a left thoracotomy, a subxiphoid incision, and a right thoracotomy or upper ministernotomy. The outflow graft is tunneled from the left thoracotomy to the subxiphoid area and then subsequently to the aorta through the right pleural space. To avoid any possible compression of the outflow graft in the subxiphoid area, an additional bend relief is easily spliced with the original one (Figure). <h3>Case Report</h3> Five patients (4 with previous CABG and one with 3 prior sternotomies) underwent LVAD implantation via the 3FIT. The mean age was 55.4 ± 16.2 years and Heartmate II Risk Score (HMRS) was2.51 + 0.5 (high risk HMRS is > 2.48). Mean pre-operative eGFR was 46+ 14 mL/min. Mean right atrial pressure was 11 + 5 mmHg and pulmonary artery pulsatility index was 3.3+ 2.8. Mean cardiopulmonary bypass time was 142 + 38 minutes. Post-operatively, the mean time to extubation was 10.4 ± 7.5 hours, mean ICU length of stay was 8.6 ± 5.7 days, and mean length of stay was 20.8 ± 4.7 days. No patients had severe or severe-acute right heart failure (RHF) by INTERMACS criteria, and no patients required long term renal replacement therapy. One patient died 16 months post-operatively of chronic heart failure. <h3>Summary</h3> The 3FIT completely avoids dissection and mobilization of either ventricle in patients with prior sternotomies. This is particularly important in patients with poor RV function and patent coronary grafts. Coronary angiography to assess bypass grafts preoperatively is not necessary, especially if renal function is compromised. None of our patients had significant RHF or required long-term dialysis in this high risk group of patients with prior sternotomies.

Hybrid Subxiphoid Perventricular Approach as an Alternative Access in Neonates and Small Children Undergoing Complex Congenital Heart Interventions.

The hybrid subxiphoid perventricular approach provides direct access through the heart and may alleviate the technical limitations of complex percutaneous interventions particularly in infants with low body weight. We present the outcomes from a tertiary cardiology center using this approach. We performed a retrospective review of all patients less than 15kg who underwent a hybrid perventricular approach via a small subxiphoid incision. Medical records were reviewed to obtain clinical, demographic and outcome data. Seventeen patients underwent 18 hybrid perventricular procedures using a subxiphoid approach. Median age at time of procedure was 4.6months (IQR = 1.6 to 18months) and median weight was 6.2 kgs (IQR = 3.4 to 8.6 kgs). Six patients underwent hybrid pulmonary valve replacement (PVR), 5 patients underwent pulmonary outflow stenting, and 5 infants underwent hybrid ventricular septal defect (VSD) device closure. One patient with a single ventricle who did not tolerate a percutaneous approach underwent left pulmonary artery (LPA) stenting for severe LPA coarctation with subsequent right ventricular outflow tract (RVOT) stenting. One further patient underwent implantation of a larger diameter stent for pulmonary artery bifurcation stenosis. Procedure success rate was 89% with two of the VSD cases reverted to open surgical repair. There were no intra-procedural complications; however, one patient died within 72h. Minor adverse events occurred in 2 patients including a wound infection in one patient with an immunodeficiency syndrome. Hybrid subxiphoid perventricular approach provides an excellent alternative access to the heart especially in low birth weight infants to prevent hemodynamic instability or in small children requiring large delivery sheaths.

Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures

The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial-only approach for patients with persistent atrial fibrillation. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation on the basis of a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives is also given.