How to optimize your set-up for a VATS right upper lobectomy

A 77-year-old woman with multiple ground-glass opacities, the largest of which measured 21 mm, has a biopsy-proven primary lung adenocarcinoma in her right upper lobe. We performed a 3-port right-sided VATS using the Copenhagen approach. There was no pleural effusion or evidence of pleural metastatic spread. A tumor was identified in the upper lobe. The surrounding lung tissue appeared normal. We performed a multilevel intercostal block using 0.25% levobupivacaine. The inferior pulmonary ligament was divided. The superior pulmonary vein and 2 branches of the pulmonary artery to the right upper lobe were dissected, encircled, and divided using tan reloads of the Endo GIA stapler. The right upper lobe bronchus was dissected, encircled, and divided in a similar fashion using a purple reload of the Endo GIA stapler following a successful test inflation of the lower and middle lobes. The horizontal fissure was completed with further firings of the stapler. Lymph nodes from stations 2, 4, 7, 8, 9, 10, and 11 were sampled and sent separately for histological analysis. There was no parenchymal or stump leak to 20 cm H20 on the test inflation. Hemostasis and pneumostasis were checked and ensured. A single 24 Fr drain was placed in the apex. Hemostasis was complete. The incision was closed in layers.

Electrical anatomy of the left atrium during atrial fibrillation

Introduction Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation. Methods Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV). Results A total of 18 patients (8 men, median age 63 IQR 58–71 years) were included. Most patients presented with persistent AF (n=12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL. Conclusion We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. FUNDunding Acknowledgement Type of funding sources: None. Short cycle length mapping

Free-breathing non-contrast flow-independent cardiovascular magnetic resonance angiography using cardiac gated, magnetization-prepared 3D Dixon method: assessment of thoracic vasculature in congenital heart disease

Background To evaluate a non-contrast respiratory- and electrocardiogram-gated 3D cardiovascular magnetic resonance angiography (CMRA) based on magnetization-prepared Dixon method (relaxation-enhanced angiography without contrast and triggering, REACT) for the assessment of the thoracic vasculature in congenital heart disease (CHD) patients. Methods 70 patients with CHD (mean 28 years, range: 10–65 years) were retrospectively identified in this single-center study. REACT-CMRA was applied with respiratory- and cardiac-gating. Image quality (IQ) of REACT-CMRA was compared to standard non-gated multi-phase first-pass-CMRA and respiratory- and electrocardiogram-gated steady-state-CMRA. IQ of different vessels of interest (ascending aorta, left pulmonary artery, left superior pulmonary vein, right coronary ostium, coronary sinus) was independently assessed by two readers on a five-point Likert scale. Measurements of vessel diameters were performed in predefined anatomic landmarks (ascending aorta, left pulmonary artery, left superior pulmonary vein). Both readers assessed artifacts and vascular abnormalities. Friedman test, chi-squared test, and Bland-Altman method were used for statistical analysis. Results Overall IQ score of REACT-CMRA was higher compared to first-pass-CMRA (3.5 ± 0.4 vs. 2.7 ± 0.4, P < 0.001) and did not differ from steady-state-CMRA (3.5 ± 0.4 vs. 3.5 ± 0.6, P = 0.99). Non-diagnostic IQ of the defined vessels of interest was observed less frequently on REACT-CMRA (1.7 %) compared to steady-state- (4.3 %, P = 0.046) or first-pass-CMRA (20.9 %, P < 0.001). Close agreements in vessel diameter measurements were observed between REACT-CMRA and steady-state-CMRA (e.g. ascending aorta, bias: 0.38 ± 1.0 mm, 95 % limits of agreement (LOA): − 1.62–2.38 mm). REACT-CMRA showed high intra- (bias: 0.04 ± 1.0 mm, 95 % LOA: − 1.9–2.0 mm) and interobserver (bias: 0.20 ± 1.1 mm, 95 % LOA: − 2.0–2.4 mm) agreements regarding vessel diameter measurements. Fat-water separation artifacts were observed in 11/70 (16 %) patients on REACT-CMRA but did not limit diagnostic utility. Six vascular abnormalities were detected on REACT-CMRA that were not seen on standard contrast-enhanced CMRA. Conclusions Non-contrast-enhanced cardiac-gated REACT-CMRA offers a high diagnostic quality for assessment of the thoracic vasculature in CHD patients.

Novel Clue to Locate Conduction Gaps in the Pulmonary Vein Isolation Ablation Line

Background: Several methods have been reported for locating the conduction gap (CG) in the pulmonary vein isolation (PVI) ablation line. However, the value of the interval between far-field atrial potential (FFP) and pulmonary vein potential (PVP) remains unknown.Methods: Consecutive patients with a CG during observation on the table after PVI were included. The PVP, FFP, and the CG location were evaluated to develop a novel algorithm to identify the CG location in the left superior pulmonary vein. The performance of this novel algorithm was prospectively tested in a validation cohort of consecutive patients undergoing repeat PVI ablation.Results: A total of 116 patients with atrial fibrillation (AF) were recruited, 56 of whom formed the validation cohort. The interval between FFP and PVP of the left superior pulmonary vein was associated with the CG location, and an interval &lt;5 ms predicted the presence of CG in the upper portion of the ostium with a sensitivity of 92.9% and a specificity of 96.9%. In the prospective evaluation, the interval was able to correctly predict the site of CG in 89.6% of cases.Conclusions: The interval between FFP and PVP is a novel and accurate index that can be used to predict the CG location in the left superior pulmonary vein. An far-field atrial potential and pulmonary vein potential (FFP–PVP) interval value of ≥5 ms could be used to exclude a CG in the upper portion of the ostium in the majority of patients undergoing AF ablation.

Dynamic Assessment of the Pulmonary Veins in the Cardiac Cycle of Adults without Heart Disease by Cardiac CT

Purpose The purpose of this study was to explore the influence of cardiac cycle and the traditional risk factors on the four pulmonary veins (PVs) of adults and to determine the phase for measuring the maximum value of PVs. Methods Cardiac CT was performed in 101 subjects. The diameter, area, cross-sectional angle, and coronal-section angle of four PVs in 10 phase were reconstructed and measured at 10% step from 5%-95% R-R interval. The differences in PVs size and spatial angles in cardiac cycles and the correlation between the indicators of four PVs and traditional risk factors were analized using two-level model. Results All the maximum size values of the four PVs were found in 45%, while the minimum values were found in 5% or 95% of cardiac phases. Gender influenced the size of three PVs—right superior pulmonary vein (RSPV), right inferior pulmonary vein (RIPV), and left inferior pulmonary vein (LSPV). The diameter of the RSPV was small in hypertensive patients and smokers. In addition, the cross-sectional angles of the left superior pulmonary vein (LIPV) changed during cardiac cycles, and age affected these changes. We found no changes in the spatial angles of the RSPV, RIPV, and LSPV, as well as the coronal-section angle of the LIPV. Conclusions PVs ostia size of normal person varies during cardiac phases. Compared with nomal person, AF could affect the cardiac phase in which the maximum and minimum of PVs is, and it may lead to a reduction of the PVs’ size slightly. For life science journals only.

Successful treatment of massive haemoptysis in a young woman with anastomosis of right internal mammary artery to right superior pulmonary vein fistula

A 21-year-old, otherwise healthy, female patient was admitted with haemoptysis. Chest X-ray and CT found a consolidated right middle pulmonary lobe. Catheter angiography of ascending aorta visualised two hypertrophic and tortuous branches of the right internal mammary artery with a fistula to the right superior pulmonary vein. The inflow was embolised with coils. Catheter angiography of descending aorta found hypertrophic right bronchial arteries and right phrenic artery supplying a web-like network of vessels, which drained to the right superior pulmonary vein with discrete filling of an accessory right middle pulmonary vein. CT angiography with a catheter for contrast administration in the ascending aorta was performed for characterisation. After two additional episodes of haemoptysis, right middle lobe lobectomy was performed. Perioperatively pulmonary artery blood supply to the right middle pulmonary lobe was absent and an atretic accessory middle pulmonary vein was seen. The patient was discharged 7 days afterwards without sequelae.