Transcutaneous Hitching Sutures in Paediatric Minimally Invasive Surgery: A Novel Technique of "Assistant Without Port"

BACKGROUND

Transcutaneous hitching sutures in paediatric minimally invasive surgery (MIS) is a unique and rare technique. This technique has been used previously in adult patients undergoing gastric resections and laparoscopic cholecystectomy; however, its use in paediatric population has never been reported in the world literature. The primary objective of this study was to bring out the advantages and feasibility of this technique in minimally invasive gastrointestinal, hepatobiliary, urological and thoracoscopic surgeries on paediatric patients.

MATERIALS AND METHODS

This retrospective observational study was conducted on 167 paediatric patients who underwent MIS surgery for different indications between April 2016 and March 2020 at two paediatric surgery tertiary care centres.

RESULTS

A total of 167 patients, including 91 boys and 76 girl patients between the age group of new-born period to 12 years were operated. The mean hospital stay was 4 days. Five out of 167 cases (3%) had post-operative surgical emphysema, which resolved spontaneously. At 6-month follow-up, parental satisfaction was 100%, and in 99% of patients, scars were imperceptible.

CONCLUSION

This versatile technique is of exemplary utility, especially in paediatric patients where there is a paucity of working space at low intra-abdominal pressure, and eases the dissection even in narrow and closed spaces with a better functional and cosmetic outcome.

Innovative Invasive Loco-Regional Techniques for the Treatment of Lung Cancer

Surgical resection is still the standard treatment for early-stage lung cancer. A multimodal treatment consisting of chemotherapy, radiotherapy and/or immunotherapy is advised for more advanced disease stages (stages IIb, III and IV). The role of surgery in these stages is limited to very specific indications. Regional treatment techniques are being introduced at a high speed because of improved technology and their possible advantages over traditional surgery. This review includes an overview of established and promising innovative invasive loco-regional techniques stratified based on the route of administration, including endobronchial, endovascular and transthoracic routes, a discussion of the results for each method, and an overview of their implementation and effectiveness.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.

OBJECTIVE

We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.

METHODS

We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.

RESULTS

Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.

CONCLUSIONS

We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.

Diastolic flow in the left ventricular outflow tract - A normal physiological and underappreciated echocardiographic finding

PURPOSE

Diastolic waveforms in the left ventricular outflow tract (LVOT) are commonly observed with Doppler echocardiography. The incidence and mechanism are not well described.

METHODS

This was a retrospective observational study of 186 adult patients, athletes and non-athletes, free of known cardiac disease, presenting for comprehensive transthoracic echocardiography at a research institute. We aimed to evaluate the incidence and echocardiographic associations between LVOT diastolic waveforms.

RESULTS

Left ventricular outflow tract early to mid-diastolic waveforms were present in 100% of athletes and 95% of non-athletes. The LVOT diastolic velocity time integral was larger in athletes than non-athletes with a mean 8.3 cm (95% CI (7.6-8.9)) vs. 5.1 cm (4.4-5.9) (P < 0.0001). Multivariate predictors of this diastolic waveform were age (P = 0.002), slower heart rate (P = 0.035), higher stroke volume (P = 0.003), large mitral E (P = 0.019) and higher E/e' (P = 0.015).

DISCUSSION

An LVOT early diastolic wave is a normal physiological finding. It is related to a flow vortex redirecting diastolic mitral inflow around anterior mitral valve leaflet into the LVOT.

CONCLUSIONS

Early to mid-diastolic LVOT waves are present in almost all patients but more prominent in young athletes than non-athletes. Diastolic LVOT waves increase with younger age, slower heart rate, larger stroke volume and enhanced diastolic function.

Antero-lateral transthoracic endoscopic approach for a calcified thoracic disc herniation

Thoracic disc herniation is one of the most therapeutically challenging spine conditions. A myriad of surgical approaches have been described in the literature, including posterior, anterior, and combined techniques. However, transthoracic and retropleural approaches are currently deemed the most effective techniques to successfully obtain anterior decompression. Herein the authors describe a 65-year-old female patient who underwent a transthoracic endoscopic approach to remove a calcified herniated thoracic disc that caused spinal cord compression. Despite having a long learning curve, the surgical technique described herein can be even used in patients with complex and calcified thoracic disc herniations. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID221.

Real-World Diagnostic Accuracy and Use of Immunohistochemical Markers in Lung Cancer Diagnostics

Objectives: Accurate and reliable diagnostics are crucial as histopathological type influences selection of treatment in lung cancer. The aim of this study was to evaluate real-world accuracy and use of immunohistochemical (IHC) staining in lung cancer diagnostics. Materials and Methods: The diagnosis and used IHC stains for small specimens with lung cancer on follow-up resection were retrospectively investigated for a 15-month period at two major sites in Sweden. Additionally, 10 pathologists individually suggested diagnostic IHC staining for 15 scanned bronchial and lung biopsies and cytological specimens. Results: In 16 (4.7%) of 338 lung cancer cases, a discordant diagnosis of potential clinical relevance was seen between a small specimen and the follow-up resection. In half of the cases, there was a different small specimen from the same investigational work-up with a concordant diagnosis. Diagnostic inaccuracy was often related to a squamous marker not included in the IHC panel (also seen for the scanned cases), the case being a neuroendocrine tumor, thyroid transcription factor-1 (TTF-1) expression in squamous cell carcinomas (with clone SPT24), or poor differentiation. IHC was used in about 95% of cases, with a higher number of stains in biopsies and in squamous cell carcinomas and especially neuroendocrine tumors. Pre-surgical transthoracic samples were more often diagnostic than bronchoscopic ones (72–85% vs. 9–53% for prevalent types). Conclusions: Although a high overall diagnostic accuracy of small specimens was seen, small changes in routine practice (such as consequent inclusion of p40 and TTF-1 clone 8G7G3/1 in the IHC panel for non-small cell cancer with unclear morphology) may lead to improvement, while reducing the number of IHC stains would be preferable from a time and cost perspective.

Brachio-azygos transthoracic arteriovenous grafts for hemodialysis patients with bilateral central venous obstruction: A small case series

BACKGROUND

It is difficult to find a reliable outflow vein for vascular access in hemodialysis patients with bilateral central venous obstruction. The lower extremity veins are currently used as the most common alternative veins to make a new vascular access. However, in patients not amenable to make lower extremity access, intrathoracic vein should be considered as an outflow vein, but there are limitations in its use due to postoperative complications.

METHODS

We introduce a series of cases that underwent arteriovenous graft operation using an intrathoracic vein, the azygos arch, as an outflow vein. Brachio-azygos transthoracic arteriovenous graft is a surgical procedure that anastomoses the azygos arch and the brachial artery with 7 mm ringed polytetrafluoroethylene graft via lateral thoracotomy without median sternotomy.

RESULTS

The chest tubes of the patients were removed on the third postoperative day and they discharged within a week. About 1 month later, hemodialysis was initiated through the BATAVG, and it has been used without access dysfunction.

CONCLUSION

Brachio-azygos transthoracic arteriovenous grafts were performed using the azygos arches without major complications. The azygos arch can be a good alternative outflow vein to make a new vascular access for hemodialysis patients with bilateral central venous obstruction.

Sternotomy Approach to the Anterior Cervicothoracic Spine

The anterior cervicothoracic spine is a challenging region to approach given the various vascular, osseous, nervous, and articular structures, which prevent adequate exposure. This region is susceptible to lesions ranging from tumors, degenerative disease, infectious processes, and traumatic fractures. Our objective was to critically evaluate the sternotomy approach in spine surgery to give the technical implications of its usage. The safety and efficacy of the transsternal approach are discussed as well as the advantages, disadvantages, indications, and contraindications. The transsternal approach is the most direct access to pathologies in the upper anterior cervicothoracic spine and enables the spine surgeon to gain direct exposure to the cervicothoracic junction for ideal visualization. Anatomical considerations must be kept in mind while performing a sternotomy to prevent complications such as denervation or bleeding. This technique is useful for the armamentarium of spinal surgeons.

Pulmonary thromboembolism with transthoracic ultrasound and computed tomography angiography

OBJECTIVE

The detection of pulmonary embolism in emergency department requires an urgent therapeutic and diagnostic attention. This study was performed to determine the accuracy and efficacy of ultrasound in the diagnosis of pulmonary embolism.

METHODS

In this study, 110 patients who referred to the emergency department with traumatic embolism symptoms were enrolled. All the patients underwent computed tomography (CT) angiography. Patients were divided into positive and negative outcomes according to the results of transthoracic ultrasonography and CT angiography.

RESULTS

In this study, 110 patients were enrolled, of whom 52 (47.3%) were male and 58 (52.7%) were female. Among the patients, 100 (90.9%) patients presented with dyspnea, whereas the frequency of pleural pain was 27% (24.5%). Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 45.67%, 77.41%, 88.09%, and 35.29%, respectively. The positive outcomes from CT scan were significantly associated with gender, p = 0.005. The gender and transthoracic ultrasonography outcomes were also significantly correlated, p = 0.019, and the outcomes of ultrasound were significantly different from those of CT scan, p = 0.008.

CONCLUSION

Transthoracic ultrasonography may be used to diagnose pulmonary embolism as a technique in the emergency department, especially in patients who are unable to move due to the severity of the disease. However, further comparative studies are required in this aspect.

Prospective multicentre cohort study of transthoracic echocardiography provision in the South West of the UK during the first wave of SARS-CoV-2 pandemic

AIMS

It was predicted internationally that transthoracic echocardiography (TTE) would be vital during the SARS-CoV-2 outbreak. We therefore, designed a study to report the demand for TTE in two large District General Hospitals during the rise in the first wave of the SARS-CoV-2 pandemic in the UK. A primary clinical outcome of 30-day mortality was also assessed.

METHODS

The TTE service across two hospitals was reconfigured to maximise access to inpatient scanning. All TTEs of suspected or confirmed SARS-CoV-2 patients over a 3-week period were included in the study. All patients were followed up until at least day 30 after their scan at which point the primary clinical outcome of mortality was recorded. Comparative analysis based on mortality was conducted for all TTE results, biochemical markers and demographics.

RESULTS

27 patients with confirmed SARS-CoV-2 had a TTE within the inclusion window. Mortality comparative analysis showed the deceased group were significantly older (mean 68.4, SD 11.9 vs 60.5, SD 13.0, p=0.03) and more commonly reported fatigue in their presenting symptoms (29.6% vs 71.4%, p=0.01). No other differences were identified in the demographic or biochemical data. Left ventricular systolic dysfunction was noted in 7.4% of patients and right ventricular impairment or dilation was seen in 18.5% patients. TTE results were not significantly different in mortality comparative analysis.

CONCLUSION

This study demonstrates an achievable approach to TTE services when under increased pressure. Data analysis supports the limited available data suggesting right ventricular abnormalities are the most commonly identified echocardiographic change in SARS-CoV-2 patients. No association can be demonstrated between mortality and TTE results.

Transhiatal versus transthoracic surgical approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

With the increasing prevalence of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (EGJ), the optimal surgical treatment is not universally agreed. This meta-analysis compares the safety and efficacy between the transhiahtal (TH) approach and the transthoracic (TT) approach.

METHODS

A systematic and electronic search of several databases was performed up to June 2020. The Newcastle-Ottawa scale was used to evaluate article quality and funnel plots were created to identify potential publication bias. The random-effects model was used when significant heterogeneity was identified.

RESULTS

In total, nine retrospective studies and two randomized controlled trials (RCTs) involving 2331 patients were included. Decreased intraoperative blood loss, shorter hospital stay, lower incidence of pulmonary complications, and longer 3-year overall survival were observed in the TH group. There were no significant differences concerning duration of surgery, R0 resection rate, number of dissected lymph nodes, perioperative mortality and morbidity rate, abdominal complication rate, or anastomotic leak rate. With regard to 5-year overall survival, a potential benefit may be achieved with the TH approach, which requires further confirmation.

CONCLUSION

In terms of surgery-related and long-term outcomes, the TH approach may be more appropriate for Siewert type Ⅱ adenocarcinoma of EGJ, especially for esophagus invasion ≤4 cm.

Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience

OBJECTIVE

In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management.

DESIGN

Retrospective case series.

SETTING

Single institution, tertiary university hospital.

PARTICIPANTS

A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series.

INTERVENTIONS

All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team.

MEASUREMENTS

Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions).

MAIN RESULTS

Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique).

CONCLUSION

Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.

Transesophageal echocardiography instead or in addition to transthoracic echocardiography in evaluating haemodynamic problems in intubated critically ill patients

Background

Transesophageal echocardiography (TEE) performed by intensivists is increasingly used in critically ill patients. However, TEE is usually not the preferred monitoring tool, especially when transthoracic echocardiography (TTE) appears to have addressed the clinical problems. As a result, it remains largely unknown whether TEE is a clinically valuable replacement or supplement for TTE as a primary tool in evaluating haemodynamic problems in critically ill surgical patients. The purpose of this study was to assess the diagnostic and therapeutic value of TEE instead or in addition to TTE in critically ill surgical patients with hemodynamic instability.

Methods

A prospective observational study was conducted. A total of 68 consecutive patients were enrolled from December 2016 to February 2018. TEE was routinely performed in addition to TTE, and the imaging data from TTE and TEE were successively disclosed to two different primary physicians, who reported any resulting changes in management. The two physicians were required to reach a consensus if there was any disagreement. The results of the additional TEE examination were compared with the clinical findings and TTE information. The image quality of TTE views was classified as a good (score 2), suboptimal (score 1) or poor view (score 0). According to the scores of TTE images, the patients were divided into two groups: patients with adequate TTE views (score ≥6) and inadequate TTE views (score <6).

Results

The results of additional TEE examination were classified into four categories. TEE failed to provide additional information about the initial diagnosis and therapy (class 1) in 26 patients (38.2%). Of the remaining 42 patients (61.8%), TEE instead or in addition to TTE revealed new findings or led to significant changes in therapy, as TTE supplied inadequate information. TEE used in addition to TTE led to a new diagnosis without therapeutic implications (class 2) in 11 patients (16.2%) and made a major clinical contribution leading to a therapeutic change (class 3) in 23 patients (33.8%). TEE used instead of TTE determined the diagnosis and therapy in 8 patients (11.8%) whose haemodynamic problems could not be addressed by TTE (class 4). In total, TEE had critical therapeutic benefits (class 3 and 4) that was not provided by TTE in 31 patients (45.6%). Of particular concern was that TEE had a higher proportion of therapeutic benefits to patients with inadequate TTE views than those with adequate TTE views (54.3% vs. 27.3%, P=0.036).

Conclusions

TEE as a feasible clinical tool is useful for critically ill surgical patients with hemodynamic instability, especially for the patients with inadequate TTE views. TEE instead or in addition to TTE could provide valuable information for diagnosis, which may bring significant therapeutic benefits.

Echocardiography during the coronavirus disease 2019 (COVID-19) pandemic: expert opinion of the Working Group on Echocardiography of the Polish Cardiac Society

Transthoracic and transesophageal echocardiography may be required in patients with coronavirus disease 2019 (COVID‑19), resulting in direct contact with the patient and risk of transmitting the infection from patients to medical personnel. Therefore, we recommend to perform problem‑oriented time‑limited transthoracic examinations. Whenever possible, examinations should be analyzed offline, outside the isolation zones. Transesophageal echocardiography is considered an aerosol‑generating procedure and should be performed only as a lifesaving procedure. Personnel should use appropriate personal protection equipment in the immediate vicinity of the patients in accordance with the relevant guidelines.

Transthoracic echocardiographic assessment of the right ventricle before and after caesarean delivery: A preliminary investigation

Transthoracic echocardiographic evaluation of the right ventricle is more difficult than the left ventricle and has not been well characterised in the parturient during delivery. As a preliminary investigation, our goal was to use bedside transthoracic echocardiography to evaluate right ventricular myocardial function before and after caesarean delivery. Term parturients undergoing caesarean delivery under spinal anaesthesia were enrolled. Echocardiography was performed pre- and postoperatively. Assessment of myocardial function included longitudinal myocardial strain using 2D-speckle tracking for both ventricles, and fractional area change for the right ventricle. Troponin-T, creatine kinase-muscle/brain and brain natriuretic peptide were measured pre- and postoperatively. One hundred patients were enrolled; 98 completed the study. Adequate images from both timepoints (pre- and postoperatively) were obtained in 85 patients for left ventricle assessment, and 66 for the right ventricle. Right ventricular fractional area change (mean (standard deviation)) (24.9% (8.9%) to 24.9% (9.2%); P = 0.99) and strain (-19.7% (6.8%) to -18.1% (6.5%); P = 0.08) measurements suggested mild baseline dysfunction and did not change after delivery. Left ventricular strain values were normal and unchanged after delivery (-23.8% (7.4%) to -24.3% (6.7%); P = 0.51). One patient had elevated troponin-T and demonstrated worse biventricular function. Elevation of brain natriuretic peptide (n=7) was associated with mildly decreased left ventricular strain, but creatine kinase-muscle/brain (n=4) was not associated with consistent changes in cardiac function. Further investigations into peripartum right ventricular function are required to validate the findings in this preliminary study. Findings of baseline mild right ventricular dysfunction and functional changes associated with troponin-T and brain natriuretic peptide warrant rigorous investigation.

Impact of transcatheter aortic valve implantation on mechanical dispersion

Objectives

The physiological determinants of left ventricular (LV) mechanical dispersion (MD) are not fully explored. We aimed to investigate the impact of afterload reduction and changes in ventricular conduction on LV MD after transcatheter aortic valve implantation (TAVI).

Methods

Patients with severe aortic stenosis (AS) were examined in a prospective, repeated measures observational cohort study before and after an uncomplicated transfemoral TAVI in a single tertiary centre. LV MD was assessed by speckle tracking echocardiography. Valvulo-arterial impedance (ZVA) was used as a measure of global afterload.

Results

We included 140 consecutive patients (83±8 years old, 49% women, logistic EuroSCORE 16±10) with severe AS (valve area 0.7±0.2 cm², mean transvalvular gradient 54±18 mm Hg) and a relatively preserved LV ejection fraction (52%±11%). After TAVI, we observed favourable changes in transvalvular gradients and ZVA in all patients. Compared with baseline, postprocedural MD was significantly lower in 108 patients with unchanged ventricular conduction (55±17 ms vs 51±17 ms, p=0.02) and higher in 28 patients with TAVI-induced left bundle branch block (51±13 ms vs 62±19 ms, p≤0.001). During 22±9 months observation, 22 patients died. Postprocedural MD was associated with mortality in a univariate Cox regression model (HR=1.24 (1.01-1.52), p<0.04, per 10 ms increase).

Conclusions

Isolated afterload reduction was associated with reduction of MD, while concomitant impairment of ventricular conduction resulted in a more pronounced MD after TAVI, indicating that loading conditions and conduction should be considered when evaluating MD. A pronounced postprocedural LV MD was associated with mortality.

Diagnostic success of transthoracic needle biopsy and PET-CT for 1 to 2 cm solid indeterminate pulmonary nodules

OBJECTIVES

Among the nodule types, the most controversial group are indeterminate solid nodules from 1 to 2 cm in size with the first choice being transthoracic needle biopsy (TTNB) or positron emission tomography (PET-CT) or both methods together. However, no single diagnostic algorithm could be applied to all cases. This research discusses the diagnostic success of PET-CT and TTNB.

MATERIALS AND METHODS

407 Patients who referred to our hospital for any reason, with solid nodules with the size from 1 to 2 cmincidentally identified on the thoracic CT tests were investigated. Among the patients who underwent biopsy, 312 cases had PET-CT, and maximum SUV (SUVmax) values of the nodules were examined. Values of ≥2.5 were accepted as hypermetabolic.

RESULTS

The mean age of the patients was 61 ± 10.8 years. 84 patients were female (20.6%) and 323 were male (79.4%). For TTNB; sensitivity, specificity and accuracy rates of all cases, who were correctly diagnosed, were 76.9%, 83.3% and 78.9%, respectively (P < .001). The 2.5 SUVmax cutoff value had sensitivity of 91%, specificity of 35.6%, accuracy of 75% (P = .034). The cutoff value of 49 years of age, nodule size of 16.4 mm, gender and 2.5 SUVmax value had high accuracy for benign-malignant differentiation. No statistically significant difference was found in the upper lobe localization of nodule.

CONCLUSION

A positive result from TTNB is a reliable finding; however, a negative result is not definitive. The high negative predictive value of PET-CT is effective in preventing the unnecessary biopsies and surgical procedures.

A Rare Case of Acquired Transthoracic Littre's Hernia

Introduction  The Littre hernia is a rare complication of Meckel's diverticulum. Meckel's diverticulum is vestigial remnant of the omphalomesenteric duct occurring in approximately 2% of the general population with an estimated 4 to 16% risk of complications. Usual sites of the Littre hernia include inguinal (50%), umbilical (20%), and femoral (20%). We report a case of an acquired transthoracic Littre's hernia occurring through the left part of the diaphragm triggered by a history of traumatic rib fractures associated with alcohol abuse. Case Report  A 71-year-old man presented with 4-day history of worsening shortness of breath, colicky lower abdominal pain, and inability to open bowels despite passing flatus, without nausea or vomiting. His past medical history was remarkable for multiple traumatic rib fractures caused by falls which were associated with excessive alcohol consumption. A noncontrast computed tomography (CT) scan of the abdomen and pelvis showed distended jejunal loops containing air/fluid levels likely resulting from herniated jejunum between the left chest wall and left diaphragm. An urgent laparotomy was performed which revealed small bowel and omentum herniating through a small defect in the left posterior hemidiaphragm. The contents of the sac were reduced and a Meckel's diverticulum was found inside the sac, characteristic of Littre's hernia. The diaphragmatic defect was closed and the Meckel diverticulum stapled and excised. Discussion  Herniation of Meckel's diverticulum through the diaphragm most commonly occurs in the pediatric population. Acquired transthoracic Littre's hernia is rare and may arise following thoracobdominal trauma caused by surgery, motor vehicle accidents, and falls from height. Left-diaphragmatic tears are characteristically more clinically apparent and symptomatic than the right since the liver often has a protective effect on the right part of the diaphragm. Herniation of abdominal contents in the chest cavity causes respiratory distress and requires urgent surgical correction. Diagnosis is often delayed since diaphragmatic hernia tends to present very late after the initial trauma, subjecting the patient to possible life-threatening complications. While it is easier to reduce the herniated contents and repair the diaphragm via a thoracic approach, laparotomy is often preferred in cases of acute trauma associated with intra-abdominal injuries. Repair of Littre's hernia then consists of resection of the diverticulum and herniorraphy. Conclusion  Internal Littre's hernia is usually of congenital origin. This is the first case of a transthoracic Littre's hernia caused by traumatic rib fractures. Hence, it is of utter importance that a clinician is aware of such uncommon pathology.

Initial Experience of Transthoracic Echocardiography at a Newly Operational Satellite Center in Hyderabad, Pakistan

Introduction Transthoracic echocardiography (TTE) is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function. The Hyderabad satellite center of National Institute of Cardiovascular Diseases (NICVD), Pakistan has recently started its operations, including TTE; therefore, it is imperative to assess the initial experience for the process improvement of the center. Therefore, the aim of this clinical audit was to review our initial experience of TTE at this newly operational satellite center. Methods In this clinical audit, we reviewed the records of patient undergone TTE at the echocardiography department of NICVD Hyderabad satellite center from May 2018 to October 2018. Demographic characteristics, clinical history, indications for the TTE, and echocardiographic diagnoses were reviewed. Results A total of 2,177 TTE procedures were performed during the study period of six months out of which 68.7% (1,496) were performed in male patients. Mean age of the patients was 50.83 ± 12.44 years with 48.2% (1,050) patients above 50 years of age. The most frequent indication for the procedure was cardiomyopathy, 54.1% (1,177), among other indications, native valve regurgitation was in 49.8% (1,085), ischemic heart disease in 23.2% (504), heart murmurs in 17.3% (377), cardiac masses in 14.3% (312), pericardial disease in 8.5% (184), pulmonary disease in 7.3% (160), infective endocarditis in 6.4% (139), aortic and major disease in 6.3% (138), and native valve stenosis in 5.4% (177) of the patients. Procedures were performed before coronary artery revascularization in 2.2% (47) and for prosthetic valve assessment in 1.7% (38) patients. The TTE was normal in 36.6% (796) patients, while the most frequent diagnosis was cardiomyopathy, 53.8% (1,172), among the other TTE findings valvular heart disease was in 21.8% (475), ischemic heart disease (IHD) in 21.6% (470), pericardial disease in 8.0% (175), and congenital heart disease (CHD) in 1.4% (30) patients. Conclusion This clinical audit showed the effective use of TTE as a noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function at a newly operational satellite center of a resource-limited country with normal TTE findings in only 36.6% of the patients.

Peculiar mechanical complication of myocardial infarction

A 58-year-old man presented to the chest pain unit with crescendo angina over 24 hours and worsening dyspnoea of 10 hours duration. He was a known diabetic and hypertensive on regular treatment for 10 years and a habitual smoker with over 15 pack-years smoking duration. Examination revealed a profusely diaphoretic and dyspnoeic (respiratory rate of 45/min) individual with a blood pressure of 100/60 mm Hg and heart rate of 124 beats/min. He was hypoxic and his oxygen saturation in the ambient air was 64%. His jugular venous pressure was elevated with a prominent V wave. Cardiovascular examination revealed a harsh grade IV/VI systolic murmur over the lower left parasternal border. There were bilateral extensive crepitations heard over the lung fields. ECG on admission revealed presence of Q wave and ST elevation in leads II and III, aVF with ST depression in I and aVL. X-ray chest showed normal cardiac shadow and features of grade III pulmonary venous hypertension. Transthoracic echocardiography is shown in figure 1.Figure 1Transthoracic echocardiogram short axis view at mid cavity level, 2D (A) and colour Doppler (B) image.

Question

What is the most likely diagnosis?A. Left ventricular (LV) true aneurysmB. LV pseudoaneurysmC. LV pseudo-pseudoaneurysmD. Ventricular septal rupture (VSR)E. LV free wall rupture.

The cardiovascular effects of crystalloid administration in endoscopy patients

Intravenous fluids are commonly administered for patients having colonoscopy despite relatively little data to support this practice. It is unclear what, if any, effect crystalloid administration has on stroke volume and cardiac output in patients who are fasting and have had bowel preparation agents. We aimed to assess the physiological effect of 10 ml/kg of crystalloid administration in colonoscopy patients on haemodynamic parameters including stroke volume, stroke volume variation and cardiac output, as measured with transthoracic echocardiography. Our secondary aims were to determine whether stroke volume variation predicted fluid responsiveness in gastrointestinal endoscopy patients and whether these haemodynamic measures are different in fasting patients with bowel preparation (colonoscopy patients) compared to fasting patients alone (gastroscopy patients). We recruited 54 patients having elective gastrointestinal endoscopy (25 colonoscopy, 29 gastroscopy). All patients had stroke volume, cardiac output and stroke volume variation measured with transthoracic echocardiography at baseline. In colonoscopy patients, stroke volume, cardiac output and stroke volume variation were remeasured after 10 ml/kg of intravenous crystalloid. Administration of 10 ml/kg of crystalloid increases stroke volume by 19.6 ml ( p < 0.00005) and cardiac output by 0.81 l/min ( p < 0.001). Stroke volume variation reduced from 23% to 14% after fluid administration ( p < 0.0011). The optimum threshold of stroke volume variation to predict fluid responsiveness was 21% with a sensitivity of 77.8% and specificity of 62.5%. Administration of 10 ml/kg of crystalloid increases stroke volume and cardiac output, and reduces stroke volume variation in fasting elective colonoscopy patients.

Left ventricular remodeling and function after transapical versus transfemoral transcatheter aortic valve replacement

BACKGROUND

The effect of utilizing transapical (TA) access for transcatheter aortic valve replacement (TAVR) on cardiac function has not been well studied.

AIMS

The aim of this retrospective study is to determine the direct effects of TA access for TAVR on myocardial function parameters and their correlation with 4-year survival.

METHODS

Three hundred and thirty propensity matched patients, who underwent TAVR using Sapien valve (Edwards Lifesciences Corp, Irvine, CA) between February 15, 2012 and June 17, 2016 (115 TA and 115 transfemoral [TF] routes) were studied. The pre- and 1 month post-TAVR echocardiographic features of both groups were compared. The 4-year survival in both groups was analyzed.

RESULTS

Baseline clinical characteristics, diastolic function parameters, left ventricular (LV) chamber size, and ejection fraction were similar between matched TA and TF groups. At 1 month following TAVR, there was a significant increase in stroke volume index (SVI) in both TA (mean increase 7 cm³ /m² ; P = 0.03) and TF groups (mean increase 7 cm³ /m² ; P < 0.001). Left ventricular ejection fraction (LVEF) significantly increased post TF TAVR (mean increase 2%; P = 0.008), but no significant increase was observed post TA TAVR (mean increase 1%; P = 0.27). Both groups had significant improvement in aortic valve (AV) hemodynamics post-TAVR (P < 0.001). Overall, there were no significant differences in the mean change of SVI, LVEF, or left ventricular end diastolic dimensions (LVEDDs) post TA versus TF TAVR. There was no significant difference in 4-year survival in the TF compared to TA group (49% vs 50%, P = 0.43).

CONCLUSION

Both TA and TF TAVR were equally associated with favorable changes in LV SVI and AV hemodynamics in 30 days. TA TAVR patients had similar 4 year survival to propensity matched TF TAVR; therefore, TA TAVR remains an acceptable alternative access route in patients not amenable to TF TAVR.

Cystic mediastinal mass

Case presentation

A 32-year-old woman with no other medical history presented with 1-month history of fever, weight loss and dyspnoea. On examination she had elevated jugular venous pressure and tachycardia. Her chest X-ray posterioranterior view (figure 1A) showed a rounded mass in the right cardiophrenic angle obscuring the right atrial margin, producing a 'silhouette' sign. Echocardiography showed a large cystic mass with thickened pericardium, lateral to the right atrium, causing right atrial compression (figure 1B). CT image of the chest showed a cystic lesion compressing the right atrium with thickened pericardium (figure 2A). There were no other lesions found in the lungs or other organs. Laboratory tests showed elevated erythrocyte sedimentation rate (ESR: 96 mm/hour) and C reactive protein (CRP: 32 mg/L). Excision of the mass with partial pericardiectomy was done. Intraoperatively, there was a cyst with thickened pericardial wall and thick yellowish brown fluid. Histopathology of the tissue is shown in figure 2B.Figure 1(A) Chest X-ray posterioranterior view showing a rounded mass in the right cardiophrenic angle. (B) Transthoracic echocardiography apical four-chamber view showing the cystic mass.Figure 2(A) CT of the chest sagittal view showing cystic lesion compressing the right atrium with thickened pericardium. (B) Histopathology specimen of the pericardial tissue.

Question

What is the diagnosis and what should be the management strategy?Congenital pericardial cyst and no further evaluation required.Features are suggestive of tuberculous pericardial cyst and needs treatment with antituberculosis regimen.Features suggestive of pericardial hydatid cyst and requires treatment with albendazole.Features are suggestive of viral pericarditis with encysted effusion.

Effect of Transmit Beamforming on Clutter Levels in Transthoracic Echocardiography

Transmit beamforming has a strong impact on several factors that govern image quality, field-of-view, and frame-rate in ultrasound imaging. For cardiac applications, the visualization of fine structures and the ability to track their motion is equally important. Consequently, beamforming choices for echocardiography aim to optimize these trade-offs. Acoustic clutter can dramatically impact image quality and degrade the diagnostic value of cardiac ultrasound imaging. Clutter levels, however, are closely tied to the choice of beamforming configuration. This study aims to quantify the impact of transmit beamforming on clutter levels under in vivo conditions. The performance of focused as well as plane wave transmit configurations in fundamental and harmonic modes is evaluated under matched conditions. Contrast between the cardiac chambers and the interventricular septum is used as a surrogate for the level of clutter in a given imaging scenario. Under in vivo conditions, contrast was found to improve incrementally across the four beamforming configurations in the following order: fundamental-plane, fundamental-focused, harmonic-plane, and harmonic-focused. Using the fundamental-focused configuration as a reference, the harmonic-plane and harmonic-focused cases showed improvements in median contrast of 2.97 dB and 6.1 dB, respectively, while the fundamental-plane case showed a contrast deterioration of 1.23 dB. Contrast was also found to vary systematically as a function of imaging depth. Median contrast for the right ventricle (shallow chamber) was measured to be 2.96 dB lower than that in the left ventricle (deep chamber).

Comparison of tricuspid annular plane systolic excursion with fractional area change for the evaluation of right ventricular systolic function: a meta-analysis

Background

Accurate determination of right ventricular ejection fraction (RVEF) is challenging because of the unique geometry of the right ventricle. Tricuspidannular plane systolic excursion (TAPSE) and fractional area change (FAC) are commonly used echocardiographic quantitative estimates of RV function. Cardiac MRI (CMRI) has emerged as the gold standard for assessment of RVEF. We sought to summarise the available data on correlation of TAPSE and FAC with CMRI-derived RVEF and to compare their accuracy.

Methods

We searched PubMed, EMBASE, Web of Science, CINAHL, ClinicalTrials.gov and the Cochrane Library databases for studies that assessed the correlation of TAPSE or FAC with CMRI-derived RVEF. Data from each study selected were pooled and analysed to compare the correlation coefficient of TAPSE and FAC with CMRI-derived RVEF. Subgroup analysis was performed on patients with pulmonary hypertension.

Results

Analysis of data from 17 studies with a total of 1280 patients revealed that FAC had a higher correlation with CMRI-derived RVEF compared with TAPSE (0.56vs0.40, P=0.018). In patients with pulmonary hypertension, there was no statistical difference in the mean correlation coefficient of FAC and TAPSE to CMR (0.57vs0.46, P=0.16).

Conclusions

FAC provides a more accurate estimate of RV systolic function (RVSF) compared with TAPSE. Adoption of FAC as a routine tool for the assessment of RVSF should be considered, especially since it is also an independent predictor of morbidity and mortality. Further studies will be needed to compare other methods of echocardiographic measurement of RV function.

Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU)

Over the past decades, ultrasound (US) has gained its place in the armamentarium of monitoring tools in the intensive care unit (ICU). Critical care ultrasonography (CCUS) is the combination of general CCUS (lung and pleural, abdominal, vascular) and CC echocardiography, allowing prompt assessment and diagnosis in combination with vascular access and therapeutic intervention. This review summarises the findings, challenges lessons from the 3rd Course on Acute Care Ultrasound (CACU) held in November 2015, Antwerp, Belgium. It covers the different modalities of CCUS; touching on the various aspects of training, clinical benefits and potential benefits. Despite the benefits of CCUS, numerous challenges remain, including the delivery of CCUS training to future intensivists. Some of these are discussed along with potential solutions from a number of national European professional societies. There is a need for an international agreed consensus on what modalities are necessary and how best to deliver training in CCUS.

Mediastinal masses-transthoracic ultrasonography aspects

Mediastinal masses are usually assessed by computer tomography (CT) and magnetic resonance imaging (MRI). Transthoracic ultrasonography (TUS) can also provide useful information concerning prevascular and posterior mediastinal masses abutting the thoracic wall, but is underused for mediastinal pathology. Moreover, it provides a valuable and safe method for guiding interventional procedures in those areas, even in cases when other approaches are difficult or impossible. Considering TUS a very useful imagistic method for diagnosing mediastinal masses, we present a pictorial essay of various mediastinal diseases which can be assessed by this method.

Assessment of Left Ventricular Dimensions by Transoesophageal Echocardiography in Patients During Coronary Artery Bypass Surgery

OBJECTIVE

Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model.

RESULTS

LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD.

CONCLUSION

LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions.

Cardioembolic strokes resulting from a self-inflicted needle puncture involving both sides of the heart

Foreign bodies in the heart are rare occurrences with a limited evidence base to guide recommendations on management. We report a case of multiple cardioembolic strokes as a result of a self-inflicted sewing needle puncture from the anterior chest through the right ventricle and interventricular septum with its tip in the left ventricle close to the subvalvular apparatus in a 39-year-old psychiatric patient. We discuss issues surrounding decision making and ongoing care and highlight the importance of further follow-up and reporting of cases to form a robust evidence base to guide future recommendations.

Real-Time Three-Dimensional Echocardiography: Characterization of Cardiac Anatomy and Function-Current Clinical Applications and Literature Review Update

Our review of real-time three-dimensional echocardiography (RT3DE) discusses the diagnostic utility of RT3DE and provides a comparison with two-dimensional echocardiography (2DE) in clinical cardiology. A Pubmed literature search on RT3DE was performed using the following key words: transthoracic, two-dimensional, three-dimensional, real-time, and left ventricular (LV) function. Articles included perspective clinical studies and meta-analyses in the English language, and focused on the role of RT3DE in human subjects. Application of RT3DE includes analysis of the pericardium, right ventricular (RV) and LV cavities, wall motion, valvular disease, great vessels, congenital anomalies, and traumatic injury, such as myocardial contusion. RT3DE, through a transthoracic echocardiography (TTE), allows for increasingly accurate volume and valve motion assessment, estimated LV ejection fraction, and volume measurements. Chamber motion and LV mass approximation have been more accurately evaluated by RT3DE by improved inclusion of the third dimension and quantification of volumetric movement. Moreover, RT3DE was shown to have no statistical significance when comparing the ejection fractions of RT3DE to cardiac magnetic resonance (CMR). Analysis of RT3DE data sets of the LV endocardial exterior allows for the volume to be directly quantified for specific phases of the cardiac cycle, ranging from end systole to end diastole, eliminating error from wall motion abnormalities and asymmetrical left ventricles. RT3DE through TTE measures cardiac function with superior diagnostic accuracy in predicting LV mass, systolic function, along with LV and RV volume when compared with 2DE with comparable results to CMR.

Principles of esophageal cancer surgery, including surgical approaches and optimal node dissection (2- vs. 3-field)

Surgery for esophageal carcinoma and carcinoma of the gastro-esophageal junction (GEJ) is considered as one of the most complex and challenging interventions on the digestive tract. This is due to the intimate relations with vital structures in the chest and the tendency of early lymphatic dissemination via a dense and complex submucosal network. This review article discusses the different aspects of surgical access routes in the light of the ever-evolving techniques, in particular the minimally invasive esophagectomy (MIE). The aspects of surgical approach are inextricably linked to the still ongoing debate on extent of lymphadenectomy, a debate that is obtaining a new dimension in view of the widely applied neoadjuvant therapy protocols as well as in view of the increasing importance of quality of life aspects after surgery. Finally, the authors provide a practical and patient tailored approach as applied in their center.

Comparison of survival outcomes between transthoracic and transabdominal surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma: a single-institution retrospective cohort study

Objective

To compare the survival outcomes of transabdominal (TA) and transthoracic (TT) surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma.

Methods

This retrospective study was conducted in patients with Siewert-II/III esophagogastric junction adenocarcinoma who underwent either TT or TA operations in the West China Hospital between January 2006 and December 2009.

Results

A total of 308 patients (109 in the TT and 199 in the TA groups) were included in this study with a follow-up rate of 87.3%. The median (P25, P75) number of harvested perigastric lymph nodes was 8 (5, 10) in the TT group and 23 (16, 34) in the TA group (P<0.001), and the number of positive perigastric lymph nodes was 2 (0, 5) in the TT group and 3 (1, 8) in the TA group (P<0.004). The 5-year overall survival (OS) rate was 36% in the TT group and 51% in the TA group (P=0.005). Subgroup analysis by Siewert classification showed that 5-year OS rates for patients with Siewert II tumors were 38% and 48% in TT and TA groups, respectively (P=0.134), whereas the 5-year OS rate for patients with Siewert III tumors was significantly lower in the TT group than that in the TA group (33% vs. 53%; P=0.010). Multivariate analysis indicated that N2 and N3 stages, R1/R2 resection and a TT surgical approach were prognostic factors for poor OS.

Conclusions

Improved perigastric lymph node dissection may be the main reason for better survival outcomes observed with a TA gastrectomy approach than with TT gastrectomy for Siewert III tumor patients.

Appropriate Use Criteria in Echocardiography: An Observational Institutional Study with the Perspective of a Quality Improvement Project

BACKGROUND

Appropriate use criteria (AUC) in echocardiography are essential tools for aligning the indications of echocardiography with the best clinical standards, improving clinical outcome, restraining abuse, and preserving health-care resources.

OBJECTIVES

The aim of this study was to ascertain the AUC for transthoracic echocardiography in a university hospital and create a quality improvement project (QIP).

METHODS

The assessment of 501 inpatients who received transthoracic cardiac echo was conducted according to the 2011 AUC report. Indications were classified as appropriate, uncertain, or inappropriate, and patients not matching any of the abovementioned divisions were grouped in the nonfitting category.

RESULTS

Of the 501 eligible patients, 374 patients (74.66%) were in the appropriate group, 85 patients (16.96%) in the inappropriate group, 20 patients (3.99%) in the uncertain group, and 22 patients (4.39%) in the nonfitting category.

DISCUSSION

Interpretation and analysis of the obtained results are presented, along with the results of many comparable studies; moreover, a QIP was set up accordingly.

CONCLUSION

AUC are useful to assess local practice, preserve health-care resources, and improve clinical outcome.

Short-term outcomes after conventional transthoracic esophagectomy

In our department, we have attempted to reduce the incidence of complications of conventional esophagectomy. The objective of this retrospective study was to report the short-term outcomes of esophagectomy. We reviewed 138 consecutive patients who had undergone subtotal esophagectomy by combined laparotomy via a 12-cm upper abdominal vertical incision combined with right anterior muscle-sparing thoracotomy from August 2010 to August 2014. Most of the cervical para-esophageal lymph node dissection was completed within the thoracic cavity. We performed three-field dissection in patients with tumors in the upper or middle third of the esophagus with clinical lymph node metastases in the superior mediastinum; the others underwent two-field dissection. We performed neck anastomoses in patients undergoing three-field dissection and thoracic anastomoses in those undergoing two-field dissection. Effective postoperative pain management was achieved with a combination of epidural anesthesia and paravertebral block. Postoperative rehabilitation was instituted for early ambulation and recovery. Enteral nutrition via a duodenal feeding tube was administered from postoperative day 2. Median hospital stay after surgery was 15 days (range, 10-129). Rates for both 30-day and in-hospital mortality were 0%. Morbidity rate for all Clavien-Dindo grades was 41.3%, whereas the morbidity rate for Clavien-Dindo grades III and IV was 7.2%. Anastomotic leakage developed in two patients (1.4%), recurrent laryngeal nerve palsy in 11 (8.0%), and pneumonia in nine (6.5%). Good short-term outcomes, especially regarding anastomotic leaks, were achieved by consistent improvements in surgical techniques, optimization of several operative procedures, and appropriate perioperative management.

[Transthoracic myotomy of a case of giant megaesophagus in Mali hospital]

Le but de ce travail est de présenter un cas clinique de mégaœsophage « en chaussette » hyper-dilaté occupant presque l'hémithorax droit chez un patient vivant en milieu rurale qui a été pris en charge dans notre centre par une myotomie de Heller par voie transthoracique et décrire les aspects cliniques paracliniques et thérapeutiques. L’œsocardiomyotomie de Heller par voie transthoracique associé à une réduction de la taille de l’œsophage a été réalisé avec la mise en place d'un système anti retour par le biais d'un lambeau diaphragmatique. Le transit œsogastroduodénale, l'endoscopie et le scanner gardent une place importante dans la recherche diagnostique et le choix du traitement.

Measurement of peak aortic jet velocity in the perioperative period-machine variability: implications for assessment of aortic stenosis severity

Variation in echocardiography machines and probes are not well described in the perioperative period. We aimed to compare the estimation of severity of aortic stenosis with transthoracic echocardiography (TTE) using two semi-portable ultrasound machines. Experienced cardiac anaesthetists performed a limited transthoracic echocardiogram with two different semi-portable ultrasound machines in patients with known aortic stenosis. The peak aortic jet velocity with continuous-wave Doppler and the time taken to obtain an acceptable envelope were recorded. The Sonosite M Turbo often underestimated the peak jet velocities (median jet velocity [IQR] 2.25 m/s [1.95 to 3.4] versus 3.85 m/s (3 to 4.2); P <0.001) and required more time to get a satisfactory envelope than the GE Vivid I. There was no statistically or clinically significant difference between the velocities obtained from the Vivid I and those measured on the patient's formal cardiology preoperative transthoracic echocardiogram (median [IQR]: 3.95 m/s [3.0 to 4.7]; P=0.3). However, the velocities obtained by the M Turbo were significantly lower than those obtained by the formal preoperative transthoracic echocardiogram (P <0.001). With the expansion of transthoracic echocardiography amongst anaesthetists, underestimation of the peak aortic jet velocity can significantly underestimate the severity of aortic stenosis with potentially lethal clinical consequences. Semi-portable ultrasound machines with echocardiographic capability are not necessarily equivalent and can result in underestimation of severity of aortic stenosis.

Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement?

OBJECTIVES

Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement.

METHODS

A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice.

RESULTS

Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation.

CONCLUSIONS

Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Ultrasound-guided transthoracic intramyocardial injection in mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. Experiments involving myocardial injection are currently performed by direct surgical access through a thoracotomy. While convenient when performed at the time of another experimental manipulation such as coronary artery ligation, the need for an invasive procedure for intramyocardial delivery limits potential experimental designs. With ever improving ultrasound resolution and advanced noninvasive imaging modalities, it is now feasible to routinely perform ultrasound-guided, percutaneous intramyocardial injection. This modality efficiently and reliably delivers agents to a targeted region of myocardium. Advantages of this technique include the avoidance of surgical morbidity, the facility to target regions of myocardium selectively under ultrasound guidance, and the opportunity to deliver injectate to the myocardium at multiple, predetermined time intervals. With practiced technique, complications from intramyocardial injection are rare, and mice quickly return to normal activity on recovery from anesthetic. Following the steps outlined in this protocol, the operator with basic echocardiography experience can quickly become competent in this versatile, minimally invasive technique.

Assessment of long-term kyphosis following transthoracic corpectomy with single adjacent level posterior instrumentation

Anterior thoracic spinal instrumentation has traditionally been supported by a posterior thoracic construct spanning from at least two levels above to two levels below; however, instrumentation at a single-level above and below may be adequate to support such a construct. We report two cases of transthoracic corpectomy with short-segment posterior fixation with success in long-term stabilization. Two patients with thoracic vertebral malignancy resulting in spinal deformity and spinal cord compression underwent transthoracic corpectomy with placement of an expandable cage proceeded by posterior fixation one level above and one level below. Using the Cobb angle, the degree of kyphosis was measured at 3, 6, and 12 months postoperatively. Long-term spinal stabilization was achieved in both patients. There was no significant increase in kyphosis and no evidence of hardware failure in either patient during the follow-up period. Transthoracic corpectomy with supplementary posterior fixation one level above and below may be adequate to stabilize the spine.

Assess the clinical applicability of transthoracic echocardiography in laparotomy patients in a general intensive care unit

BACKGROUND

Echocardiography is one of the diagnostic tools that can be applied at the bedside, along with avoiding transporting critically ill patients. This prospective observational study was designed to assess the clinical applicability of the transthoracic echocardiography (TTE) device by noncardiologist intensivists.

MATERIALS AND METHODS

Intensivists performed a limited TTE examination on critically ill patients admitted to the surgical intensive care unit (ICU). After initial cardiac clinical assessment in 85 critically ill adult patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status as well as valvular function and qualitative factors. Data were analyzed and presented in proportions using descriptive statistics. The setting was in surgical ICU of an academic medical center.

RESULTS

Valvular abnormalities (44.8%) as well as qualitative indices (68.3%) were the most frequently detected abnormalities. The ejection fraction was the only alteration, which was affected by the risk factors (P = 0.05, mean = 55.57).

CONCLUSION

Transthoracic approach can provide useful information on cardiac anatomy and function in most ICU patients along with detecting severe previously unknown conditions in some patients.

Anatomical advantage to percutaneous insertion of the intra-aortic balloon through the left brachial artery over the right brachial artery

Off-label use of the intra-aortic balloon (IAB) is not recommended in ideal situations and certainly not a Food and Drug Administration-approved activity. The instruction-for-use manual for the IAB recommends percutaneous insertion. However, there are certain extreme situations where "thinking outside the box" appears necessary. We have successfully inserted a transthoracic IAB (TIAB) in the operating room where an open sternum is an option. This has been instituted whenever severe peripheral vascular disease (PVD) precludes a percutaneous attempt or when attempted insertion fails. An open chest is not a choice in the catheterization laboratory or the postoperative setting. We have successfully inserted the IAB through the brachiall axillary artery in a patient with bilateral aortofemoral grafts, with a history of severe PVD, in the cardiac catheterization laboratory. A left-sided approach is advisable for brachial artery insertion and an axillary approach is also possible under sedation. This case report details our experience with transbrachial insertion of the IAB and establishes counterpulsation through this route as a viable option, where an open chest is not available and a percutaneous femoral approach has failed.

Atrial septal defect in an elderly woman-a case report

RATIONALE

The atrial septal defect is one of the most common congenital anomalies in adults, but it is rarely diagnosed. It is characterized by a defect in the interatrial septum that allows pulmonary venous return to pass from the left to the right atrium.

OBJECTIVE

A case of a 75-year-old female who presented with dyspnea, orthopnea, lower extremities swelling and palpitations is reported here. She had a 3 years history of atrial fibrillation and one-year history of cardiac failure NYHA (New York Heart Association) class Ⅱ.

METHODS AND RESULTS

Transthoracic echocardiography revealed a dilated right atrium of 74,2 mm, a dilated left atrium of 55,2 mm, a dilated left ventricle of 64/72,3 mm, a dilated right ventricle of 44,4 mm. Atrial septal defect ostium secundum type, with left-to-right shunt. Severe tricuspid insufficiency with a maximum gradient of 55,4 mm Hg. 4th degree mitral insufficiency. Severe pulmonary hypertension of 75 mm Hg. The ejection fraction of 29%. Atrial fibrillation. Interventricular sept with paradoxical motion.

DISCUSSION

Ostium secundum defect is the most common type of atrial septal defect and accounts for 60-70% of all cases. The malformation often goes unnoticed for decades because symptoms may be absent and because physical signs are subtle. Symptoms usually take 30-40 years to develop. They are the consequences of pulmonary hypertension, atrial tachyarrhythmias and, sometimes, associated mitral valve disease. The echocardiography can establish the size and location of the atrial septal defect, the magnitude and hemodynamic impact of the left-to-right shunt, and the presence and degree of pulmonary hypertension. The particularity of this case is that the patient lived for over 70 years almost asymptomatic.

Trans-aortic counterpulsation: a viable alternative?

Transthoracic intra-aortic balloon pump (IABP) insertion has been a relatively rare and uncommon procedure. However, it is an established beneficial option in patients with severe peripheral vascular disease (PVD) accompanied with bi-lateral femoral arterial occlusion. There are several viable alternatives to trans-aortic IABP insertion, including trans-axillary or in abdominal aorta (requiring a laparotomy). Cardiac surgery has the advantage of an open sternum, facilitating effortless direct intra-aortic balloon (IAB) insertion into the aorta. The IAB can be inserted either through a 9-mm graft or directly into the ascending aorta. During cardiac surgery, direct insertion into the ascending aorta with the balloon tip lying distally in the abdominal aorta is facilitated with an open sternum. The base of the balloon lies approximately 2 cm below the left subclavian and can be confirmed through a trans-esophageal echocardiogram (TEE). Elimination of a graft insertion saves the team from time-consuming maneuvers and additional hemorrhagic complications. In our experience, postoperative vasoplegic syndrome coupled with myocardial edema contributed to patent instability and was treated with vasopressin and transthoracic IAB insertion. The CS 100 (Datascope Corp., Mahwah, NJ) console allowed the ability to time the balloon accurately. This case report details our experience with one such patient and establishes trans-aortic counter-pulsation as a safe and viable option in patients with severe PVD, where percutaneous insertion is precluded or has failed.

Papillary fibroelastoma presenting as left ventricular mass

A 38-year-old woman presented with chest pain. Two-dimensional echocardiography revealed a mobile mass in the left ventricle, attached to the posterior papillary muscle of the mitral valve without valvular involvement. The tumor was resected. Histopathology confirmed the tumor as papillary fibroelastoma. Our case highlights an atypical presentation of papillary fibroelastoma.

Pharmacological closure of the patent ductus arteriosus

Pharmacological closure by indomethacin is customary if symptoms of PDA are not controlled adequately with fluid restriction and diuretics. Its use, however, requires a comprehensive clinical assessment of all the vital perinatal factors and a vigilant monitoring of the sick infant. Prophylactic use of indomethacin is discouraged. The decision to use pharmacological versus surgical treatment or both should be individualized based on evidence-based research and clinician's own experience. Surgical ligation remains the primary mode of therapy in cases of pharmacological treatment failure or recurrence.

The persistently patent arterial duct in the premature infant

The presence of a persistently patent arterial duct is common in premature neonates and may be associated with high morbidity. Early accurate diagnosis, assessment of the significance of the left to right shunt and prompt treatment are required to improve the outcome in this infant population.