Balloon needle for the atraumatic transcortical ventricular approach: technical note

We have designed a double-lumen inflatable needle for the atraumatic dissection of brain substance. This balloon needle has been successfully used for the ventricular approach in brain grafting procedures to obtain a rounded corticotomy with a diameter of 1.5-2 cm in the treatment of Parkinson's disease.     

Intramyocardial foreign body: sewing needle with the uncommon clinical feature of constrictive pericarditis.

A rare case of intracardiac injury with a sewing needle causing constrictive pericarditis is reported. A 72-year-old woman was admitted with edema of the face and legs. A chest radiogram showed a needle-shaped metallic image overlying the cardiac silhouette. Computed tomography revealed the needle was located in the left ventricular myocardium, and also showed a thickened pericardium. Surgical removal of the needle and pericardectomy were performed simultaneously.     

Intramyocardial foreign body

A rare case of intracardiac injury with a sewing needle causing constrictive pericarditis is reported. A 72-year-old woman was admitted with edema of the face and legs. A chest radiogram showed a needleshaped metallic image overlying the cardiac silhouette. Computed tomography revealed the needle was located in the left ventricular myocardium, and also showed a thickened pericardium. Surgical removal of the needle and pericardectomy were performed simultaneously.     

Myocardial norepinephrine assay of needle biopsy specimens

A sensitive and specific radioenzymatic norepinephrine (NE) assay based on the conversion of norepinephrine to tritiated epinephrine has been modified for myocardial needle biopsy specimens. The tritiated epinephrine is quantitated by scintillation counting of similarly processed standards and specimens and is reported as micrograms of NE per gram of wet tissue. Norepinephrine levels have been determined in 5- to 30-mg samples of canine left ventricular free wall, ventricular apex, and right ventricular free wall and of rat right and left ventricles. The technique is compared to other previous spectrofluorometric methods.     

Clinical value of percutaneous needle trephination (PNT)

Summary In 56 neurosurgical patients 70 percutaneous needle trephinations were performed. This method was mostly used in patients with acute increase of ICP due to occlusive hydrocephalus of various aetiologies. Thanks to the accuracy and exhaustiveness of CT information, and thanks to the simplicity and safety of percutaneous needle trephination, this latter could be more and more used in daily clinical practice as a diagnostic and therapeutic procedure, for example for the study of adult hydrocephalus, for provisional external ventricular drainage, for treatment of CSF infections, and for ventricular bleedings (also in newborns and premature infants). No serious complication was seen even after prolonged CSF drainage over a period of 41 days. The method of PNT, as described in detail, can be used under sterile conditions at the bedside, on the stretcher in the emergency room, or in the CT or X-ray laboratory. It fulfils the criteria for clinical acceptance: simplicity, low risk, reliability, exactness, and effectiveness.     

Needle in the left ventricular myocardium

A sewing needle which had accidentally penetrated through the chest wall and got embedded in the left ventricular myocardium was surgically removed without the use of cardiopulmonary bypass.     

Percutaneous needle trephination. Experience in 200 cases

Summary For many years percutaneous needle and classic burr-hole trephination with insertion of plastic catheters for external ventricular drainage are in use. The shortcomings of the conventional puncture needles were compensated for by the development of a modified instrument in recent years.In this prospective study we tried to define advantages and disadvantages of percutaneous ventriculostomy with this modified needle in a large number of patients. We treated and followed a total number of 200 patients with external ventricular drainage for various reasons (42% obstructive hydrocephalus, 27% haematocephalus, 11% malresorptive hydrocephalus, 11% elevated ICP and 9% infections). The ventriculostomy is performed — after percutaneous trepheication with a 1.5 mm drill and 1.2 mm needle under the local aesthesia as a bedside procedure. The modified blunt needle is provided with markings and a set screw which allows insertion to a prefixed depth and a sharp guide which is withdrawn after penetration of the dura. It is then bent rostrally and fixed by a plaster cast. The mean duration of drainage was 9 days (1–30 days). Mean operating time for the whole procedure including fixation and connection to the drainage system was 20 minutes. Overall complication rate was 13% (N=26). Two intracerebral haemorrhages (1%) occurred, of which one was caused by overdrainage. Five (3%) infections in primarily not infectious cases (N=182) were seen. Only one case of infection occurred without loosing of the needle on day 17. In 19 patients (10%) the needles had loosened. Fifteen times this complication was repaired in time and no infection occurred. The overall complication rate (13%) and the needle related risk of bleeding (0.5%) seem average. The true risk of infection with correct handling (0.5%) is very low despite the very long average duration of drainage. The main risk lies in the markedly high danger of loosening (10%), which entails a disproportionally high demand for nursing care. Nevertheless, we regard percutaneous needle trephination as the ventriculostomy method of choice because of its better practicability and low infection rate.     

Coronary artery surgery with induced temporary asystole and intermittent ventricular pacing: an experimental study

Coronary artery bypass grafting performed without cardiopulmonary bypass points a difficulty in performing coronary anastomoses on a beating heart. A non-cardiopulmonary bypass technique in sheep by which individual sutures can be placed on a still heart is described. Epicardial pacing wires were placed and a curved needle passed between the aorta and pulmonary artery into the muscular interventricular septum and directed caudally and to the right. The tip of the needle now lay in the vicinity of the outflow of the bundle of His. No cardiac chamber or vital structures were traversed. Injection of lignocaine here resulted in immediate ventricular asystole. Ventricular pacing restored cardiac output. After establishing local control of the vessel coronary anastomosis was performed stopping ventricular pacing for the few seconds required to place a single suture and reinstating it between the passage of sutures. Reversion to sinus rhythm occurred spontaneously.     

Ventricle puncture for external CSF drainage and pressure measurement using a modified puncture needle

Summary A modified needle for external ventricular drainage is presented. Contrary to conventional spinal needles with this instrument the sharp guide can be withdrawn after penetration of the dura, thus, no sharp instrument affects the brain, nor remains within the ventricles in cases of continuous drainage. Furthermore, depth of penetration can be determined preoperatively by means of a set screw also facilitating fixation of the needle. To date, we have used this modified needle in 50 patients for short or long term CSF drainage and for CSF pressure measurements. Trephination was performed with a hand or battery-driven drill. Except for an infection in one case we found no serious complications in our patients. In our opinion, ventricle puncture for external drainage and pressure measurement with this device is a simple and safe method and can be performed on the ward under local anaesthesia.     

Management of proximal shunt obstruction. Technical note

Proximal shunt obstruction or obstruction of the ventricular catheter may present with signs and symptoms of shunt failure with either no cerebrospinal fluid flow or a falsely low intracranial pressure (ICP) upon shunt tap. The author reports a technique for lowering the ICP and for measuring the pressure in patients with such obstruction by cannulation of the reservoir and ventricular catheter to penetrate into the ventricle with a 3 1/2-in. No. 22 spinal needle. The findings in 20 cases in which this approach was utilized are summarized.     

ELECTROMANOMETRIC CONFIRMATION OF NEEDLE POSITION IN HAEMOPERICARDIUM WITH SEVERE TAMPONADE

Simultaneous recording of the electrocardiogram and of the pressuretransmitted through the drainage needle in patients with haemopericardiumprovided confirmation that the needle tip was in the pericardialcavity. Proper position was indicated by a positive pressurewave beginning before the QRS complex, reaching its maximumvalue in the first part of the ST segment and ending with theT wave. In contrast, ventricular penetration was signalled bya positive pressure wave beginning in the first part of theQRS complex, reaching its maximum during the T wave and endingbetween the T and P waves.     

Haemodynamic measurements prior to ventricular fibrillation or asystole following experimental coronary occlusion

Dogs under general anaesthesia were studied following occlusion of a branch of the left circumflex artery produced by wedging a radio-opaque catheter under fluoroscopic control. In two dogs an aluminium-coated steel needle was lodged in place via the catheter. Pressures in the left atrium, left ventricle, pulmonary artery, and right atrium were recorded in nine dogs following this procedure, and in two of these serial cardiac outputs were determined. In four dogs the fatal dysrhythmia was preceded by bursts of ventricular rhythm disturbances without evidence of heart failure, and in one dog sudden fatal ventricular tachycardia occurred without any preceding warning. Flow measurements in one of these dogs showed no fall in output or stroke volume. In two dogs the left ventricular filling pressure gradually rose before the development of ventricular fibrillation. No change in output or stroke volume was shown in one of these dogs. Two dogs developed increasing ventricular irritability together with evidence of left ventricular failure, and in one dog, who was resuscitated from ventricular fibrillation, left ventricular failure leading to death occurred later the same day. Right atrial pressure was shown to be a misleading index of myocardial function, and the only evidence for impending acute circulatory embarrassment was increasing ventricular irritability.     

Preoperative diagnosis of a pulmonary artery sarcoma.

A pulmonary artery sarcoma was diagnosed preoperatively by magnetic resonance imaging enhanced with gadolinium and confirmed by percutaneous computed tomographic guided needle biopsy. Accurate preoperative diagnosis allowed planned curative surgery with removal of the right ventricular outflow tract and reconstructive surgery using a cryopreserved homograft.     

Surgical Removal of an Intracardiac Sewing Needle in a 13-Month-Old Chinese Girl: Report of a Case

Sewing needles, albeit rare in the case of penetrating cardiac injury, are highly lethal; especially in children, because the injury is difficult to diagnose and treat. We herein present the case of a 13-month-old girl who was injured by a sewing needle inserted in the myocardium; it is the first report of its kind from mainland China. The 13-month-old girl was referred to our hospital with a range of symptoms, including convulsions, diarrhea, and cough. Chest X-ray and echocardiogram revealed a needle located below the aortic valve, passing through the ventricular septum and aortic root. Surgical removal of the needle was performed under extracorporeal circulation. No hemorrhage or arrhythmia was seen, so the operation was ended, and the patient was discharged 8 days after the surgery. An early diagnosis and intervention proved to be lifesaving for this patient with a penetrating cardiac injury. We hope this case can provide a reference for the treatment of similar situations.Key words: Cardiac function, Foreign body, Pediatric, Patient safety, SurgeryA needle in the heart is a comparatively rare event. It is typically considered to be life threatening as it may induce adverse events such as cardiac tamponade, infection, mural thrombus, peripheral embolism, and valve dysfunction. Especially in children, a sharp needle in the heart poses a serious hazard requiring immediate intervention. However, because of the limited communication skills of children, it is difficult to make a timely and accurate diagnosis, which adds complexity to the treatment. To date, no similar cases have been reported from China. In this report, we present a case of a child who had a sewing needle inserted in the myocardium. The needle was successfully extracted under extracorporeal circulation.     

Ventricular septal fistula formation due to infectious endocarditis in a hemodialysis patient with aortic valve replacement

We report a case of infectious endocarditis in a 77-year-old woman who was undergoing maintenance hemodialysis therapy, and who was also having a prosthetic aortic valve replacement. The disease resulted from a local skin infection at the needle puncture site of the arteriovenous fistula. Ampicillin-resistant Staphylococcus aureus was the causal organism. Surgical treatment could not be performed because of associated intracranial hemorrhage due to septic embolism. In spite of intensive treatment with several antibiotics, a ventricular septal abscess just beneath the prosthetic aortic valve progressed to form a ventricular septal fistula. The resultant intracardiac left-to-right shunt led to refractory congestive heart failure. The patient finally died of heart failure. The formation of a ventricular septal fistula is considered to be a rare and extraordinary complication of infectious endocarditis in a hemodialysis patient with aortic valve replacement. Received: July 25, 2001 / Accepted: November 3, 2001     

Intraoperative, two-dimensional echocardiography-guided removal of retained intracardiac air

The removal of intracardiac air after cardiotomy may be simplified with the use of two-dimensional echocardiography. This technique can be used to readily identify retained pockets of air and can function as a guide to needle aspiration of the ventricular chambers. With a valve prosthesis in place, de-airing can be accomplished with minimal displacement of the heart. The technique is easy to use and the images are simple to interpret.     

Functional comparison of transmyocardial revascularization by mechanical and laser means

Background. As a result of the clinical benefit observed in angina patients treated by transmyocardial revascularization (TMR) with a laser, interest in mechanical TMR has been renewed. Although the injury induced by mechanical TMR is similar to laser TMR, the resultant impact on myocardial contractility is unknown. The purpose of this study was to determine whether mechanical TMR improves ventricular function as compared with laser TMR in chronically ischemic myocardium.

Methods. After establishing an area of chronic myocardial ischemia, 25 domestic pigs were randomized to treatment by: excimer laser (group I), a hot needle (50°C) (group II), a normothermic needle (group III), an ultrasonic needle (40 KHz) (group IV), or no treatment (group V). All devices create a transmural channel of the same diameter; 22 ± 1 transmural channels were created in each animal. Regional myocardial contractility was assessed by measuring ventricular wall thickening at rest and with dobutamine stress echocardiography. Six weeks after revascularization, the animals were restudied at rest and with stress. Postsacrifice and histologic analysis of angiogenesis and TMR effects was then assessed.

Results. Laser TMR provided significant recovery of ischemic myocardial function. This improvement in contractility after laser TMR was a 75% increase over the baseline function of the ischemic zone (p < 0.01). Mechanical TMR provided no significant improvement in function posttreatment. In fact, TMR achieved with an ultrasonic needle demonstrated a 40% worsening of the contractility versus the pretreatment baseline (p < 0.05). Histologic analysis demonstrated a significant increase in new blood vessels in the ischemic zone after laser TMR, which was not demonstrated for any of the other groups (p < 0.05). Additionally, evaluation of the mechanical TMR channels demonstrated significant scarring, which correlated with the functional results.

Conclusions. Using devices to create an injury analogous to the laser, mechanical TMR failed to improve the function of chronically ischemic myocardium. Only laser TMR significantly improved myocardial function.     

Use of muscular VSD Amplatzer occluder for closing right ventricular free wall perforation after hybrid procedure.

In some patients, so cold hybrid cardiologic procedures are performed whereas a heart is exposed surgically to puncture directly the heart cavity. After performing the interventional procedure, the opening in ventricular wall is closed surgically. We present our initial experience with closing the right ventricular (RV) cavity opening with the muscular ventricular septal defect Amplatzer occluder (A-MVSDO). In four sheep, heart was exposed surgically and punctured under direct vision by needle and guide wire, 14F and 26F sheath were introduced into right ventricle and the A-MVSDO was introduced causing closure of the RV opening. In all four cases, the occluder was successfully placed closing the opening in RV. No major bleeding after occlusion was observed. Following complications were observed: pneumothorax in two animals, rhythm disturbances and thrombus suspected in one. A-MVSDO occluder seems to be a useful device to close RV opening after hybrid interventional cardiologic procedure.     

Repair of multiple muscular ventricular septal defects: septal obliteration technique

BACKGROUND: The management of the apical multiple muscular ventricular septal defects (VSDs) remains still controversial. There are various surgical techniques and approaches for closure of "Swiss-cheese" VSDs. In this study, we report the outcome of multiple muscular VSDs repair, using the septal obliteration technique. METHODS: We used the septal obliteration technique in five "Swiss-cheese" ventricular septal defects cases through right atriotomy. Four of the cases had isolated multiple VSDs. One case also had an aortic arch interruption type A, which was repaired prior to cardiopulmonary bypass. Their ages varied between 43 days and 6 years. RESULTS: We did not experience any mortality or serious morbidity. Tracheostomy was required in one patient. There was no important residual shunt in postoperative period, except a minimal shunt in one case. CONCLUSION: The closure technique of "Swiss-cheese" trabecular multiple VSDs using a large single patch was not troubling. Transatrial approach prevented postoperative problems of ventricular incision. Using a large needle with a large pledgett is the key, which provides deep tissue penetration to avoid residual shunt.