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Aims The extravascular implantable cardioverter-defibrillator (EV ICD) has been shown to be safe and effective for patients at risk of sudden cardiac death, but little is known about EV ICD lead removal in humans. This analysis aimed to characterize the EV ICD lead removal experience thus far. Methods and results This was a retrospective analysis of lead removals from the EV ICD Pilot, Pivotal, and Continued Access Studies. Patients with a successful EV ICD implant who underwent lead removal were included. The main objective was lead removal success. Ancillary objectives included characterizing technique used, procedure complications, and reimplantation status. An EV ICD system was successfully implanted in 347 patients across the 3 studies (25.9% female; 53.4 ± 13.3 years; left ventricular ejection fraction: 39.7 ± 15.9). Of these patients, 29 (8.4%) underwent lead removal with a mean lead dwell time of 12.6 ± 14.3 months (0.2–58.4). The main reason for lead removal was lead dislodgement (n = 9, 31.0%). Lead removal was successful in 27/29 (93.1%) cases [100% (19/19) success rate <1 year and 80% (8/10) success rate >1 year post-implant]. Simple traction was used in 22/26 (84.6%) and extraction tools in 4/26 (15.4%) successful cases where technique was known. No complications were reported for any of the removal procedures. All 11 EV ICD reimplant attempts were successful. Conclusion Complete removal of the EV ICD lead was successful in 93.1% of cases, and simple traction was sufficient in most instances. Based on these results, lead removal from the substernal space was safe and achievable up to 3 years post-implant. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the prevalence of extracervical approaches (ECAs) for substernal goiter (SSG) excision. Data Sources Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021. Review Methods Participants included adults ages >18 years undergoing SSG excision. The primary outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), ≥50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the Methodological Index for Non‐Randomized Studies criteria. Results Of the 551 studies identified, 69 studies were included for analysis. Definition 1 included 3441 patients from 31 studies; definition 2 included 2957 patients from 26 studies; and definition 3 included 2921 patients from 12 studies. A random‐effect model estimating the pooled prevalence of ECA using definition 1 resulted in prevalence of 6.12% (95% confidence interval: 3.48‐9.34, I2 = 90.72%). Conclusion Extension below the thoracic inlet is the most widely used definition of SSG. Approximately 6% of patients with a SSG undergo an ECA. Patients with SSG undergoing surgery should be counseled on the prevalence, risks, and morbidity of an ECA in the rare occurrence it is needed.

Background: Implantable cardioverter‐defibrillators (ICDs) provide clinically significant therapy for the prevention of sudden cardiac death. This study aimed to characterize the substernal space using computed tomography (CT) in patients with and without prior midline sternotomy to investigate the feasibility of substernal ICD lead implantation in post‐sternotomy patients. Methods: High‐quality electrocardiogram‐gated CT images from 100 patients (71% male, average body mass index 23.5 ± 2.9) were retrospectively collected, including 50 patients with prior midline sternotomy (S‐group) and 50 patients with no prior sternotomy (NS‐group). Distances were measured from the retrosternal surface to the epicardial surface of the heart and segmented into four regions from the xiphoid tip and superiorly along the sternum. Results: Results generally showed a measurable but narrower average sternum‐to‐heart distance in the prior sternotomy group compared to the non‐sternotomy group in all four regions (p <.05). In the S‐group, the sternum‐to‐heart distances across all regions ranged from 0 to 32.0 mm, while in the NS‐group, the distances ranged from 0 to 39.9 mm. Conclusion: Small but measurable separations between the heart and sternum were observed in patients with prior sternotomy, particularly near the xiphoid region, indicating the potential viability of extravascular substernal ICD lead implantation in post‐sternotomy patients. [ABSTRACT FROM AUTHOR]

Introduction: Substernal extravascular defibrillators (EV ICDs) have been shown to be effective and safe for patients at risk of sudden cardiac death, however, there is little evidence around the safety of extracting chronic devices., Methods and Results: We present a 50-year-old patient in whom a Medtronic EV ICD system was successfully removed without specialist extraction tools, 186 weeks after implantation, by an operator experienced in transvenous lead extraction but without formal training in EVICD implantation., Conclusion: The successful extraction of an EV ICD system is possible without specialised tools at least 3.6 years post-implant., (© 2024 Wiley Periodicals LLC.)

Introduction: The extravascular implantable cardioverter‐defibrillato (EV ICD) system with substernal lead placement is a novel nontransvenous alternative to current commercially available ICD systems. The EV ICD provides defibrillation and pacing therapies without the potential long‐term complications of endovascular lead placement but requires a new procedure for implantation with a safety profile under evaluation. Methods: This paper summarizes the development of the EV ICD, including the preclinical and clinical evaluations that have contributed to the system and procedural refinements to date. Results: Extensive preclinical research evaluations and four human clinical studies with >140 combined acute and chronic implants have enabled the development and refinement of the EV ICD system, currently in worldwide pivotal study. Conclusion: The EV ICD may represent a clinically valuable solution in protecting patients from sudden cardiac death while avoiding the long‐term consequences of transvenous hardware. The EV ICD offers advantages over transvenous and subcutaneous systems by avoiding placement in the heart and vasculature; relative to subcutaneous systems, EV ICD requires less energy for defibrillation, enabling a smaller device, and provides pacing features such as antitachycardia and asystole pacing in a single system. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study is to provide a thorough, quantified assessment of the substernal space as the site of extravascular implantable cardioverter-defibrillator (ICD) lead placement using computed tomography (CT) scans and summarizing adverse events and defibrillation efficacy across anatomical findings. Subcutaneous ICDs are an alternative to transvenous defibrillators but have limitations related to ICD lead distance from the heart. An alternative extravascular system with substernal lead placement has the potential to provide defibrillation at lower energy and pacing therapies from a single device.Methods and Results: A multi-centre, non-randomized, retrospective analysis of 45 patient CT scans quantitatively and qualitatively assessing bony, cardiac, vascular, and other organ structures from two human clinical studies with substernal lead placement. Univariate logistic regression was used to evaluate 15 anatomical parameters for impact on defibrillation outcome and adjusted for multiple comparisons. Adverse events were summarized. Substernal implantation was attempted or completed in 45 patients. Defibrillation testing was successful in 37 of 41 subjects (90%) using ≥10 J safety margin. There were two intra-procedural adverse events in one patient, including reaction to anaesthesia and an episode of transient atrial fibrillation during ventricular fibrillation induction. Anatomical factors associated with defibrillation failure included large rib cage width, myocardium extending very posteriorly, and a low heart position in the chest (P-values <0.05), though not significant adjusting for multiple comparisons.Conclusion: Retrospective analysis demonstrates the ability to implant within the substernal space with low intra-procedural adverse events and high defibrillation efficacy despite a wide range of anatomical variability. [ABSTRACT FROM AUTHOR]

Background: The extravascular implantable cardioverter‐defibrillator (EV ICD) with lead implantation in the substernal space may provide an alternative to transvenous and subcutaneous systems. This is the first‐reported chronic extraction experience for EV ICD leads. The aim of the study is to evaluate the chronic encapsulation and extractability of EV ICD leads. Methods: Two EV ICD leads and one transvenous lead were implanted in each of 24 mature sheep. A subset of animals was evaluated yearly for histology and lead extractability. Extractions were performed using simple traction or extraction tools. Histology evaluated the encapsulating tissue. Results: At 1 year, extraction was performed successfully for two of five EV ICD leads with traction alone using ≤3.1 kg‐force (kgf) and the remainder extracted successfully with extraction tools; no transvenous leads were removed with traction alone. At 2 years, no EV ICD or transvenous leads were extracted with traction alone, while at 3 years, one of eight EV ICD leads and two of four transvenous leads were extracted with traction (0.8 and ≤2.3 kgf, respectively). There was one observation of hemopericardium resulting in tamponade with EV ICD extraction but without injury to cardiovascular structures and related to the unique implant tract. Among transvenous leads, inversion of the ventricle with loss of cardiac output resulted in abandonment of traction for two animals. Conclusions: Chronic extraction of EV ICD leads from the substernal space was successfully performed using traction and simple tools through 3 years in sheep with one observation of hemopericardium that did not originate from cardiovascular injury. [ABSTRACT FROM AUTHOR]

BackgroundSternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter.MethodsA retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy.ResultsOf the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy.ConclusionsSternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.

The rate of unexpected thyroid cancers found at the time of thyroidectomy is thought to be similar in patients with cervical and substernal multinodular goiters (MNGs).The objective of this study was to compare the prevalence of undiagnosed cancer found in patients undergoing a thyroidectomy for a cervical or substernal MNG. We conducted a review of patients with a preoperative diagnosis of an MNG (both cervical and substernal) at a tertiary referral center between 2005 and 2012.We identified 538 patients who underwent thyroidectomy for an MNG (144 with substernal MNGs and 394 with cervical MNGs). Patients with substernal MNGs were older (59.6 vs. 52.3; p < 0.001), more likely to be men (34 vs. 11.1 %; p < 0.001), and less likely to have a history of radiation exposure to the neck (2.1 vs. 12.4 %; p < 0.001). Thyroid cancer (>1 cm) was found in 13.7 % of substernal MNG specimens and in 6.3 % of cervical MNG specimens (p = 0.003). On multivariate analysis, substernal location [odds ratio (OR) = 2.360; confidence interval (CI), 1.201-4.638] was the only variable independently associated with an unexpected thyroid cancer on surgical pathology.The rate of postoperatively discovered thyroid cancer is significant in patients with substernal MNGs and is increased when compared to patients with cervical MNGs. Surgeons should counsel their patients regarding the possibility of this unexpected result.

Minimally invasive esophagectomy has emerged as the established standard for treating esophageal cancer. The gastric graft is usually placed in the posterior mediastinum or the retrosternal tunnel for reconstruction. Hiatal hernia occurrence is more common in the posterior mediastinal reconstruction and is more frequently observed in laparoscopic compared to open approach. On the other hand, retrosternal hernia is a rare complication that deserves greater attention, considering the increasing popularity of retrosternal reconstruction in esophageal cancer treatment. We present the case of a 55-year-old male patient who underwent minimally invasive esophagectomy with retrosternal reconstruction using gastric conduit and cervical anastomosis. After four years, the patient experienced symptoms, including dyspnea and chest pain. CT scan revealed transverse colon herniation into the retrosternal tunnel. Our diagnosis was retrosternal herniation of the transverse colon. Although there was no sign of obstruction, the abundant colon in the retrosternal space caused mass effect symptoms. For that reason, we performed laparoscopic surgery to release the herniated organ and close the hernia hole. Postoperatively, the patient had a satisfactory recovery, and a follow-up CT scan confirmed the absence of any remaining herniated organs. While hiatal hernia is a well-known complication in minimally invasive esophagectomy, retrosternal hernia is a lesser-known entity. Surgical intervention is necessary to alleviate symptoms caused by herniation or address complications such as strangulation. The occurrence of retrosternal hernia warrants further attention and research in the future. • Retrosternal hernia is a rare but specific complication after esophagectomy. • Retrosternal hernia can cause mass effects, which require reoperation to repair. • Laparoscopy has the advantages of being less invasive and effective in mobilizing the abundant colon. [ABSTRACT FROM AUTHOR]

Abstract Background Thyroid swellings enlarge caudally into the mediastinum behind the sternum. Pre-sternal swelling of thyroid origin is very rare. We present our case of pre-sternal thyroid swelling which was albeit a surprisingly rare site of papillary thyroid carcinoma recurrence and review of pre-sternal thyroid swellings reported till date. Case summary A 60 year old female presented with a painless, progressive swelling on the anterior part of the chest for the past 2 years. A 15 cm × 8 cm vertically aligned, non tender, well defined swelling was present on the pre-sternal region, with consistency ranging from soft to firm. The swelling was fixed to the underlying tissues and a fixed level IV lymph node was palpable on the right side. Ultrasonography revealed a large mass of 15 × 7 cm with multiple cystic areas. Fine needle aspiration cytology was inconclusive twice. Patient had undergone a total thyroidectomy for papillary carcinoma 10 years back. Computed tomography findings revealed a large 15 × 6.6 × 7 cm lobulated, pre-sternal, soft tissue lesion with solid & cystic components. The mass was infiltrating the right sided strap muscles and sternocleidomastoid. FNAC was inconclusive and thyroid scan could not pick up any activity in the mass. Henceforth a PET scan was done that showed increased FDG uptake by the lesion and the level IV lymph node. The patient underwent wide excision of the mass with right functional neck dissection, along with removal with both sternal head of sternocleido-mastoid, the strap muscles and the surrounding fascia. Histopathology confirmed papillary thyroid carcinoma. Patient received post-operative radioactive iodine ablation and is healthy with no recurrence up to 30 months of follow up. Discussion The mechanisms for pre-sternal thyroid swelling are not understood due to paucity of cases. The mechanisms proposed are invasion of strap muscles and cervical linea alba and tumor cells spread anterior to sternum, truly ectopic thyroid tissue, de novo carcinogenesis in the embryonal remnants like the thyro-thymic residues, sequestered thyroid tissue which grows later or migration of thyroid cells, incomplete clearance at the time of primary surgery or intraoperative seeding. Conclusion Pre-sternal region masses of thyroid origin are very rare. A proper work up, suspicion for thyroid mass and array of tests will be required to come to a provisional diagnosis. Since the masses reported in literature were primarily malignant, any such mass may be treated on lines of malignancy with radical surgery.

Background: Transvenous implantable cardioverter defibrillators (TV ICD) provide life‐saving therapy for millions of patients worldwide. However, they are susceptible to several potential short‐ and long‐ term complications including cardiac perforation and pneumothorax, lead dislodgement, venous obstruction, and infection. The extravascular ICD system's novel design and substernal implant approach avoids the risks associated with TV ICDs while still providing pacing features and similar generator size to TV ICDs. Study Design: The EV ICD pivotal study is a prospective, multicenter, single‐arm, nonrandomized, premarket clinical study designed to examine the safety and acute efficacy of the system. This study will enroll up to 400 patients with a Class I or IIa indication for implantation of an ICD. Implanted subjects will be followed up to approximately 3.5 years, depending on when the patient is enrolled. Objective: The clinical trial is designed to demonstrate safety and effectiveness of the EV ICD system in human use. The safety endpoint is freedom from major complications, while the efficacy endpoint is defibrillation success. Both endpoints will be assessed against prespecified criteria. Additionally, this study will evaluate antitachycardia pacing performance, electrical performance, extracardiac pacing sensation, asystole pacing, appropriate and inappropriate shocks, as well as a summary of adverse events. Conclusion: The EV ICD pivotal study is designed to provide clear evidence addressing the safety and efficacy performance of the EV ICD System. [ABSTRACT FROM AUTHOR]

The article discusses the development and evaluation of the extravascular implantable cardioverter-defibrillator (EV-ICD) as an alternative to transvenous ICD (TV-ICD) and subcutaneous ICD (SC-ICD), highlighting its potential benefits in reducing implantation risks and complications. The study, conducted by Sears et al., presents patient-reported outcome metrics, demonstrating a significant improvement in physical quality of life with the EV-ICD.

Aims: The extravascular implantable cardioverter-defibrillator (EV ICD) has been shown to be safe and effective for patients at risk of sudden cardiac death, but little is known about EV ICD lead removal in humans. This analysis aimed to characterize the EV ICD lead removal experience thus far., Methods and Results: This was a retrospective analysis of lead removals from the EV ICD Pilot, Pivotal, and Continued Access Studies. Patients with a successful EV ICD implant who underwent lead removal were included. The main objective was lead removal success. Ancillary objectives included characterizing technique used, procedure complications, and reimplantation status. An EV ICD system was successfully implanted in 347 patients across the 3 studies (25.9% female; 53.4 ± 13.3 years; left ventricular ejection fraction: 39.7 ± 15.9). Of these patients, 29 (8.4%) underwent lead removal with a mean lead dwell time of 12.6 ± 14.3 months (0.2-58.4). The main reason for lead removal was lead dislodgement (n = 9, 31.0%). Lead removal was successful in 27/29 (93.1%) cases [100% (19/19) success rate <1 year and 80% (8/10) success rate >1 year post-implant]. Simple traction was used in 22/26 (84.6%) and extraction tools in 4/26 (15.4%) successful cases where technique was known. No complications were reported for any of the removal procedures. All 11 EV ICD reimplant attempts were successful., Conclusion: Complete removal of the EV ICD lead was successful in 93.1% of cases, and simple traction was sufficient in most instances. Based on these results, lead removal from the substernal space was safe and achievable up to 3 years post-implant., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The term goiter is used to describe any abnormal growth of the thyroid gland, which can be diffuse or nodular, and can be associated with normal, diminished, or increased thyroid function. Multinodular goiter is a common disease whose prevalence increases at age 50. Clinical manifestations can be due to thyroid function impairment or related to size and location of the gland with compressive symptoms. Intrathoracic location is less frequent, can be mistaken with pulmonary lesions and usually implies a difficult surgical approach. Case presentation: A 66-year-old woman with a history of subtotal thyroidectomy presented with 7-month dyspnea, dry cough. There was no evidence of neck masses, or jugular engorgement. Physical examination was normal. Chest x-ray showed an 11 cm mass in the upper right hemithorax. Computed tomography (CT)-scan, showed calcifications, and compression of the superior vena cava without infiltration, the right subclavian vein and left displacement of the trachea. Distinction between intrapulmonary or mediastinal location was not clear. Biopsy showed thyroid origin, and bilateral thoracotomy was performed with confirmation of a giant multinodular goiter. Conclusions: Intrathoracic goiter should undergo surgical or ablative management if compressive symptoms of the airway and cervical or thoracic vessels are present. The large size of the tumor along with the presentation after thyroidectomy and the seeming location in the right upper lobe made this particular case striking. Specially in the elderly, multidisciplinary perioperative management is key for a successful recovery. [ABSTRACT FROM AUTHOR]

Background: A thyroidectomy can be performed via a cervical incision in most patients with retrosternal goiter. Aims: To investigate the correlation between the volume of the mediastinal portion of the thyroid gland and the need for an extra-cervical approach for retrosternal goiter. Study Design: Diagnostic accuracy study. Methods: The measurement of craniocaudal length and the volume of the mediastinal component of the thyroid gland on computerised tomography images was performed in 47 patients with retrosternal goiter. Of these 47 patients, 8 (17%) required an extra-cervical approach and were classified as group 1, and 39 (83%) patients that required a cervical incision were classified as group 2. Receiver operating characteristic analysis was performed to determine the cut-off value for the craniocaudal length and the volume of the mediastinal thyroid mass, which significantly correlated with an extra-cervical approach for retrosternal goiter. Results: Reoperative surgery was significantly more frequent in group 1 than in group 2 (50% vs 13%; p=0.03). The craniocaudal length of the mediastinal thyroid gland was significantly longer in group 1 than in group 2 (77±11 mm vs 31±21 mm, respectively; p=0.0001). The volume of the mediastinal component was significantly larger in group 1 compared to group 2 (264±106 cm3 vs 40±41 cm3, respectively; p=0.0001). The receiver operating characteristic curve of craniocaudal length and the volume of the mediastinal component identified ≥66 mm and ≥162 cm3 as the cut-off values with the maximum accuracy, respectively. The craniocaudal length of the thyroid mass below the thoracic inlet ≥66 mm or a volume of the mediastinal portion ≥162 cm3 were significantly associated with an extra-cervical approach (p=0.0001). For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off value for craniocaudal length was 87.5%, 64% and 97%, respectively. For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off values for the mediastinal volume were 100%, 89% and 100%, respectively. Conclusion: A thyroid volume of ≥162 cm3 extending below the thoracic inlet was a significant determining factor for an extra-cervical approach, with a negative predictive value for the extra-cervical approach of 100% for retrosternal goiter with smaller volumes. Further studies with an increased number of patients are needed to determine the value of volumetric analysis of retrosternal goiter to predict the need for an extra-cervical approach in retrosternal goiter

Multinodular goiter (MNG), one of the disorders of the thyroid gland, is often detected as a mass in the neck, but sometimes produces pressure symptoms. We present successful anesthetic management of a case of an obese woman having MNG with retrosternal extension, in the setting of severe OSA, planned for total thyroidectomy. The complicated presentation of the disorder, with challenging airway management during the peri-operative period and a positive outcome is a reason for sharing this experience.

Background: Subcutaneous implantable cardioverter-defibrillators provide an alternative to transvenous defibrillation but require higher shock outputs and offer no antitachycardia pacing. The Substernal Pacing Acute Clinical Evaluation (SPACE) study evaluated the feasibility of pacing from an extravascular substernal location.Objectives: The primary purpose of the SPACE study was to characterize pacing from the substernal space. Secondary objectives included evaluating extracardiac stimulation and recording electrograms.Methods: The SPACE study prospectively evaluated the feasibility of pacing with a commercially available electrophysiology catheter acutely implanted in the substernal space via minimally invasive subxiphoid access. Pacing data were collected in ≥7 vectors using constant current stimulation up to 20 mA and pulse width up to 10 ms.Results: Catheter placement was successful in all 26 patients who underwent the procedure, with a mean placement time of 11.7 ± 10.1 minutes. Eighteen patients (69%) had successful ventricular capture in ≥1 tested vector. The mean pacing threshold at a pulse width of 10 ms was 7.3 ± 4.2 mA across all vectors (5.8 ± 4.4 V). Failed capture was generally associated with suboptimal catheter placement or presumed air ingression. A low level of extracardiac stimulation was observed in 1 patient. The mean R-wave amplitude ranged from 2.98 to 4.11 mV in the unipolar configuration and from 0.83 to 3.95 mV in the bipolar configuration.Conclusion: The data from the SPACE study demonstrate that pacing is feasible from the extravascular substernal location. A substernal electrode configuration has the potential to provide pacing in a future extravascular device without need for intracardiac hardware placement. [ABSTRACT FROM AUTHOR]

Background: A thyroidectomy can be performed via a cervical incision in most patients with retrosternal goiter. Aims: To investigate the correlation between the volume of the mediastinal portion of the thyroid gland and the need for an extra-cervical approach for retrosternal goiter. Study Design: Diagnostic accuracy study. Methods: The measurement of craniocaudal length and the volume of the mediastinal component of the thyroid gland on computerised tomography images was performed in 47 patients with retrosternal goiter. Of these 47 patients, 8 (17%) required an extra-cervical approach and were classified as group 1, and 39 (83%) patients that required a cervical incision were classified as group 2. Receiver operating characteristic analysis was performed to determine the cut-off value for the craniocaudal length and the volume of the mediastinal thyroid mass, which significantly correlated with an extra-cervical approach for retrosternal goiter. Results: Reoperative surgery was significantly more frequent in group 1 than in group 2 (50% vs 13%; p=0.03). The craniocaudal length of the mediastinal thyroid gland was significantly longer in group 1 than in group 2 (77±11 mm vs 31±21 mm, respectively; p=0.0001). The volume of the mediastinal component was significantly larger in group 1 compared to group 2 (264±106 cm3 vs 40±41 cm3, respectively; p=0.0001). The receiver operating characteristic curve of craniocaudal length and the volume of the mediastinal component identified ≥66 mm and ≥162 cm3 as the cut-off values with the maximum accuracy, respectively. The craniocaudal length of the thyroid mass below the thoracic inlet ≥66 mm or a volume of the mediastinal portion ≥162 cm3 were significantly associated with an extra-cervical approach (p=0.0001). For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off value for craniocaudal length was 87.5%, 64% and 97%, respectively. For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off values for the mediastinal volume were 100%, 89% and 100%, respectively. Conclusion: A thyroid volume of ≥162 cm3 extending below the thoracic inlet was a significant determining factor for an extra-cervical approach, with a negative predictive value for the extra-cervical approach of 100% for retrosternal goiter with smaller volumes. Further studies with an increased number of patients are needed to determine the value of volumetric analysis of retrosternal goiter to predict the need for an extra- cervical approach in retrosternal goiter. [ABSTRACT FROM AUTHOR]

This study aims to evaluate surgical approaches to the management of retrosternal goitre. Between 2004 and 2014, 35 patients (eight males; mean age 67.4 ± 10.9 years) with retrosternal goitre (mainly right-sided in 9, left-sided in 14 and bilateral in 12) underwent surgery. A palpable neck mass was found in 11 (31.4%), stridor in 10 (28.6%) and thyrotoxicosis in 4 (11.4%) cases. 4 (11.4%) patients were asymptomatic. Tracheal compression was detected radiologically in 27 (77.2%) patients with deviation in 18 (51.4%). A collar incision was performed in 34 patients, 6 (17.1%) of whom required additional sternotomy, 1 (2.9%) was assisted by an anterior mediastinotomy. 1 (2.9%) had a right lateral thoracotomy. There was no operative mortality. Transient vocal changes occurred in 3 (8.6%) patients, recurrent laryngeal nerve palsy in 3, atrial fibrillation in 2, and wound complications in 2 (5.7%). Hospital stay ranged from 2 to 12 days (5.5 ± 2.0). Multinodular goitre was found in 33 patients, diffuse goitre in 1 and ectopic thyroid in 1. The average vertical length of goitres in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. The average weight of specimens was 156.3 g in patients with collar incisions and 307.5 g in the sternotomy group. Removal of retrosternal goitre is more commonly performed via a cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the risk of sternotomy. Surgical outcomes are not affected by surgical approach. [ABSTRACT FROM AUTHOR]

Intrathoracic herniation of gastric conduit (IHGC) is a specific complication following esophagectomy with retrosternal gastric pull-up but is not well recognized. Diagnosis and management are challenging due to the lack of literature reviews. We report a 50-year-old man where a reconstructed gastric conduit hernia into the mediastinal pleural cavity after esophagectomy. The patient underwent minimally invasive esophagectomy with cervical anastomosis for middle esophageal carcinoma followed by retrosternal reconstruction; during the tunneling phase, the mediastinal pleura was injured. Subsequently, the patient developed progressive dysphagia postoperatively, and chest CT scans revealed that the dilating gastric tube had moved into the mediastinal pleural cavity. After ruling out the pyloric stenosis by endoscopy, our diagnosis was severe gastric outlet obstruction due to gastric conduit herniation. We performed laparoscopic surgery to mobilize and straighten the redundant gastric conduit. No recurrence occurred throughout the follow-up for one year. IHGC can cause gastric conduit obstruction, which requires reoperation to repair. The laparoscopic approach is an appropriate strategy with the advantages of being less invasive and effective in mobilizing and straightening the gastric conduit. To prevent mediastinal pleural injury - which affects the continuation of the reconstructions, the surgeon should use blunt dissection with direct observation during the route creation. • IHGC is an uncommon but specific complication after esophagectomy with retrosternal reconstruction. • IHGC can cause gastric conduit obstruction, which requires reoperation to repair. • Laparoscopy has the advantages of being less invasive and effective in mobilizing and straightening the gastric conduit. • Blunt dissection of the retrosternal space under direct observation from the camera is crucial to minimize pleural injuries, preventing IHGC. [ABSTRACT FROM AUTHOR]

Substernal goiter is, space-occupying character within the chest cavity, mediastinuma growing that extended from the upper cervical goiter which may be of primary origin as well as mediastinal and this pathology of the thyroid gland which can cause symptoms of compression. Also known as mediastinal, intrathoracic or retrosternal goiter. Substernal goiter can lead to symptoms of compression, create potentially airway obstruction and the possibility of malignancy so that a condition that should be treated surgically. Our case 67-year old female patient has neck mass, respiratory distress, chest pain symptoms. Our case mass was filling the middle line, right and left lateral of the neck, cranial extension of submandibular gland, caudal extension in mediastinuma, forming egg shell calcification, displaced to the left that laryngeal air column and trachea, elongation of the aortic arch and pulmonary clonus. Because of these features with thyroid tissue found and case discussed with literature.

A goiter is considered thoracic when more than 50% of the thyroid gland is in the mediastinum, under the level of the upper thoracic inlet. It is an infrequent disease, which represents about 10% of the mediastinal masses. Two cases are presented of patients who underwent endothoracic goiter surgery in the Hospital Dr. Gustavo Aldereguía Lima of Cienfuegos. The surgical treatment applied was right hemithyroidectomy, with isthmectomy and resection of the mediastinic tumor extension. It is an infrequent entity, reason for which it is considered a publication of interest. [ABSTRACT FROM AUTHOR]

Background: Ectopic substernal thyroid is a rare symptom of thyroid disease that entirely results from the developmental defects at early stages of thyroid embryogenesis and during its descent. Cases were seldom reported as primary ectopic substernal thyroid cancer, especially those with severe local invasion and tracheal relapse. Case Presentation: In this report, the patient presented odynophagia and a sense of progressing swallowing obstruction. She underwent total thyroidectomy and lump resection. However, she refused to use postoperative radioactive iodine or take adjuvant external-beam radiotherapy, except for thyroid hormone replacement therapy. Tracheal relapse was observed after 6 months. Tracheal stent was used to reconstruct the airway twice. Conclusions: Trachea invasion might be a worse independent predictor of prognosis than any others and should be given particular attention. Furthermore, tracheal stent might be a palliative option for patients with tracheal relapse. [ABSTRACT FROM AUTHOR]

Introduction Goiter is localized or generalized thyroid hypertrophy. It is usually cervical, but may show intra-thoracic development beyond the thoracic inlet and down to the mediastinum: i.e., substernal goiter. The purpose of this study was to analyze the epidemiological, clinical and paraclinical profile of substernal goiter and the difficulties of management. Material and methods A retrospective study included 50 cases from our ENT department. Results Mean age was 47 years, with a sex ratio of 0.06. Clinical symptomatology was dominated by medial anterior cervical swelling. Compression signs were observed in 26 patients, and cervical lymph nodes in 3. Mean time to consultation was 7 years. Fiberoptic endoscopy found vocal cord palsy in 3 patients. Cervical ultrasonography was the first-line diagnostic test. Cervical-thoracic CT scan was requested in 45 patients to study thoracic extension and the relation of the thyroid mass with the supra-aortic vascular axes. Treatment systematically comprised total thyroidectomy on a cervical approach. There were 6 cases of malignancy. Discussion-conclusion Substernal goitre is fairly frequent. Despite particularities, an exclusively cervical approach is sufficient in a large majority of cases. The substernal nature of the goitre did not have major impact on postoperative complications. [ABSTRACT FROM AUTHOR]

Intrathoracic goiter is not uncommon but one that requires a sternotomy in addition to a cervical incision, to aid its removal, is. We describe the case of a 51-year-old woman whose intrathoracic goiter was successfully removed via a sternotomy. [ABSTRACT FROM AUTHOR]

Substernal Pacing in Humans Introduction The objective of this study was to assess feasibility of ventricular pacing and thresholds from within the substernal space to examine a new extravascular ICD configuration with pacing capabilities. Methods In patients undergoing midline sternotomy, a duodecapolar diagnostic pacing catheter was positioned in the substernal space anterior to the pericardium, and a cutaneous patch in left lateral position. Different unipolar and bipolar pacing configurations were assessed. Strength-duration curves were performed to identify the optimal output, starting at 25 mA with a pulse width of 10 milliseconds. Results Eight patients with mean age 69 ± 9 years were included. In 5, ventricular capture was achieved in ≥1 configuration. The mean bipolar pacing thresholds at PW 10, 5, 3, 1 milliseconds were 12.4 ± 3.7 mA (5 patients), 13.3 ± 5.8 mA (3 patients), 18.3 ± 5.7 mA (3 patients), and 25 ± 0 mA (2 patients), respectively. The 60-mm electrode spacing was the most successful bipolar configuration. Unipolar pacing was successful in 3 out of 4 patients with mean thresholds of 10 ± 0 mA at 10 milliseconds (3 patients), 15 ± 0 mA at 5 milliseconds (3 patients), 16.7 ± 2.9 mA at 3 milliseconds (3 patients), and 20 ± 7.1 mA at 1 milliseconds (2 patients). Conclusion Ventricular pacing from the substernal space in patients with midline sternotomy is feasible. Closed sternum studies are needed to determine pacing thresholds more accurately. [ABSTRACT FROM AUTHOR]

Chest pain requires a detailed differential diagnosis with good history-taking skills to differentiate between cardiogenic and noncardiogenic causes. Moreover, when other symptoms such as fever and elevated white blood cell count are involved, it may be necessary to consider causes that include infectious sources. A 53-year-old female with no significant past medical history returned to the hospital with recurrent complaints of chest pain that was constant, substernal, reproducible, and exacerbated with inspiration and expiration. The chest pain was thought to be noncardiogenic, as electrocardiography did not demonstrate changes, and cardiac enzymes were found to be negative for signs of ischemia. The patient's blood cultures were analyzed from a previous admission and were shown to be positive for Staphylococcus aureus. The patient was started empirically on vancomycin, which was later switched to ceftriaxone as the bacteria were more sensitive to this antibiotic. A transthoracic echocardiogram did not demonstrate any vegetation or signs of endocarditis. There was a small right pleural effusion discovered on X-ray. Therefore, computed tomography as well as magnetic resonance imaging of the chest were performed, and showed osteomyelitis of the chest. The patient was continued on intravenous ceftriaxone for a total of 6 weeks. Tests for HIV, hepatitis A, B, and C were all found to be negative. The patient had no history of childhood illness, recurrent infections, or previous trauma to the chest, and had had no recent respiratory infections, pneumonia, or any underlying lung condition. Hence, her condition was thought to be a case of primary sternal osteomyelitis without known cause. [ABSTRACT FROM AUTHOR]

An editorial is presented on the long‐term evaluation of a novel extravascular implantable cardioverter defibrillator. Topics include the implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy have been the mainstay of care for patients at risk of sudden cardiac death for decades, and the efficacy of transvenous ICD devices by the considerable morbidity and mortality associated with transvenous lead complications are lead failure, infection, and venous obstruction.

Introduction: A bulky retrosternal goiter means for the surgeon to consider an extracervical approach, usually from a partial sternotomy. Methods: Retrospective evaluation of a group of thyroid operations requiring sternotomy in a ten-year period (year 2012–2021), in an attempt to predict the need for sternotomy. Results: We performed a total of 1254 thyroid operations, with partial sternotomy required in 11 cases (0.88%): in 6 women and 5 men aged 43–84 years (mean 73.1 years). For these, 3 total thyroidectomies and 6 hemithyroidectomies (lobectomies) were performed. In 2 cases, we operated on the mediastinal residue, or regenerate, after a previous thyroidectomy from the cervical approach. The duration of hospitalization was 5–14 days, once there was bleeding with the need for operative revision, otherwise the procedures were without complications, including phonation. The border of the lower part of the thyroid gland in relation to the upper border of the aortic arch was in the range of +20 to -22 mm. The mean was -8.5 mm. Conclusion: All sternotomy thyroidectomies performed by us had a close relationship to, or overlapped with the upper line of the aortic arch. Significantly retrosternal propagating goiters are mostly eufunctional (81.9 % in our group) and develop in patients in the seventh or eighth decade of life. Therefore, if only one lobe propagates intrathoracically, a hemithyroidectomy is sufficient. A carcinoma is rarely present; in one case in our group. We believe that the necessity of sternotomy cannot be accurately predicted, but it is necessary to be prepared for it, especially in the case of a goiter exceeding the level of the aortic arch. In case of greater retrosternal propagation, it is certainly appropriate to perform a CT, for surgical reasons (possibility of sternotomy, risk of leaving part of the gland) and anesthetic reasons (compression and deviation of the trachea).

Summary: Substernal goiter can be classified as primary or secondary, depending on the site of origin. Primary substernal goiters (< 1% of substernal goiters), also known as mediastinal aberrant goiters, arise from ectopic thyroid tissue in the mediastinum, and receive their blood supply from intrathoracic arteries instead of thyroid arteries. A secondary substernal goiter is defined as one that has descended from the neck to the plane below the thoracic inlet, or one that has more than 50% of its mass lying inferior to the thoracic inlet. Surgical resection should be considered even for elderly patients because of the risks of mass compression symptoms (e.g., dyspnea and dysphasia), malignancy, and low morbidity of surgery. Most of the primary substernal goiters can be resected through the cervical approach. In most instances, sternotomy or thoracotomy is needed only in cases of previous cervical thyroidectomy, invasive carcinoma, or ectopic goiter. [Copyright &y& Elsevier]

Background Our objective was to evaluate morbidity and mortality of thyroidectomy in substernal goiters and identify patients at risk for these events. Methods The medical records of 127 patients with substernal goiters were retrospectively reviewed. Results The most common preoperative symptom was shortness of breath (48%). 13% of the 127 patients were asymptomatic. Preoperative imaging identified tracheal deviation in 69% and tracheal compression in 41% of the cases. Substernal goiters were resected via a cervical approach in 100% of the cases. Six patients (5%) had postoperative hoarseness, 1 had permanent vocal cord paralysis, and 19 (15%) had transient postoperative hypocalcemia. The mortality and permanent hypoparathyroidism were null. Patients with postoperative complications had larger goiters and were more likely to have tracheal compression. Conclusions Thyroid resection via a cervical approach for substernal goiters is associated with low rate of morbidity and no mortality. Patients with large tumors and tracheal compression are more likely to develop postoperative complications. © 2009 Wiley Periodicals, Inc. Head Neck, 2010 [ABSTRACT FROM AUTHOR]

Objective: To determine what factors predispose patients with retrosternal goiters to median sternotomy. Study Design: Retrospective review. Methods: Analysis of a single surgeon experience with 113 substernal goiters operated upon during a 10-year period. Results: 108 goiters were successfully removed through a cervical approach. Four patients required sternotomy, and it was concluded that one patient who did not receive sternotomy might have been better managed with sternotomy. Factors that led to sternotomy were malignancy, involvement of the posterior mediastinum, extensive substernal extension, and the presence of an ectopic nodule. The latter two were the most important factors. Revision surgery and tracheal compression did not influence the need for sternotomy. Conclusions: On the basis of preoperative imaging, it is possible to predict which patients with retrosternal goiters are likely to require median sternotomy. These factors are malignancy, extension into the posterior mediastinum, substernal extension inferior to the level of the aortic arch, and the lack of a solid attachment between the cervical and mediastinal components of the thyroid gland. Although previously reported, the latter factor has not received sufficient recognition in the management of retrosternal goiter. Laryngoscope, 2009 [ABSTRACT FROM AUTHOR]

Substernal goiter is considered to be a diagnostic differential for all anterosuperior mediastinal masses. For a substernal goiter, surgical removal is suggested when it is large in size, with a possibility for malignancy or has local compression of adjacent structures. This can be performed through the neck or by the addition of a partial or complete sternotomy if necessary. A 58-year-old Chinese man from Guangdong Province had had dry cough for a year. A subsequent CT scan in our hospital suggested “ectopic intrathoracic thyroid”. Fine needle percutaneous mass biopsy also suggested “ectopic intrathoracic thyroid”. We performed a standard median sternotomy to remove the mass. It measured 13 cm × 8 cm × 6 cm in size, and weighed 2.8 kg. The pathological diagnosis confirmed a benign thyroid adenoma. The patient had no hoarseness, dyspnea or hypocalcemia and was quickly extubated in the operating room. Recently, we encountered a big substernal goiter and had performed successful resection, which is reported here for reference. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study is to provide a thorough, quantified assessment of the substernal space as the site of extravascular implantable cardioverter-defibrillator (ICD) lead placement using computed tomography (CT) scans and summarizing adverse events and defibrillation efficacy across anatomical findings. Subcutaneous ICDs are an alternative to transvenous defibrillators but have limitations related to ICD lead distance from the heart. An alternative extravascular system with substernal lead placement has the potential to provide defibrillation at lower energy and pacing therapies from a single device., Methods and Results: A multi-centre, non-randomized, retrospective analysis of 45 patient CT scans quantitatively and qualitatively assessing bony, cardiac, vascular, and other organ structures from two human clinical studies with substernal lead placement. Univariate logistic regression was used to evaluate 15 anatomical parameters for impact on defibrillation outcome and adjusted for multiple comparisons. Adverse events were summarized. Substernal implantation was attempted or completed in 45 patients. Defibrillation testing was successful in 37 of 41 subjects (90%) using ≥10 J safety margin. There were two intra-procedural adverse events in one patient, including reaction to anaesthesia and an episode of transient atrial fibrillation during ventricular fibrillation induction. Anatomical factors associated with defibrillation failure included large rib cage width, myocardium extending very posteriorly, and a low heart position in the chest (P-values <0.05), though not significant adjusting for multiple comparisons., Conclusion: Retrospective analysis demonstrates the ability to implant within the substernal space with low intra-procedural adverse events and high defibrillation efficacy despite a wide range of anatomical variability., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)