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Journal of Cardiothoracic Surgery Apr 2024Cardiac herniation occurs when there is a residual pericardial defect post thoracic surgery and is recognised as a rare but fatal complication. It confers a high...
BACKGROUND
Cardiac herniation occurs when there is a residual pericardial defect post thoracic surgery and is recognised as a rare but fatal complication. It confers a high mortality and requires immediate surgical correction upon recognition. We present a case of cardiac herniation occurring post thymectomy and left upper lobectomy.
CASE PRESENTATION
Initial presentation: A 48-year-old male, hypertensive smoker presented with progressive breathlessness and was found to have a left upper zone mass confirmed on CT biopsy as carcinoid of unclear origin. PET-CT revealed avidity in a left anterior mediastinal area, left upper lobe (LUL) lung mass, mediastinal lymph nodes, and a right thymic satellite nodule. Intraoperatively: Access via left thoracotomy and sternotomy. The LUL tumour involved the left thymic lobe (LTL), left superior pulmonary vein (LSPV), left phrenic nerve and intervening mediastinal fat and pericardium, which were resected en-masse. The satellite nodule in the right thymic lobe (RTL) was adjacent to the junction between the left innominate vein and superior vena cava (SVC). The pericardium was resected from the SVC to the left atrial appendage. Clinical deterioration: Initially the patient was doing well clinically on day 1, however there was sudden bradycardia, hypotension, clamminess, and oligoanuria, with raised central venous pressures and troponins. ECG: no capture in leads V1-2, but positive deflections seen on posterior leads. Echo: no acoustic windows, but good windows seen posteriorly. CXR: left mediastinal shift. Redo operation: After initial resuscitation and stabilisation on the intensive care unit, on day 2 a redo-sternotomy revealed cardiac herniation into the left thoracic cavity with the left ventricular apex pointing towards the spine, and inferior caval kinking. After reduction and repair of the pericardial defect with a fenestrated GoreTex patch, the patient recovered well with complete resolution of the ECG and CXR.
CONCLUSION
Cardiac herniation can even occur following sub-pneumonectomy lung resections and should be considered as a differential when faced with a sudden clinical deterioration, warranting early surgical correction.
Topics: Male; Humans; Middle Aged; Thymectomy; Vena Cava, Superior; Positron Emission Tomography Computed Tomography; Clinical Deterioration; Heart Diseases; Hernia; Pneumonectomy
PubMed: 38627781
DOI: 10.1186/s13019-024-02713-y -
Europace : European Pacing,... May 2024Pulmonary vein isolation using cryoablation is effective and safe in patients with atrial fibrillation (AF). Although both obesity and underweight are associated with a...
Association between body mass index and results of cryoballoon ablation in Korean patients with atrial fibrillation: an analysis from the Korean Heart Rhythm Society Cryoablation registry.
AIMS
Pulmonary vein isolation using cryoablation is effective and safe in patients with atrial fibrillation (AF). Although both obesity and underweight are associated with a higher risk for incident AF, there is limited data on the efficacy and safety following cryoablation according to body mass index (BMI) especially in Asians.
METHODS AND RESULTS
Using the Korean Heart Rhythm Society Cryoablation registry, a multicentre registry of 12 tertiary hospitals, we analysed AF recurrence and procedure-related complications after cryoablation by BMI (kg/m2) groups (BMI < 18.5, underweight, UW; 18.5-23, normal, NW; 23-25, overweight, OW; 25-30, obese Ⅰ, OⅠ; ≥30, obese Ⅱ, OⅡ). A total of 2648 patients were included (median age 62.0 years; 76.7% men; 55.6% non-paroxysmal AF). Patients were categorized by BMI groups: 0.9% UW, 18.7% NW, 24.8% OW, 46.1% OI, and 9.4% OII. Underweight patients were the oldest and had least percentage of non-paroxysmal AF (33.3%). During a median follow-up of 1.7 years, atrial arrhythmia recurred in 874 (33.0%) patients (incidence rate, 18.9 per 100 person-years). After multivariable adjustment, the risk of AF recurrence was higher in UW group compared with NW group (adjusted hazard ratio, 95% confidence interval; 2.55, 1.18-5.50, P = 0.02). Procedure-related complications occurred in 123 (4.7%) patients, and the risk was higher for UW patients (odds ratio, 95% confidence interval; 2.90, 0.94-8.99, P = 0.07), mainly due to transient phrenic nerve palsy.
CONCLUSION
Underweight patients showed a higher risk of AF recurrence after cryoablation compared with NW patients. Also, careful attention is needed on the occurrence of phrenic nerve palsy in UW patients.
Topics: Humans; Atrial Fibrillation; Cryosurgery; Male; Female; Middle Aged; Registries; Body Mass Index; Republic of Korea; Aged; Treatment Outcome; Recurrence; Risk Factors; Pulmonary Veins; Obesity; Thinness; Time Factors; Postoperative Complications
PubMed: 38624037
DOI: 10.1093/europace/euae095 -
Cureus Apr 2024The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed... (Review)
Review
The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed the possible phrenic dysfunctions, with the final aim of presenting an osteopathic manual approach for the treatment of the most superficial portion of the nerve, using a gentle technique. The approach we propose is, therefore, a theory based on clinical experience and the rationale that we can extrapolate from the literature. We hope that the article will be a stimulus for further experimental investigations using the technique illustrated in the article. To the authors' knowledge, this is the first article that takes into consideration the hypothesis of an osteopathic treatment with gentle techniques for the phrenic nerve.
PubMed: 38606024
DOI: 10.7759/cureus.58012 -
Surgical and Radiologic Anatomy : SRA Jun 2024The phrenic nerve innervates the respiratory diaphragm, the primary muscle active during ventilation. The canonical path of the phrenic nerve originates from the...
The phrenic nerve innervates the respiratory diaphragm, the primary muscle active during ventilation. The canonical path of the phrenic nerve originates from the cervical spine at C3-C5 spinal nerves and travels inferiorly through the neck and thoracic cavity to reach the diaphragm. During a cadaver dissection, a variation of the phrenic nerve was discovered in a 93-year-old male specimen. A traditional origin of the phrenic nerve was noted; however, the nerve branched into medial and lateral components at the level of the superior trunk of the brachial plexus. The branches reconnected at the apex of the aortic arch and continued inferiorly to innervate the ipsilateral diaphragm. This case study describes a rare type of branching of the phrenic nerve and explores its potential impact on clinical procedures.
Topics: Humans; Phrenic Nerve; Male; Aged, 80 and over; Anatomic Variation; Cadaver; Diaphragm; Brachial Plexus; Dissection
PubMed: 38597949
DOI: 10.1007/s00276-024-03341-w -
Europace : European Pacing,... Mar 2024Phrenic nerve injury (PNI) is the most common complication during cryoballoon ablation. Currently, two cryoballoon systems are available, yet the difference is unclear.... (Observational Study)
Observational Study Comparative Study
AIMS
Phrenic nerve injury (PNI) is the most common complication during cryoballoon ablation. Currently, two cryoballoon systems are available, yet the difference is unclear. We sought to compare the acute procedural efficacy and safety of the two cryoballoons.
METHODS
This prospective observational study consisted of 2,555 consecutive atrial fibrillation (AF) patients undergoing pulmonary vein isolation (PVI) using either conventional (Arctic Front Advance) (AFA-CB) or novel cryoballoons (POLARx) (POLARx-CB) at 19 centers between January 2022 and October 2023.
RESULTS
Among 2,555 patients (68.8 ± 10.9 years, 1,740 men, paroxysmal AF[PAF] 1,670 patients), PVIs were performed by the AFA-CB and POLARx-CB in 1,358 and 1,197 patients, respectively. Touch-up ablation was required in 299(11.7%) patients. The touch-up rate was significantly lower for POLARx-CB than AFA-CB (9.5% vs. 13.6%, p = 0.002), especially for right inferior PVs (RIPVs). The touch-up rate was significantly lower for PAF than non-PAF (8.8% vs. 17.2%, P < 0.001) and was similar between the two cryoballoons in non-PAF patients. Right PNI occurred in 64(2.5%) patients and 22(0.9%) were symptomatic. It occurred during the right superior PV (RSPV) ablation in 39(1.5%) patients. The incidence was significantly higher for POLARx-CB than AFA-CB (3.8% vs. 1.3%, P < 0.001) as was the incidence of symptomatic PNI (1.7% vs. 0.1%, P < 0.001). The difference was significant during RSPV (2.5% vs. 0.7%, P < 0.001) but not RIPV ablation. The PNI recovered more quickly for the AFA-CB than POLARx-CB.
CONCLUSIONS
Our study demonstrated a significantly higher incidence of right PNI and lower touch-up rate for the POLARx-CB than AFA-CB in the real-world clinical practice.
Topics: Humans; Phrenic Nerve; Male; Female; Atrial Fibrillation; Pulmonary Veins; Aged; Cryosurgery; Prospective Studies; Incidence; Registries; Peripheral Nerve Injuries; Middle Aged; Treatment Outcome; Catheter Ablation
PubMed: 38588039
DOI: 10.1093/europace/euae092 -
Cureus Mar 2024Regional anaesthesia for shoulder surgery remains challenging in patients with pre-existing respiratory comorbidities. Various alternative phrenic sparing techniques...
Regional anaesthesia for shoulder surgery remains challenging in patients with pre-existing respiratory comorbidities. Various alternative phrenic sparing techniques have been described in the literature, but to our knowledge, none have explored the benefits of using short-acting local anaesthetics in combination to achieve surgical anaesthesia for awake surgery. This case report describes the successful use of the superior trunk block catheter, a relative phrenic sparing shoulder nerve block, and 2% chloroprocaine, a short-acting local anaesthetic, to provide surgical anaesthesia for awake shoulder surgery in a patient with severe respiratory disease.
PubMed: 38586677
DOI: 10.7759/cureus.55761 -
Experimental Neurology Jun 2024Ampakines are positive allosteric modulators of AMPA receptors. We hypothesized that low-dose ampakine treatment increases diaphragm electromyogram (EMG) activity after...
Ampakines are positive allosteric modulators of AMPA receptors. We hypothesized that low-dose ampakine treatment increases diaphragm electromyogram (EMG) activity after mid-cervical contusion injury in rats. Adult male and female Sprague Dawley rats were implanted with in-dwelling bilateral diaphragm EMG electrodes. Rats received a 150 kDyn C4 unilateral contusion (C4Ct). At 4- and 14-days following C4Ct, rats were given an intravenous bolus of ampakine CX717 (5 mg/kg, n = 10) or vehicle (2-hydroxypropyl-beta-cyclodextrin; HPCD; n = 10). Diaphragm EMG was recorded while breathing was assessed using whole-body plethysmography. At 4-days, ampakine administration caused an immediate and sustained increase in bilateral peak inspiratory diaphragm EMG bursting and ventilation. The vehicle had no impact on EMG bursting. CX717 treated rats were able to increase EMG activity during a respiratory challenge to a greater extent vs. vehicle treated. Rats showed a considerable degree of spontaneous recovery of EMG bursting by 14 days, and the impact of CX717 delivery was blunted as compared to 4-days. Direct recordings from the phrenic nerve at 21-24 days following C4Ct confirmed that ampakines stimulated bilateral phrenic neural output in injured rats. We conclude that low-dose intravenous treatment with a low-impact ampakine can enhance diaphragm activation shortly following mid-cervical contusion injury, when deficits in diaphragm activation are prominent.
Topics: Animals; Diaphragm; Rats; Rats, Sprague-Dawley; Male; Female; Electromyography; Spinal Cord Injuries; Disease Models, Animal; Contusions; Cervical Cord; Isoxazoles
PubMed: 38582278
DOI: 10.1016/j.expneurol.2024.114769 -
Journal of Cardiothoracic Surgery Apr 2024A frequent complication of Fontan operations is unilateral diaphragmatic paresis, which leads to hemodynamic deterioration of the Fontan circulation. A potential new...
BACKGROUND
A frequent complication of Fontan operations is unilateral diaphragmatic paresis, which leads to hemodynamic deterioration of the Fontan circulation. A potential new therapeutic option is the unilateral diaphragmatic pacemaker. In this study, we investigated the most effective stimulation location for a potential fully implantable system in a porcine model.
METHODS
Five pigs (20.8 ± 0.95 kg) underwent implantation of a customized cuff electrode placed around the right phrenic nerve. A bipolar myocardial pacing electrode was sutured adjacent to the motor point and peripherally at the costophrenic angle (peripheral diaphragmatic muscle). The electrodes were stimulated 30 times per minute with a pulse duration of 200 µs and a stimulation time of 300 ms. Current intensity was the only variable changed during the experiment.
RESULTS
Effective stimulation occurred at 0.26 ± 0.024 mA at the phrenic nerve and 7 ± 1.22 mA at the motor point, a significant difference in amperage (p = 0.005). Even with a maximum stimulation of 10 mA at the peripheral diaphragm muscle, however, no effective stimulation was observed.
CONCLUSION
The phrenic nerve seems to be the best location for direct stimulation by a unilateral thoracic diaphragm pacemaker in terms of the required amperage level in a porcine model.
Topics: Humans; Child; Swine; Animals; Phrenic Nerve; Diaphragm; Respiratory Paralysis; Electrodes; Prostheses and Implants; Electric Stimulation
PubMed: 38580985
DOI: 10.1186/s13019-024-02707-w