How We Perform a David Procedure With an Upper Hemisternotomy Approach

Objective Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183–208] vs 212 [183–223] min, P = 0.309) and aortic cross-clamp (169 [155–179] vs 188 [155–199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

Measurement of the QT interval using the Apple Watch

The inherited and acquired long QT is a risk marker for potential serious cardiac arrhythmias and sudden cardiac death. Smartwatches are becoming more popular and are increasingly used for monitoring human health. The present study aimed to assess the feasibility and reliability of evaluating the QT interval in lead I, lead II, and V2 lead using a commercially available Apple Watch. One hundred nineteen patients admitted to our Cardiology Division were studied. I, II, and V2 leads were obtained after recording a standard 12-lead ECG. Lead I was recorded with the smartwatch on the left wrist and the right index finger on the crown. Lead II was obtained with the smartwatch on the left lower abdomen and the right index finger on the crown. The V2 lead was recorded with the smartwatch in the fourth intercostal space left parasternal with the right index finger on the crown. There was agreement among the QT intervals of I, II, and V2 leads and the QT mean using the smartwatch and the standard ECG with Spearman’s correlations of 0.886; 0.881; 0.793; and 0.914 (p < 0.001), respectively. The reliability of the QTc measurements between standard and smartwatch ECG was also demonstrated with a Bland–Altman analysis using different formulas. These data show that a smartwatch can feasibly and reliably assess QT interval. These results could have an important clinical impact when frequent QT interval monitoring is required.

Penetrating Thoracic Trauma Arising From Knife Injuries Into the Hemithorax: A Case Report

BackgroundTrauma is associated with a high morbidity and mortality, and thoracic trauma accounts for a quarter of these deaths. This is due to the penetrating thoracic trauma that often causes serious injury to the heart and great vessels. Most penetrating thoracic wounds are caused by stabbing, which is usually caused by knives. Here, we report a patient who had penetrating thoracic trauma who was caused by a knife.Case presentationA 16-year-old girl was stabbed by a knife due to an accidental fall, which caused a penetrating injury in her left chest. Despite a decreased blood pressure (100/90 mmHg), the patient was conscious. The unenhanced CT at emergency clearly showed that the knife penetrated between the pericardium and the left lung without heart injury. Exploratory thoracotomy was performed in the fourth intercostal space in combination with thoracoscopy, confirmed that the knife penetrated between the pericardium and the left lung without causing any injury to the heart.ConclusionsCT can not only clearly display foreign bodies of knives, but also accurately judge the damage of important structures such as lungs, heart and great vessels. Therefore, CT can provide information for further diagnosis and intervention.

Correlation of Central with Jugular and Upper-limb Venous Pressure Measurements

Background: Correlation data of different external reference points and methods used to measure venous pressures are scarce in the literature. We correlated central venous pressure with jugular venous pressure measured from sternal angle and with jugular and upper-limb venous pressures from zero level corresponding to mid-right-atrium level. Methods: A hospital-based observational study in the medical and surgical intensive care units was conducted for period of one year.” Central venous pressure was measured from right fourth intercostal space in mid-axillary line and jugular venous pressure from sternal angle and jugular and upper-limb venous pressures from horizontal plane through the midpoint of anteroposterior line from anterior end of right fourth intercostal space to back. We measured central venous pressure by central venous cannulation and jugular and upper-limb venous pressures clinically by JVP Meter®. Upper-limb venous pressure was indicated by collapse of visible veins in dorsum of hands as the arm was slowly raised from dependent position.Results: Correlation coefficient (r) values were 0.61 between central venous pressure and jugular venous pressure from zero level, 0.48 between central venous pressure and jugular venous pressure from sternal angle, and 0.31 between central and upper-limb venous pressures; and 0.67 and 0.50 between central venous pressure measured from right internal jugular vein and jugular venous pressure from zero level and sternal angle respectively and0.52 and 0.44 between central venous pressure from right sub-clavian vein and jugular venous pressure from zero level and sternal angle respectively. Conclusions: Different correlation values indicate the need to have future investigations and consensus on the common external reference point and methods to measure venous pressures. Keywords: CVP; heart failure; JVP; JVP Meter; shock

Winged scapula following axillary thoracotomy with long thoracic nerve preservation

Winged scapula is a rare condition caused by injuries to the long thoracic nerve (LTN) and accessory nerves. A 69-year-old man underwent surgery for right lung cancer. Video-assisted thoracic surgery was converted to axillary thoracotomy at the fourth intercostal space. The latissimus dorsi was protected, and the serratus anterior was divided on the side anterior to the LTN. Two months after discharge, he presented with difficulty in elevating his right arm and protrusion of the scapula from his back. Active forward flexion of the right shoulder was limited to 110° and abduction to 130°. He was diagnosed with winged scapula. After 6 months of occupational therapy, the symptoms improved. The LTN may have been overstretched or damaged by the electric scalpel. We recommend an increased awareness of the LTN, and to divide the serratus anterior at a site as far as possible from the LTN to avoid postoperative winged scapula.

Early Response after Catheter Ablation of the Epicardial Substrate in a Patient with Brugada Syndrome Can Be Predicted by High Precordial Leads

A 52-year-old male with Brugada syndrome presented with repeated and appropriate shock from an implantable cardioverter defibrillator (ICD). Catheter ablation for substrate elimination targeting low-voltage, complex, and fractionated electrocardiograms and late potentials in the epicardial right ventricular outflow tract was successfully performed. Brugada phenotype in the right precordial leads from the third intercostal space disappeared in the early stage after catheter ablation and that from the standard fourth intercostal space disappeared later. He remained free from ventricular fibrillation over the next fourteen months. We suggest that this novel ablation strategy is effective in Brugada syndrome patients with ICD, and early response after catheter ablation can be predicted by high precordial leads.

Prospects of Jugular Venous Pulse Assessment

There is no controversy regarding the current clinical method of examination of waveform of jugular vein pulse. However there are limitations of clinical assessment of central venous pressure by jugular vein pressure measurement from the level of sternal angle. There are variations in the reported distances from sternal angle to right atrium as well as to upper limit of JVP. In erect position, anterior end of fourth intercostal space is at about the level of mid-right atrium. In patients with visible JVP at neck in erect position, measurement of CVP can be done more accurately directly from the anterior end of fourth intercostal space. For others, the position of mid-right atrium can be marked in lateral chest wall first in erect position at the mid-point of an anteroposterior line from anterior end of fourth intercostal space to back. Subsequently in reclining position, the vertical height of venous pressure can be measured from the horizontal plane of the midpoint marked at lateral chest wall to visible upper limit of JVP. Such measurement can be done in a more reliable way with venous pressure (VP) manometer with its indicator rod at the horizontal plane of mid-right atrium and with its horizontal surface at upper limit of JVP. The venous pressure manometer can also be used to measure relatively less reliable upper limb venous pressure (ULVP), as indicated by the vertical distance at which veins of upper limb collapse, especially when JVP is not visualized due to subnormal CVP as in hypovolemia. Keywords: CVP, JVP, right atrium, sternal angle, upper limp venous pressure, venous pressure, venous pressure manometer

Central cardiovascular pressures during graded water immersion in humans

Thermoneutral (34.9 degrees C) water immersion (WI) was conducted with 12 upright seated normal males at four consecutive water levels (5–10 min each): knee (reference), xiphoid process, fourth intercostal space, and sternoclavicular notch. Thereafter, water was let out of the tank and the experiment was repeated from the neck to the knees at the same levels. Arterial pulse pressure (PP), central venous pressure (CVP), and transmural CVP (TCVP = CVP - esophageal pressure; n = 4) gradually increased with increasing water levels (P < 0.05). Heart rate (HR) decreased at WI to the xiphoid process (P < 0.05) and thereafter remained at this level, whereas mean arterial pressure remained unchanged. There was a closer linear correlation between HR and PP (r = -0.35, P < 0.01) than between HR and CVP (r = -0.13, P > 0.05). Furthermore, there was a significant positive linear correlation between CVP and TCVP (r = 0.83, P < 0.01). We conclude that WI in humans induces an increase in cardiac filling pressures with an increase in PP and a consequent decrease in HR. Furthermore, changes in CVP accurately reflect changes in cardiac distension (TCVP) during WI.