High Tidal Volume, High Positive End Expiratory Pressure and Apneic Breath Hold Strategies (Lung Navigation Ventilation Protocol) With Cone Beam Computed Tomography Bronchoscopic Biopsy of Peripheral Lung Lesions: Results in 100 Patients.

BACKGROUND: A dedicated anesthesia protocol for bronchoscopic lung biopsy-lung navigation ventilation protocol (LNVP)-specifically designed to mitigate atelectasis and reduce unnecessary respiratory motion, has been recently described. LNVP demonstrated significantly reduced dependent ground glass, sublobar/lobar atelectasis, and atelectasis obscuring target lesions compared with conventional ventilation. METHODS: In this retrospective, single-center study, we examine the impact of LNVP on 100 consecutive patients during peripheral lung lesion biopsy. We report the incidence of atelectasis using cone beam computed tomography imaging, observed ventilatory findings, anesthesia medications, and outcomes, including diagnostic yield, radiation exposure, and complications. RESULTS: Atelectasis was observed in a minority of subjects: ground glass opacity atelectasis was seen in 30 patients by reader 1 (28%) and in 18 patients by reader 2 (17%), with good agreement between readers (κ = 0.78). Sublobar/lobar atelectasis was observed in 23 patients by reader 1 and 26 patients by reader 2, also demonstrating good agreement (κ = 0.67). Atelectasis obscured target lesions in very few cases: 0 patients (0%, reader 1) and 3 patients (3%, reader 2). Diagnostic yield was 85.9% based on the AQuIRE definition. Pathology demonstrated 57 of 106 lesions (54%) were malignant, 34 lesions (32%) were benign, and 15 lesions (14%) were nondiagnostic. CONCLUSION: Cone beam computed tomography images confirmed low rates of atelectasis, high tool-in-lesion confirmation rate, and high diagnostic yield. LNVP has a similar safety profile to conventional bronchoscopy. Most patients will require intravenous fluid and vasopressor support. Further study of LNVP and other ventilation protocols are necessary to understand the impact of ventilation protocols on bronchoscopic peripheral lung biopsy.

Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years.

BACKGROUND: Cerebrospinal fluid drainage, a well-established means of preventing paraplegia after thoracic aortic aneurysm surgery, can result in serious, sometimes lethal complications. In a large group of patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage, we examined the incidences of and potential risk factors for these outcomes. METHODS: The records were reviewed of 504 patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage at the Texas Heart Institute at St. Luke's Episcopal Hospital between February 2005 and December 2009. All historical data, inpatient records, and billing data were searched for evidence of complications. RESULTS: Of the 504 patients, 14 (2.8%) had intracranial hemorrhage, of whom 10 (72%) had subdural hematoma. Postdural puncture headache developed in 49 patients (9.7%), of whom 17 (34.6%) required epidural blood patch placement for resolution. Multivariable analysis identified having a connective tissue disorder (odds ratio, 3.08; 95% confidence interval, 1.33-7.13) as an independent predictor of postdural puncture headache, but not age less than 40 years (odds ratio, 0.97; 95% confidence interval, 0.94-0.99). CONCLUSIONS: Cerebrospinal fluid drainage, as performed by our method, seems to be associated with a modest rate of intracranial bleeding in patients who undergo surgical thoracic aortic aneurysm repair. In contrast, postdural puncture headache is not uncommon, particularly in patients with connective tissue disease. Clinicians caring for these patients should consider the likelihood of postdural puncture headache, and any such patient with postoperative headache should be assessed for epidural blood patch placement.

Left atrial dissection after left ventricular aneurysm repair.

Left atrial (LA) dissection is an uncommon entity that occurs most often after mitral valve surgery. We present a case of a 52-year-old man who developed an LA dissection after repair of a postinfarction left ventricular (LV) aneurysm. Transesophageal echocardiography was used to establish the diagnosis of an LA dissection that almost completely occluded the LA, limiting LV filling and causing hemodynamic instability.