The Safety and Feasibility of Laryngeal Mask Airway (LMA) Management in Non-intubated Subxiphoid-subcostal Thoracoscopic Thymectomy: Preliminary Results

Intubated general anesthesia and single-lung ventilation are considered mandatory for conventional thoracoscopic surgery. Non-intubated thoracoscopic thymectomy is technically challenging. The aim of this article was to present the initial results of non-intubated subxiphoid-subcostal thoracoscopic thymectomy (NI-STT) under LMA management for patients with thymic tumor or myasthenia gravis (MG) and to investigate the feasibility and safety of the procedure. A retrospective analysis of patients undergoing NI-STT for thymic tumor or MG at our department from January 2017 to January 2020 was performed. The clinical characteristics and perioperative outcomes of the patients were reviewed and analyzed. A total of 61 patients were received NI-STT in this analysis, of which 19 patients with MG undergone an extended thymectomy and the rest (n=42) undergone a partial thymectomy. The anesthetic induction duration, surgical duration and global operating room duration were 24.83±12.27 min, 118.75±32.49 min and 173.51±41.80 min, respectively. The lowest SpO2 and peak EtCO2 during operation were 96.15±2.93 mmHg and 41.79±7.53 mmHg, respectively. The mean duration of chest drainage and postoperative hospital stays were 1.87 days, and 2.91 days, respectively. Three cases had sore throat and irritable cough and two cases suffered nausea and vomiting occurred. one patient suffered from an atrial fibrillation, two patients experienced pneumonia, and one patient suffered wound infection, respectively. There were no phrenic nerve paralysis and mortality occurred in the study group. The postoperative pain was low on 1,3, 7, 14, 30, 90 and 180 postoperative days. NI-STT was a technically safe and feasible approach for treating thymic tumors or MG. It could be an alternative to intubated single-lung ventilation for thymectomy in selected patients.

Acute safety and performance outcomes from the inspIRE trial using a novel pulsed field ablation system for the treatment of paroxysmal atrial fibrillation

Background/Introduction The inspIRE clinical trial was designed to assess the safety and efficacy of a fully integrated biphasic pulsed field ablation (PFA) system comprised of a multi-channel generator, variable decapolar irrigated loop circular catheter, and mapping system (Figure A) for the treatment of paroxysmal atrial fibrillation (PAF). Purpose Using this novel PFA system in a multicentre clinical trial, we present the initial feasibility of electrical pulmonary vein isolation (PVI), procedural performance, and acute safety results. Methods inspIRE is a prospective, non-randomized, multi-centre study, planned to enrol up to 550 patients. PVI is performed with the novel, variable loop circular catheter, compatible mapping system and generator. Acute procedural effectiveness (entrance block in all clinically targeted PVs post adenosine/isoproterenol challenge) and the incidence of primary adverse events (PAEs) were assessed. PAEs are defined as the occurrence of cardiac tamponade/perforation, myocardial infarction, stroke/cerebrovascular accident, thromboembolism, transient ischemic attack, permanent phrenic nerve paralysis, pulmonary edema, pericarditis, and any major vascular access complications within 7 days of the ablation procedure. Additionally, any incidence of procedure or device related death, atrio-esophageal fistula, or PV stenosis (related to the ablation procedure or study catheter) within the 12M follow-up period is classified as a PAE. Results A total of 35 PAF subjects (age 59.7±10.7 years, 54.3% male) were treated across 5 European sites by 6 operators. Acute procedural success was achieved in 100% of study subjects (Figure B) with zero incidence of PAEs. Mean total procedure time was 82.9±19.9 minutes with 27.0±11.9 minutes of PFA from first to last application. Average fluoroscopy use was 10.6±6.8 minutes and LA dwell time was 45.6±15.3 minutes. Conclusion Initial results of the inspIRE trial demonstrate the acute safety and effectiveness of the new integrated IRE circular catheter, mapping system and generator for PVI in PAF patients. FUNDunding Acknowledgement Type of funding sources: Other. Main funding source(s): inspIRE is a company-sponsored study funded by Biosense Webster, Inc. Figure 1. (A) PFA System; (B) PVI Voltage Map

Direct Comparison Between Second-Generation Cryoballoon Ablation Versus Contact Force-Sensing Radiofrequency Ablation in Paroxysmal Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis Study

Background Pulmonary vein isolation (PVI) is the main ablation approach for paroxysmal atrial fibrillation (AF). The superiority of the second-generation cryoballoon (2G-CB) ablation over contact force-sensing radiofrequency (CF-RF) ablation is unclear. Therefore, we sought to investigate the superiority of 2G-CB ablation over CF-RF ablation in paroxysmal AF patients. Methods A systematic review and meta-analysis study was conducted. We included 12 studies involving 1419 patients. The overall effects were quantified using pooled odds ratio (OR) or mean difference (MD) for categorical or continuous variables. Results Freedom from atrial tachyarrhythmias (ATAs) (OR = 0.88; 95% confidence interval [CI] = 0.68 to 1.15; p = 0.35), freedom from AF (OR = 0.93; 95% CI = 0.64 to 1.34; p = 0.7), and acute PVI (OR = 1.00; 95% CI = 1.00 to 1.00; p = 0.99) between 2G-CB ablation and CF-RF ablation were not different. The 2G-CB ablation took shorter procedure time (MD = -18.78 minutes; 95% CI = -27.72 to -9.85 minutes; p < 0.01) and relative similar fluoroscopy time (MD = 2.66 minutes; 95% CI = -0.52 to 5.83 minutes; p = 0.10). Phrenic nerve paralysis was higher in 2G-CB ablation group (OR = 7.25; 95% CI = 2.37 to 22.16; p = < 0.005). Conclusion The 2G-CB ablation was not superior to CF-RF ablation in paroxysmal AF in terms of acute PVI, freedom from ATAs, and freedom from AF. The 2G-CB ablation procedure can be performed faster than CF-RF ablation, although correlated with a higher phrenic nerve paralysis.

Feasibility and Safety of Laparoscopic‐Guided Epicardial Access for Ventricular Tachycardia Ablation

Background The usual approach to epicardial access in patients with Chagas cardiomyopathy and megacolon is surgical access to avoid bowel injury. However, there are concerns regarding its safety in cases of Chagas cardiomyopathy with reports of prolonged mechanical ventilation and high mortality in this clinical setting. The aim of this study was to examine feasibility and complication rates for ventricular tachycardia ablation performed with laparoscopic‐guided epicardial access. Methods and Results This single center study examined complication rates of the first 11 cases of ventricular tachycardia ablation in patients with Chagas cardiomyopathy, using laparoscopic guidance to access epicardial space. All 11 patients underwent epicardial VT ablation using laparoscopic‐guided epicardial access, and the complication rates were compared with historical medical reports. The main demographic features of our population were age, 63±13 years; men, 82%; and median ejection fraction, 31% (Q1=30% and Q3=46%). All patients were sent for ventricular tachycardia ablation because of medical therapy failure. The reason for laparoscopy was megacolon in 10 patients and massive liver enlargement in 1 patient. Epicardial access was achieved in all patients. Complications included 1 severe cardiogenic shock and 1 phrenic nerve paralysis. No intra‐abdominal organ injury occurred; only 1 death, which was caused by progressive heart failure, was reported more than 1 month after the procedure. Conclusions Laparoscopic‐guided epicardial access in the setting of ventricular tachycardia ablation and enlarged intra‐abdominal organ is a simple alternative to more complex surgical access and can be performed with low complication rates.

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

Background Continuous interscalene block is widely used for pain management in shoulder surgery. However, continuous interscalene block performed using the catheter-through-needle method is reportedly associated with adverse events such as pericatheter leakage of the local anesthetic, phrenic nerve paralysis, and hoarseness. Because we expected that the catheter-over-needle method would reduce these adverse events, we examined cases in which continuous interscalene block was performed using the catheter-over-needle method to determine what adverse events occurred and when. Methods We retrospectively reviewed the anesthesia and medical records of adult patients who underwent catheter insertion to receive a continuous interscalene block performed using the catheter-over-needle method at our hospital from July 2015 to July 2017. Results During the surveillance period, 122 adult patients underwent catheter insertion to receive a continuous interscalene block administered using the catheter-over-needle method. No case of pericatheter local anesthetic leakage was observed. Adverse events, such as dyspnea, hoarseness, insufficient anesthetic effect, dizziness, cough reflex during drinking, or ptosis, were observed in 42 patients (34.4%; 95% confidence interval 26–42.7). Most of the adverse events occurred on postoperative day 2. The median time between surgery and the onset of adverse events was 28.5 h. Conclusions The catheter-over-needle method may prevent the pericatheter leakage of the local anesthetic. However, adverse events occurred in more than one-third of the patients. During continuous interscalene block, patients must be carefully observed for adverse events, especially on postoperative day 2. Trial registration This study was registered at the UMIN Clinical Trials Registry on August 13th, 2019 (UMIN000037673).

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

Background: Continuous interscalene block is widely used for pain management in shoulder surgery. However, continuous interscalene block performed using the catheter-through-needle method is reportedly associated with adverse events such as pericatheter leakage of the local anesthetic, phrenic nerve paralysis, and hoarseness. Because we expected that the catheter-over-needle method would reduce these adverse events, we examined cases in which continuous interscalene block was performed using the catheter-over-needle method to determine what adverse events occurred and when. Methods: We retrospectively reviewed the anesthesia and medical records of adult patients who underwent catheter insertion to receive a continuous interscalene block performed using the catheter-over-needle method at our hospital from July 2015 to July 2017. Results: During the surveillance period, 122 adult patients underwent catheter insertion to receive a continuous interscalene block administered using the catheter-over-needle method. No case of pericatheter local anesthetic leakage was observed. Adverse events, such as dyspnea, hoarseness, insufficient anesthetic effect, dizziness, cough reflex during drinking, or ptosis, were observed in 42 patients (34.4%; 95% confidence interval 26–42.7). Most of the adverse events occurred on postoperative day 2. The median time between surgery and the onset of adverse events was 28.5 h. Conclusions: The catheter-over-needle method may prevent the pericatheter leakage of the local anesthetic. However, adverse events occurred in more than one-third of the patients. During continuous interscalene block, patients must be carefully observed for adverse events, especially on postoperative day 2. Trial registration: This study was registered at the UMIN Clinical Trials Registry on August 13th, 2019 (UMIN000037673).