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Acute eosinophilic myocarditis is a rare cause of acute heart failure. We present the case of a 32-year-old woman who had presumptive eosinophilic myocarditis as part of a generalized hypersensitivity reaction (Drug Rash with Eosinophilia and Systemic Symptoms [DRESS] syndrome) that exhibited a dramatic response to steroid therapy. We highlight the central role of 2-dimensional and tissue-Doppler echocardiography in the diagnosis of myocarditis and the serial evaluation of left ventricular systolic and diastolic function in this setting. [ABSTRACT FROM AUTHOR]

Background: Mechanisms of the pseudonormalization (PN) of the transmitral flow (TMF) velocity pattern have been mainly attributed to left ventricular diastolic function. Purpose: To assess the influence of left atrial (LA) function on the PN with two-dimensional tissue tracking technique. Methods: The subjects consisted of 21 healthy volunteers and 70 patients with various cardiac dis-eases. Images of one cardiac cycle in the apical four-chamber view were stored by the HIVIS10N 900 (Hitachi Medico, Chiba, Japan). The LA volume (LAV) loop was created using two-dimensional tissue tracking technique and LAV index (LAVI) at a given cardiac phase was calculated. A preload of 90 mmHg was applied using a customized lower body positive pressure (LBPP) system. Patients were divided into the PN group (n = 18) with their early diastolic TMF velocity (£) increased and late diastolic TMF velocity (A) decreased, and the non-(N)-PN group (n = 52) with both ? and A wave velocities increased by LBPP. Results: (1) During LBPP, the LAVImax in both the groups increased significantly. (2) In the N-PN group, the LAVlpass (p< 0.001), LAVIact (p<0.01), and LAVItotai (p< 0.0001) increased significantly. The dV/dts (p<0.0001) and dV/dtE (p< 0.0001) increased significantly with an increase in the dV/dtA. On the other hand, there was no change in those parameters except LAVIpass (p < 0.05) and dV/dtE (p < 0.05) significantly increased in the PN group. (3) As a result, the LAVImin was significantly greater in the PN group than in the N-PN group (p < 0.0001 ) during LBPP. The ratio of ? velocity to early diastolic mitral annular velocity (£/£') during LBPP was significantly greater in the PN group than in the N-PN group (p < 0.0001 ). Conclusions: The lack of an increase in active LA emptying volume in response to an increase of preload leads to elevated LA pressure and the pseudonormalization of the TMF velocity pattern in patients with various cardiac diseases. [ABSTRACT FROM AUTHOR]

Background: Surgery is the only option for curative treatment in patients with esophageal carcinoma. Despite the debates related to the peri-operative therapy regime, a generally accepted consensus on surgical approach is not reached yet. The debate focuses mainly on pros and cons between radical transthoracic resection and the (limited) transhiatal resection in the last decade. Methods: The PubMed database was searched for randomized trials, meta-analyses, and retrospective single-center studies. The search terms were 'esophageal carcinoma,' 'esophageal junction carcinomas,' 'transhiatal,' 'transthoracic,' 'morbidity,' 'mortality,' and 'surgery.' Results: The radical transthoracic approach should be the standard of care for esophageal carcinoma since it does not go along with an increased risk of postoperative morbidity or mortality but reveals an improved survival. Patient-related co-morbidities are the most influencing factors for the postoperative outcome. For type II esophageal junction carcinoma, treatment options from transhiatal extended gastrectomy to esophagectomy with hemigastrectomy or esophagogastrectomy with colonic interposition are existing. In type III esophagogastric junction carcinomas, the transhiatal extended gastrectomy is the standard of care, and the minimally invasive approach should be performed in specialized centers. Conclusion: Based on current available study results, this expert review provides a decision support for the best surgical strategy depending on tumor localization and patients' characteristics. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication., (© 2022, The Authors.)

Objectives: The aim of this study was to assess the risk and predictive value of cardiac pathology detected on an anesthesiologist-performed focused transthoracic echocardiogram with adverse cardiac outcomes in the perioperative period. Design: A retrospective review of 222 patients having a focused transthoracic echocardiogram and evaluating the incidence and echocardiographic risk factors associated with perioperative adverse cardiac events. Setting: A single tertiary referral university teaching hospital. Participants: Two hundred twenty patients who had a focused transthoracic echocardiogram performed by an anesthesiologist. Interventions: All patients who had a focused transthoracic echocardiogram had their discharge summary and any perioperative troponin levels reviewed, looking for evidence of adverse cardiac events, including cardiac death before discharge, myocardial infarction, pulmonary edema, hypotension requiring vasoactive drug infusion, or new arrhythmia. Measurements and Main Results: Data were collected on the 222 patients who had an anesthesiologist-performed focused transthoracic echocardiogram, with 39 (18%) having an adverse cardiac event. There were 24 (11%) myocardial infarctions, 6 (2.7%) new arrhythmias, 5 (2.3%) deaths, and 4 (1.8%) episodes of severe hypotension. High-risk pathology detected on echocardiography included adverse cardiac events in 64% of the patients with pulmonary hypertension, 56% of the patients with left or right ventricular dysfunction, and 17% of the patients with stenotic valvular disease. In particular, patients with a combination of pulmonary hypertension, ventricular dysfunction, and/or stenotic valvular disease had a 77% risk of an adverse cardiac event. In contrast, no patients with a completely normal study, flow murmur, or isolated regurgitant valvular disease had adverse cardiac events. Conclusions: Anesthesiologist-performed focused transthoracic echocardiography predicts perioperative adverse cardiac events in noncardiac surgical patients. [Copyright &y& Elsevier]

Background: To evaluate the left atrial (LA) volume and function of obese patients with/without obstruc-tive sleep apnea (OSA) and its association with left ventricular (LV) diastolic function independent of obesity. Methods: LA volumetric and functional parameters were measured by 2-dimensional and strain echocar-diography in 49 obese (body mass index≥25 kg/m2) subjects (24 non-OSA and 25 OSA). Results: OSA group showed larger maximal LA volume indexed for body surface area, larger volume before atrial contraction, a reduction in the LA passive emptying fraction, and an increase in the LA active emptying fraction with no significant change in LA total emptying fraction. Mitral annular early diastolic velocity (Ea) was significantly reduced, whereas the ratio of mitral valve early diastolic velocity (E) to Ea (ElEa) and late diastolic velocity (Aa) were significantly increased in OSA group. Although the mean peak late diastolic strain rate had not shown any differences, the LA mean peak systolic strain/strain rate, and mean peak early diastolic strain rate were significantly lower in the OSA group. Apnea-hypopnea index (AH1) of the OSA patients was significantly correlated with £/Ea (r=0.67, p < 0.001). There is a significant correlation between LA active emptying volume index and E/Ea (r=0.77, p< 0.001), and between LA passive emptying volume index and E/Ea (r= -0.51, p = 0.009). Conclusion: LA structural and functional remodeling was significantly correlated with the severity of OSA and LV diastolic filling pressure. OSA impaired LA wall compliance and passive contraction independent of obesity. [ABSTRACT FROM AUTHOR]

We aimed to assess the impact of obstructive sleep apnea (OSA) on the left ventricular (LV) function independent of obesity using the myocardial performance index (Tei index) and the global longitudinal LV strain (GLS) and its reversibility after surgery. Twenty-five newly diagnosed OSA patients, normal weight (n = 15) and obese (body mass index [BMI] ≥ 25; n = 20) controls without OSA were enrolled and underwent transthoracic echocardiographic evaluation. The OSA and obese groups had a significantly comparable increased BMI and LV chamber dimension, prolonged isovolumic relaxation time, reduced early mitral filling velocity, and increased late mitral filling velocity and Tei index as compared to the normal weight group. However, GLS was significantly reduced only in the OSA group (-16.5 ± 1.9%) as compared to the normal weight group (-20.6 ± 2.0%, P < 0.001) and obese group (-19.1 ± 2.5%, P < 0.001). As a treatment, 13 of 25 patients underwent surgical modification, and the follow-up echocardiogram revealed significantly improved Tei index and GLS as compared to baseline (0.37 ± 0.06 and -18.9 ± 3.3% vs. 0.42 ± 0.04 and -16.3 ± 2.4%, P = 0.006 and 0.031, respectively), which was comparable to the obese controls. A reduction in the apnea-hypopnea index had a significant effect on the improvement in the GLS (r = 0.73, P < 0.001). LV systolic and diastolic function significantly deteriorated in the patients with OSA beyond obesity, and an improvement in the LV function was observed within 6 months after the surgical modification. GLS is considered to be one of the parameters that can be used in the early detection of LV systolic dysfunction in patients with OSA and a normal ejection fraction. [ABSTRACT FROM AUTHOR]

The article focuses on a study which investigated the incidence and nature of clinically important cardiac pathology in patients presenting to an anaesthetic pre-admission clinic in a general hospital setting. Study authors utilized transthoracic echocardiography (TTE) directed by the American College of Cardiology Foundation criteria for echocardiography (ACCF AUC). They concluded that appropriate use criteria results to a high detection rate of clinically important cardiac pathology.

In the current era of expanding catheter-based and complex repair procedures to treat aortic valve (AV) diseases, growing consideration is being given to understanding the functional anatomy of the AV complex. Echocardiography is the primary imaging modality to assess and follow-up AV diseases, and the recent three-dimensional (3D) capabilities allow clinicians to appreciate the functional complexity of the aortic root in the beating heart. Despite being subject to several limitations, 3D echocardiography (3DE) holds promise as a more suitable imaging backup for aortic interventions of mounting complexity and for circumventing some of their current complications. In this review, we discuss the key principles of 3DE for assessing the AV pathology and the incremental clinical benefits in comparison with conventional 2DE and Doppler echocardiography, justifying its implementation in the diagnostic workup of aortic diseases. In view of an effective clinical use, a brief section is dedicated to the acquisition modalities, display, and interpretation of various abnormalities by 3DE. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the interpretative skills of medical practitioners with a limited transthoracic echocardiography (TTE) training course "H.A.R.T. Scan" in assessing haemodynamic events in perioperative and critical care patients. It shows that the TTE training provides rapid assessment of cardiac function and status without critical echocardiography. It suggests that TTE-trained practitioners had a high level of agreement in interpreting valve and ventricular function.

Abstract: Objectives: We have previously demonstrated deterioration in cardiac function at term in human pregnancy. To explore further, we investigated central arterial hemodynamics and association with maternal weight during gestation. Study design: Primiparous women (n =32) were recruited in a tertiary referral obstetric hospital and a longitudinal cohort study with analyses at median 16 and 37weeks gestation undertaken. Subgroups of normal body mass index, <25kg/m2, and overweight, ⩾25kg/m2, at 16weeks were created. Main outcome measures: We performed 2D speckle tracking echocardiography strain analysis and tonometric measures of central arterial pressures, waveforms and pulse wave velocity. Results: A reduction in cardiac strain (2P =0.002) from 16 to 37weeks gestation was associated with increased systemic vascular resistance (2P =0.008), reduced arterial compliance (2P =0.004) and increased central arterial pressures (2P <0.001) and augmentation index (2P =0.001). Conclusions: By 37weeks, compared with values in earlier pregnancy, overweight women had higher systemic vascular resistance (2P <0.05). Additionally, their central diastolic pressure was higher (2P <0.05) and their ventricular strain was lower (2P <0.05) than in normal weight pregnant women. An increase in systemic vascular resistance and central arterial pressures by term may contribute to the observed deterioration in cardiac function. This appears more prominent in overweight women. [Copyright &y& Elsevier]

Background: The aim of this study was to analyze the early postoperative outcome of esophageal cancer treated by subtotal esophageal resection, gastric interposition and either intrathoracic or cervical anastomosis in a single center study. Methods: 72 patients who received either a cervical or intrathoracic anastomosis after esophageal resection for esophageal cancer were matched by age and tumor stage. Collected data from these patients were analyzed retrospectively regarding morbidity and mortality rates. Results: Anastomotic leakage rate was significantly lower in the intrathoracic anastomosis group than in the cervical anastomosis group (4 of 36 patients (11%) vs. 11 of 36 patients (31%); p = 0.040). The hospital stay was significantly shorter in the intrathoracic anastomosis group compared to the cervical anastomosis group (14 (range 10-110) vs. 26 days (range 12 - 105); p = 0.012). Wound infection and temporary paresis of the recurrent laryngeal nerve occurred significantly more often in the cervical anastomosis group compared to the intrathoracic anastomosis group (28% vs. 0%; p = 0.002 and 11% vs. 0%; p = 0.046). The overall In-hospital mortality rate was 6% (4 of 72 patients) without any differences between the study groups. Conclusions: The present data support the assumption that the transthoracic approach with an intrathoracic anastomosis compared to a cervical esophagogastrostomy is the safer and more beneficial procedure in patients with carcinoma of the lower and middle third of the esophagus due to a significant reduction of anastomotic leakage, wound infection, paresis of the recurrent laryngeal nerve and shorter hospital stay. [ABSTRACT FROM AUTHOR]

Background: Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE). Methods: After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1 year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires. Results: The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher ( P < 0.001) than that with open THEs (median = 12). The percentage of patients requiring intraoperative blood transfusion in the MIE group (23.4%) was significantly lower ( P < 0.001) than in the open TTE (73.1%) and THE (67.7%) groups. The volume of intraoperative blood product transfusion was significantly lower for the MIE patients (median = 0 ml) than for the open TTE (median = 700 ml) and THE (median = 700 ml) patients. The incidence of respiratory complications with MIEs (10.64%) was significantly lower than with open TTEs (34.61%) and THEs (32.26%). The groups did not differ significantly in terms of R0 resection rates, OS, DFS, or QOL. Conclusions: MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL. [ABSTRACT FROM AUTHOR]

The article offers information on the usefulness of three-dimensional (3D) echocardiographic (3DE) imaging, representing a major innovation in cardiovascular ultrasound. It discusses the evaluation of cardiac chamber volumes and mass as well as the assessment of regional left ventricular (LV) wall motion and quantification of systolic dyssynchrony. It also discusses the transthoracic 3DE examination protocol.

We present our experience with 2 options for device closure of perimembranous ventricular septal defect with aneurysm. Thirty-four patients with perimembranous ventricular septal defect with aneurysm, aged from 14 to 42 years, underwent transcatheter closure with modified double-disk occluders. A sheath was used to deliver the occluder after establishment of a stable "arteriovenous loop" under fluoroscopy. Electrocardiography and transthoracic echocardiography were used for follow-up. All but 1 patient experienced successful transcatheter closure of perimembranous ventricular septal defect with aneurysm, when occluders were used in 2 different positions. There were 19 patients whose perimembranous ventricular septal defects were closed at the inlet of the aneurysm and 15 patients whose defects were closed at the outlet. Eight patients had a residual shunt immediately after the procedure, which disappeared during follow-up. One patient developed minor aortic regurgitation. Four patients who manifested different types of conductive block were all in the group that underwent closure at the inlet of the aneurysm. No other complications were observed during follow-up. We infer that perimembranous ventricular septal defect with aneurysm can be successfully closed with modified double-disk occluders. Each of the 2 options that we have presented for transcatheter closure of perimembranous ventricular septal defect with aneurysm has its advantages and disadvantages. Ultimately, the configuration of the lesion should decide the type and position of the device. [ABSTRACT FROM AUTHOR]

The following on the treatments of adenocarcinomas in Barrett's esophagus contains commentaries on endo mucosal resection; choice between other ablative therapies; the remaining genetic abnormalities following stepwise endoscopic mucosal resection and possible recurrences; the Fotelo-Fotesi PDT; the CT TNM classification of early stages of Barrett's carcinoma; the indications of lymphadenectomy in intramucosal cancer; the differences in lymph node yield in transthoracic versus transhiatal dissection; video-assisted lymphadenectomy; and the importance of the length of proximal esophageal resectipon; and indications of sentinel node dissection. [ABSTRACT FROM AUTHOR]

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The article discusses a study on the use of minimally invasive surgery (MIS) techniques in the treatment of pathology located in the thoracic spine specifically the mini-open lateral approach to remove thoracic tumors. A review of a prospectively maintained spine tumor database on patients who underwent a minimally invasive lateral approach to treat thoracic tumor was done. It concludes that an MIS lateral approach was successful in the surgical treatment of different types of tumors and should be considered as an excellent alternative by spine surgeons.

Our institution is in development of a low frequency, non-invasive Diastolic Timed Vibrator (DTV) for use in emergency treatment of ST Elevation Myocardial Infarction (STEMI). It is preferable to avoid vibration emissions during the IsoVolumetric Contraction Period (IVCP) and at least the majority of mechanical systole thereafter, as systolic vibration may cause a negative inotropic effect in the ischemic heart. Furthermore diastolic vibration should preferably include the IsoVolumetric Relaxation Period (IVRP) which has been shown in clinical studies to improve cardiac performance and enhance coronary flow. Electrocardiographic (ECG) monitoring can be used to enable diastolic tracking, however, the timing of the phases of the cardiac cycle in relation to the ECG waveform must first be verified. The objective of this study was therefore to determine timing of onset of mechanical systole and diastole in reference to the QRS-T Complex. One hundred and twenty-three adult echocardiographic studies were assessed for the point of mitral and aortic valve closure in relation to the QRS complex and T wave in a representative population. We found that onset of mechanical systole occurred on and usually shortly after the peak of a first dominant QRS complex deflection, and onset of diastole occurred at the earliest on and most commonly beyond the peak or midpoint of the T wave. A DTV should ideally be able to stop vibrating on or before the peak of the first dominant deflection of a QRS complex, and begin vibrating near the peak of the T wave. Given early detection of ventricular depolarization can occur 10-20 ms prior to R wave peak, it is proposed that a DTV should preferably be able to stop vibrating within 10 ms of a triggered stop command. Onset of vibration during peak of T wave could be approximated by a rate adapted Q-T interval regression equation, and then fine tuned by manual adjustment during therapy. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. Methods: A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. Results: Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213ml (range 100–400ml) for the TH group and 216ml (range 80–500ml) for the TT group. The median operating times for both approaches were similar (398min TH vs 382min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80mmHg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥10mmHg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p =0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p =0.01. Conclusion: This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient''s pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact. [Copyright &y& Elsevier]

Three-dimensional echocardiography (3DE) is becoming part of everyday clinical practice worldwide. However, 3DE requires adequate electrocardiographic and respiratory gating and it complements instead of replacing bidimensional echocardiography (2D). The instantaneous full-volume echocardiography technique is trying to overcome some of these limitations and to present an effective alternative to 2D echocardiography. In this article we aim to review the contribution of 3DE to our knowledge of anatomic and functional valvular anatomy and the potential advantages of instantaneous full-volume color Doppler echocardiography. [ABSTRACT FROM PUBLISHER]

The article discusses the application of focused transthoracic echocardiography (TTE) in the perioperative phase. TTE is slow to be adapted in anaesthesia due to lack of formal training opportunities. Among the suitable perioperative indications are haemodynamic instability and hypoxaemia. TTE has been used to detect cardiac murmurs in elective surgical patients. The major common indication for focused TTE is haemodynamic instability in the perioperative stage.

Abstract: Primary tuberculosis often occurs in children with the main types of hilar lymphonode tuberculosis or Ghon complex. When pulmonary tuberculosis aggravates and tubercule bacillus invades pulmonary veins, a disseminated disease may occur clinically. One 8-year-old girl presented with hypodynamia and emaciation. CT indicated the disseminated disease and extensive mediastinal and hilar lymphadenopathy. But she had negative sputum smears and negative PPD test. The bronchi showed inflammatory change in fiberoptic bronchoscopy. Percutaneous transthoracic needle biopsy (PTNB) guided by CT was used as a means for the diagnosis of pulmonary tuberculosis. The case was rapidly diagnosed as sub-acute disseminated pulmonary tuberculosis with the help of combined CT imagine and histology. [Copyright &y& Elsevier]

Summary: A 19-year-old male was admitted to the emergency room of our hospital after a motor vehicle accident. During his first physical examination, a holosystolic murmur was heard at the fourth left parasternal border. Transthoracic echocardiography showed severe tricuspid insufficiency, but the cause of tricuspid insufficiency was unclear. Therefore, three-dimensional echocardiography was performed and demonstrated flail anterior, posterior and septal leaflets of the tricuspid valve. The diagnosis was tricuspid insufficiency due to papillary muscle rupture secondary to chest blunt trauma. Surgical repair of the tricuspid valve was performed in this patient. After surgery, the signs and symptoms of right ventricular heart failure were relieved. In this case, three-dimensional echocardiography was very useful for the evaluation of spatial destruction of the tricuspid valve and papillary muscle. [Copyright &y& Elsevier]

Summary: Background and objective: Plasma B-type natriuretic peptide (BNP) levels are determined by several factors. The presence of atrial fibrillation (AF) is one of these factors. Meanwhile, plasma BNP levels are well correlated with left ventricular (LV) filling pressure in patients with sinus rhythm. Furthermore, LV filling pressure can be estimated by the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/e′ ratio) in patients with sinus rhythm or with AF. However, it is still unclear if elevated plasma BNP levels reflect increases in LV filling pressure in patients with AF, especially with preserved LV systolic function. This study was designed to examine which factors determine plasma BNP levels in patients with persistent nonvalvular AF and preserved LV systolic function. Methods and results: We examined 195 clinically stable outpatients with persistent nonvalvular AF and preserved LV systolic function. They underwent comprehensive 2-dimensional and Doppler echocardiography, plasma BNP and creatinine levels, clinical history, and heart rate were determined. Then we statistically analyzed the correlation between plasma BNP levels and several variables including E/e′ ratio. On univariate analyses, plasma BNP levels were significantly correlated with age, LV diastolic diameter (LVDd), E/e′ ratio, and mitral E wave deceleration time. In addition, plasma BNP levels were significantly higher in males and in patients with a history of congestive heart failure and those who had been administered a β-blocker. On multiple linear regression analyses, E/e′ ratio, age, LVDd, and administration of β-blocker were independent determinant factors of plasma BNP levels. Conclusions: Plasma BNP levels in patients with persistent AF and preserved LV systolic function are affected by E/e′ ratio, age, LVDd, and administration of β-blockers. [Copyright &y& Elsevier]

The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. A parallel development has been the concept of limited transthoracic echocardiography that can be performed by practitioners with limited experience. The basis of these examinations is to provide the practising clinician with immediate information to help guide management with a focus on haemodynamic evaluation, and limited structural (valve) assessment to categorise whether there is a valve disorder that may or may not cause haemodynamic instability. The limited examination is therefore goal directed. A number of named examinations exist which differ in their scope and views. All of these require a limited knowledge base, and are designed for the clinician to recognise patterns consistent with haemodynamic or anatomical abnormalities. They range from very limited two-dimensional assessments of ventricular function to more complex (yet presently limited) studies such as HEART (haemodynamic echocardiography assessment in real time) scan, which is designed to provide haemodynamic state, as well as basic valvular and pericardial assessment. It is suitable for goal-directed examination in the operating theatre, emergency department or intensive care unit (ICU) and for preoperative screening. [ABSTRACT FROM AUTHOR]

Abstract: Two major surgical strategies to improve survival rates after oesophagectomy for oesophageal cancer have emerged during the past decades; (limited) transhiatal oesophagectomy and (extended) transthoracic oesophagectomy with two-field lymphadenectomy. This overview describes short and long-term advantages of these two strategies. In the short term, transhiatal oesophagectomy is accompanied by less morbidity. In the long term, this strategy is only preferable for patients with tumours located at the gastro-oesophageal junction, without involved lymph nodes in the proximal compartment of the chest. For patients with tumours located in the oesophagus, the transthoracic route with extended lymphadenectomy is probably preferred, because of improved long-term survival. [Copyright &y& Elsevier]

Background: Tracheal laceration is a rare but life-threatening complication of esophagectomy. It is seen both with transhiatal and transthoracic esophagectomy.Methods: Three hundred eighty-two esophagectomies were performed from 1998 to 2008. The medical records of five patients with laceration of trachea during esophagectomy managed at a tertiary care center were reviewed retrospectively.Results: There were three males and two females with age range 18-62 years. The overall incidence of tracheal laceration was 1.31%. Four lacerations (1.30%) occurred during transhiatal and one (1.35%) during transthoracic resection of esophagus. Tracheal laceration was detected intraoperatively in all. Laceration was long (>3 cm) in three patients and short (<2 cm) in two. Patients with long laceration required direct suturing, while those with short laceration could be managed with gastric reinforcement. No patient required additional thoracotomy to access the lesion. Two patients had pneumonia, one had recurrent nerve palsy, while another developed anastomotic disruption. No patient died.Conclusion: Laceration of trachea is a potentially morbid complication of esophagectomy. Management should be individualized based on the extent and type of laceration. The surgical strategy depends upon the index procedure. The present series describes successful management of patients with tracheal injury associated with esophagectomy. [ABSTRACT FROM AUTHOR]

The article describes the process of a transthoracic echocardiographic (TTE) examination and presents examples of normal echocardiograms. Echocardiography is referred to the practice of imaging the heart and the great vessels using the ultrasound and an essential investigation in the diagnosis and management of patients with cardiac disease. However, the TTE is the standard approach to imaging the heart that involves the insonation of the cardiac chambers from the patient's chest.

Background: The postoperative monitoring and treatment of the patient undergoing aortic valve replacement is a complex challenge. Echocardiography is the only method which provides dynamic and real-time bedside imaging of the heart. Focused assessed transthoracic echocardiography has been shown to provide a usable window for cardiac imaging in a mixed ICU population. The aim of this study was to evaluate the feasibility of perioperative imaging of the heart and pleura according to the focused assessed transthoracic echocardiography protocol in patients scheduled for aortic valve replacement. Method: Thirty-five adult patients scheduled for aortic valve replacement were followed perioperatively with focused assessed transthoracic echocardiography examinations. A Vivid-7 echo-machine and a 2.5 MHz matrix transducer with second-harmonic imaging were used for data acquisition. The image quality for the cardiac window was graded 1–5 (1 = no image, 2 = poor and unusable image quality, 3 = usable image quality, 4 = good image quality and 5 = perfect image quality). A score ⩾3 equalled an image quality judged to be of sufficient quality to be interpreted and thereby to contribute to clinical decision-making. Results: All patients had at least one usable window preoperatively. At least one usable window was obtained in 88% of patients on the first postoperative day, and in 97% at discharge. The image quality changed over time, with the poorest quality being observed on the first postoperative day. The apical view with the patient in the left lateral position provided the best cardiac window on all occasions. The presence of drains did not significantly affect the achievability of a satisfactory examination. The number of patients with pleural effusion was relatively high. On the first postoperative day, 10 subjects had unilateral and one subject had bilateral pleural effusions. At discharge, 14 patients had unilateral and four patients had bilateral effusions. Conclusions: We conclude that the image quality of the heart and pleura, according to the focused assessed transthoracic echocardiography concept, is sufficient to undergo interpretation and thereby contribute to the perioperative clinical decision-making in patients with aortic stenosis. [ABSTRACT FROM AUTHOR]

Objective: This study was designed to assess the clinical applicability of a small, handheld, portable transthoracic echocardiography device by noncardiologist intensivists. Design: Prospective, observational study. After 10 one-hour tutorials, intensivists performed a limited transthoracic echocardiography (TTE) (2–4 views, without Doppler or M-mode) examination with the 5.6-lb SonoHeart Echo System (SonoSite, Bethell, WA) on critically ill patients admitted to the surgical intensive care unit. After initial cardiac clinical assessment in 90 patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status. Each study was immediately reviewed and repeated by an echocardiographer to determine the technical quality of the TTE and the accuracy of the intensivist’s interpretation. Data were analyzed and presented in proportions using descriptive statistics. Setting: Surgical intensive care unit of an academic medical center. Participants: Ninety critically ill adult patients. Interventions: After initial cardiac clinical assessment, a limited TTE was performed by an intensivist to assess LV size and function, to rule out significant pericardial effusions, and to estimate circulatory volume. Results: Intensivists successfully performed a diagnostic limited TTE in 94% of patients and interpreted their studies correctly in 84%. Limited TTE provided new cardiac information and changed management in 37% of patients. TTE added useful information in an additional 47% of patients but did not alter immediate management. The mean “goal-directed TTE” acquisition time was 10.5 ± 4.2 minutes. Conclusion: After a brief formal training in using this handheld echocardiographic system in intensive care unit patients, surgical intensivists successfully performed and correctly interpreted a limited TTE in critically ill patients. Limited TTE provided new information and altered management in a significant number of patients. This study supports incorporating bedside goal-directed, limited TTE into intensivists’ training programs. [Copyright &y& Elsevier]

Background and objective: To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring. Methods: The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed. Results: Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. Conclusions: By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients. [ABSTRACT FROM AUTHOR]

(ECHOCARDIOGRAPHY, Volume 21, July 2004) [ABSTRACT FROM AUTHOR]

Objective: During open heart surgery, direct transthoracic insertion of the intra-aortic balloon pump (IABP) is an alternative to the routine transfemoral insertion especially in the presence of severe peripheral vascular disease.Methods: Over 19 years (1980-1998), 646 patients were treated with IABP. In 24 of them, the balloon was inserted transthoracic (TIABP) due to failure of transfemoral insertion in 13 or extensive occlusive aorto-iliac disease in 11 cases.Results: Early mortality was 58.3% in patients having TIABP compared to 46.1% in patients with transfemoral IABP insertion (p > 0.2). Of the 24 patients receiving IABP transthoracic, none suffered vascular injury (i.e. perforation or dissection). Complications which could be related to TIABP occurred in 10 patients: 3 balloon ruptures, 1 mediastinal haemorrhage, 3 cerebrovascular accidents, 1 post-operative mediastinitis, and 2 late graft infections.Conclusions: TIABP is a useful alternative when transfemoral insertion of IABP is not feasible or hazardous because of occluded or severely diseased ilio-femoral arteries. Being a second choice and a more invasive treatment, transthoracic IABP is associated with increased mortality. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND . CT-guided percutaneous transthoracic needle biopsy (PTNB) is widely used for evaluation of indeterminate pulmonary lesions, although guidelines are lacking regarding the experience needed to gain sufficient skill. OBJECTIVE . The purpose of our study was to investigate the learning curve among a large number of operators in a tertiary referral hospital and to determine the number of procedures required to obtain acceptable performance. METHODS . This retrospective study included CT-guided PTNBs with coaxial technique performed by 17 thoracic imaging fellows from March 2, 2011, to August 8, 2017, who were novices in the procedure. A maximum number of 200 consecutive procedures per operator were included. The cumulative summation method was used to assess learning curves for diagnostic accuracy, false-negative rate, pneumothorax rate, and hemoptysis rate. Operators were assessed individually and in a pooled analysis. Pneumothorax risk was also assessed in a model adjusting for risk factors. Acceptable failure rates were defined as 0.1 for diagnostic accuracy and false-negative rate, 0.45 for pneumothorax rate, and 0.05 for hemoptysis rate. RESULTS . The study included 3261 procedures in 3134 patients (1876 men, 1258 women; mean age, 67.7 ± 12.1 [SD] years). Overall diagnostic accuracy was 94.2% (2960/3141). All 17 operators achieved acceptable diagnostic accuracy (37 procedures required in the pooled analysis; median, 33 procedures required [range, 19-67 procedures required]). Overall false-negative rate was 7.6% (179/2370). All 17 operators achieved acceptable false-negative rate (52 procedures required in the pooled analysis; median, 33 procedures required [range, 19-95 procedures required]). Pneumothorax occurred in 32.6% of the procedures (1063/3261 procedures), and hemoptysis occurred in 2.7% of the procedures (89/3261 procedures). All 17 operators achieved acceptable pneumothorax rate (20 procedures required in the pooled analysis; median, 19 procedures required [range, 7-63 procedures required]). In the risk-adjusted model, 15 operators achieved acceptable pneumothorax rate (54 procedures required in the pooled analysis; median, 36 procedures required [range, 10-192 procedures required]). Sixteen operators achieved acceptable hemoptysis rate (67 procedures required in the pooled analysis; median, 55 procedures required [range, 41-152 procedures required]). CONCLUSION . For CT-guided PTNB, at least 37 and 52 procedures are required to achieve acceptable diagnostic accuracy and false-negative rate, respectively. Not all operators achieved acceptable complication rates. CLINICAL IMPACT . The findings may help set standards for training, supervision, and ongoing assessment of operator proficiency for this procedure.

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., (© 2021 John Wiley & Sons Ltd.)