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Introduction:Quadrantectomy is a surgical procedure traditionally performed under general anaesthesia with intraoperative and postoperative opioid-based analgesia. The use of locoregional anaesthesia techniques in breast surgery has become widespread and allows excellent management of intraoperative and postoperative pain with reduced opioid consumption. We chose thoracic paravertebral block as regional anaesthesia technique in breast surgery to investigate the possibility of carrying out this surgery with the patient awake.Methods:A prospective observational study on 50 patients was designed. The primary outcome for this study was the possibility to carry out the surgery with only the paravertebral block associated with mild sedation without general anaesthesia. Forty minutes before the start of the surgery, an ultrasound-guided thoracic paravertebral block was performed at two thoracic levels, and for each level, 7 mL of ropivacaine 0.7% was injected. Sedation was obtained with target-controlled infusion of propofol.Results:Forty-nine patients underwent the operation awake; in one case, we had to place an I-gel and perform general anaesthesia. No patient needed intraoperative or postoperative opioids. The numeric rating scale, recorded at 0, 2, 6, 12, 24, and 36 hours, was greater than 3 in only five patients.Conclusions:We believe that if in the future we try to make quadrantectomy an intervention in which the anaesthesia is exclusively regional, therefore with a patient awake and collaborating, it will not be possible to ignore the use of thoracic paravertebral block.

Rib fractures are a frequent occurrence in trauma victims. Patients with a “flail chest” pattern of injury, defined as two fractures per rib in three (or more) consecutive ribs, often struggle with hypoxemic respiratory failure related to inefficient ventilatory mechanics, inability to expectorate, underlying pulmonary contusion and subsequent pneumonia. The operative indications for rib fracture repair have not been established and are considered to be an issue of debate. Over the last ten years, surgical stabilization of rib fractures has emerged as a promising therapy for patients with severe chest wall injuries. When surgical treatment is performed for patients with rib fracture, general anesthesia is the gold standard but, considered the patients clinical condition, we decided to perform the surgery with regional anesthesia and awake patients to avoid risk of ventilator-induced lung injury. Epidural anesthesia, thoracic paravertebral block and erector spinae plane block for analgesia in patients with rib fractures have been reported. In our report, we discussed the use of ultrasound-guided thoracic paravertebral block with administration of local anesthetic posteriorly to superior costo-transverse ligament and erector spinae plane block to perform surgical stabilization of rib fractures.

Background: Thoracic paravertebral block is a technique for perioperative analgesia in patients undergoing thoracic, chest wall, or breast surgery, or for pain management with rib fractures, which can be performed with or without ultrasound guidance. The ultrasound guidance technique can be used to identify the thoracic paravertebral space, guide needle placement, monitor the spread of local anesthetic (LA) solution, and reduce complications such as pleural puncture and pneumothorax. The possibility of assessing anesthetic spread in real time using ultrasound guidance during paravertebral block offers numerous advantages, including the immediate and accurate identification of the extent of nervous block, with a consequent reduction of LA dose. The real-time visualization of spread may be used to achieve good anesthetic cover by administering the block at a single level, thus reducing complications normally associated with the technique. Case summary: This case report describes the use of ultrasound-guided thoracic paravertebral block, at thoracic (T) 4 and 5 levels, in a patient undergoing breast surgery for perioperative analgesia. The authors were able to witness cranial diffusion of LA at T3-T4 in real time, and measure the increase in space between the costotransverse ligament and pleura, as an indication of anesthetic spread, at T2-T3 and T6-T7 levels. Conclusions: This is the first known case in the literature of direct viewing of LA diffusion in a paravertebral space other than the one in which the block is administered and may open important scenarios for the improvement of anesthesia technique.

Aims Paroxysmal atrial arrhythmias occur in myotonic dystrophy type 1 (MD1) patients frequently. Pacemaker (PM) including detailed diagnostic functions may facilitate the diagnosis and management of frequent paroxysmal atrial tachyarrhythmias that may remain undetected during conventional clinical follow-up. Aim of our study was to evaluate the preventive effects of interatrial septum pacing in the Bachmann's Bundle region on atrial fibrillation (AF) in MD1 patients during 12 months follow up period. Methods and results Thirty MD1 patients (age 50.3 ± 7.3; 11 F) who underwent dual chamber PM implantation were randomized at implantation to receive right atrial appendage pacing (16 patients) or Bachmann's bundle pacing (14 patients). No statistically significant difference in the electrical parameters (P wave amplitude, pacing threshold and lead impedance) was found between the two groups at implantation. Patients were followed at 1 month, 3 months, and every 6 months thereafter. They underwent clinical assessment, a standard 12-lead ECG and assessment of device performance at every visit. We counted the number of episodes of atrial arrhythmia occurred during the collection period and the duration of each episode. At 12 months of follow-up, no statistically significant differences in the number of AF episodes or in AF duration were found. Lead parameters remained stable over time and there were no displacements of the electrodes after implantation. Conclusion Implantation of an atrial-active fixation lead on the atrial septum is safe and feasible. However, this study showed no significant difference between septal pacing and high atrial pacing, using the endpoints of AF duration and number of AF episodes.

Introduction: Our study was designed to analyze dynamic changes in autonomic tone before the onset of typical sustained atrioventricular nodal reentry tachycardia (AVNRT) in a large group of patients without structural heart disease. Materials and Methods: Twenty-four-hour Holter tapes from 42 consecutive patients (27 men and 15 women; aged 30 ± 21 years) with several episodes of sustained typical AVNRT were analyzed. The diagnosis was validated by transesophageal electrophysiological study. The time-domain calculated parameters were SDNN, SDANN, rMSSD, pNN50; the frequency-domain parameters were low-frequency power (LF, 0.04–0.15 Hz), high-frequency power (HF, 0.15–0.40 Hz), very low-frequency power (VLF, 0.008 to 0.04 Hz) and LF/HF. The mean values in the hour before the onset of sustained AVNRT were compared with the mean values of 2 hours before and 1 hour after the onset of sustained AVNRT. Results: The mean SDNN, rMSSD, pNN50, HF were significantly decreased during the hour preceding the onset of AVNRT, when compared to the mean values observed during the time periods selected. Instead, the LF values and LF/HF were increased before the onset of sustained AVNRT. No significant change in the VLF and atrial ectopic beats were observed. Conclusion: This study suggests that sustained typical AVNRT episodes are preceded by increase in adrenergic drive. Ann Noninvasive Electrocardiol 2010;15(1):49–55

Aim: We performed a two-year follow-up comparative study of long-term electrical parameters between the right atrial appendage (RAA) and Bachmann’s Bundle (BB) stimulation in myotonic dystrophy type 1 (MD1) patients. Methods: Twenty-five MD1 patients (18 men; age: 54 ± 13 years) with no difference in the electrical parameters between the RAA site and the BB region at implantation were randomized into two groups: in group I (13 patients; age: 52 ± 14 years; four women) the atrial lead was placed in the RAA and in group II (12 patients, age: 56 ± 12 years, three women) the lead was placed in the BB region. Measurements of electrical parameters were recorded at follow-up intervals of 6 weeks and then 12 and 24 months postimplant. Results: There was no statistically significant different in P-wave amplitude, pacing threshold, and impedance values between the two groups at 6 weeks. At 24 months follow-up, the intrinsic P-wave amplitude was 2.05 ± 1.45 mV in the RAA group versus 3.28 ± 1.09 mV in the BB group (P < 0.05); the pacing threshold was 1.85 ± 1.8 V in the RAA group versus 0.50 ± 0.39 V in the BB group (P = 0.03); there were no differences in the atrial impedance between the two groups during the follow-up period. Conclusions: In a direct two-year follow-up comparison between the RAA and BB atrial pacing sites, we showed a statistically significant increased pacing threshold and decreased intrinsic P-wave amplitude during RAA stimulation in MD1 patients. (PACE 2009; 32:1191–1196) Bachmann’s bundle, myotonic dystrophy, pacemaker, arrhythmias, heart block, fibrosis, sensing,pacing, impedance, atrial lead

Objective: Atrioventricular nodal reentrant tachycardia (AVNRT) accounts for about 60% of the patients presenting with paroxysmal supraventricular tachycardia. The radiofrequency (RF) catheter ablation of the slow atrioventricular (AV) node pathway is the preferred therapeutic approach in patients with AV node reentrant tachycardia. The aim of our study was describe the electrophysiological properties of successful slow pathway RF ablation in patients with common atrioventricular nodal reentrant tachycardia. Methods: The study design was a retrospective analysis involving fifty consecutive patients (18 males; mean age of 39±22 years) who underwent slow pathway ablation because of AVNRT. Results: Slow junctional beats with a cycle length longer than 550 ms were observed in 39 patients (79%); the presence of rapid junctional beats with a cycle length less than 550 ms was showed in 5 patients (10%). Moreover, in 32 of 50 patients (65%) duration of atrial electrogram more than 40 ms was noticed. Analyzing data reported, we found the statistically significant presence of slow junctional beats (p40 ms (p40 ms and slow junctional beats with cycle length >550 ms during the application of RF energy describe the electrophysiological properties of successful slow pathway RF ablation. (Anadolu Kardiyol Derg 2010; 10: 126-9) © Telif Hakki 2010 AVES Yayincilik Ltd. Sti.