Christopher C. Harle

Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope

PurposeThe GlideScope® videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords is sometimes difficult. The goal of the study was to determine which of two ETT angles (60°vs 90°) and cambers (forwardvs reverse) was better, as determined by time to intubation (TTI).MethodsTw o hundred patients requiring orotracheal intubation for elective surgery were randomly allocated to one of four groups: A) 90° angle, forward camber; B) 90° angle, reverse camber; C) 60° angle, forward camber; D) 60° angle, reverse camber. Time to intubation was assessed by a blinded observer. Operators were blinded until the point of intubation. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were recorded.ResultsThe angle of the ETT had an impact on TTI but camber did not. The 90° angle demonstrated a 13% faster TTI than the 60° angle (47.1 ± 21.2 secvs 54.4 ± 28.2 sec,P = 0.042), and it resulted in easier intubation (VAS 16.4 ± 14.2 mmvs 27.3 ± 23.5 mm,P = 0.0001). The overall incidence of a grade 1 or 2 Cormack-Lehane glottic view was 99%.ConclusionsIn a heterogeneous group of operators and patients intubated with the GlideScope®, a 90° ETT angle provided the best result and should be the initial configuration. The camber of the ETT does not affect the time to intubation.RésuméObjectifLe vidéo-laryngoscope GlideScope® offre en général une excellente visualisation glottique; toutefois, il est parfois difficile d’orienter la sonde endotrachéale (SET) entre les cordes vocales. Le but de cette étude était de déterminer lequel de deux angles de SET (60° vs 90°) et quelle cambrure (avant vs arrière) étaient les meilleurs, déterminés selon le temps requis pour l’intubation (TRI).MéthodesDeux cents patients nécessitant une intubation oro-trachéale pour une chirurgie réglée ont été répartis en quatre groupes de façon aléatoire: a) angulation de 90°, cambrure avant; b) angulation de 90°, cambrure arrière; c) angulation de 60°, cambrure avant; d) angulation de 60°, cambrure arrière. Le temps requis pour l’intubation était estimé par un observateur ignorant le groupe d’allocation. Les opérateurs ont été tenus ignorants du groupe d’allocation jusqu’à l’intubation. Une échelle visuelle analogique (VAS) permettait d’estimer la facilité d’intubation. Le nombre de tentatives d’intubation, d’échecs, les grades glottiques ainsi que l’utilisation de manipulation laryngée externe étaient notés.RésultatsL’angulation de la SET a eu un impact sur le TRI mais pas la cambrure. Avec une angulation de 90°, le TRI était de 13% plus rapide qu’avec une angulation de 60° (47,1 ± 21,2 sec vs 54,4 ± 28,2 sec, P = 0,042), et l’ intubation était plus facile (VAS 16,4 ± 14,2 mm vs 27,3 ± 23,5 mm, P = 0,0001). L’incidence globale d’une visualisation glottique Cormack-Lehane de grade I ou 2 a été de 99 %.ConclusionsDans un groupe hétérogène d’opérateurs et de patients intubés avec le GlideScope®, une angulation de la SET de 90° offre le meilleur résultat et devrait être la configuration initiale. La cambrure de la SET n’affecte pas le temps requis pour l’intubation.

A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation.

BACKGROUND: In this study, we compared the effectiveness of direct laryngoscopy (DL) and the GlideScope® videolaryngoscope (GVL) for nasotracheal intubation, as judged by the time to intubation (TTI—the primary outcome) and the ease of intubation. METHODS: Seventy patients requiring nasotracheal intubation for elective surgery were randomly allocated to intubation with the GVL or DL. TTI was assessed by a blinded observer. Operators were blinded until the start of laryngoscopy. A Visual Analog Scale assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, amount of bleeding, usage of Magill forceps, and the severity of postoperative sore throat were recorded. RESULTS: The median TTI was 23.2 s faster with the GVL (43.5 s, interquartile range [IQR]: 39.8–67.3) than with DL (66.7 s, IQR: 53.8–89.9), P = 0.0023. Nasotracheal intubation was easier with the GVL than with DL (Visual Analog Scale 10 mm, IQR: 5.5–18, vs 20 mm, IQR: 10–32, P = 0.0041). The incidence of postoperative moderate or severe sore throat was significantly reduced in the GVL group (9% vs 34%, P = 0.018). Glottic exposure was significantly better with the GVL. Magill forceps were not used in the GVL group, but were used 49% of the time in the DL group, P < 0.0001. The incidence and severity of bleeding were similar between groups. CONCLUSIONS: Compared with DL, the GVL has superior performance characteristics when used for nasotracheal intubation and demonstrates an important reduction of postoperative sore throat. The GVL has a clear role in routine nasotracheal intubation.

The GlideScope®-specific rigid stylet and standard malleable stylet are equally effective for GlideScope® use

PurposeThe GlideScope® videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords can be challenging. The goal of the study was to compare the dedicated GlideScope®-specific rigid stylet to the standard malleable stylet, assessed by time to intubation (TTI).MethodsEighty patients requiring orotracheal intubation for elective surgery were randomly allocated to either the GlideScope® rigid stylet (GRS) or a standard malleable stylet to facilitate intubation using the GlideScope®. Time to intubation was recorded by blinded assessors; operators were blinded until after laryngoscopy. The operator assessed the ease of intubation using a visual analogue scale (VAS). The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were documented.ResultsThe median TTI was 42.7 sec (inter-quartile range (IQR) 38.9-56.7) for the GRS group compared to 39.9 sec (IQR 34.1-48.2) for the control group (P = 0.07). The median VAS score for ease of intubation was 20 (IQR 12.0-33.0) for the GRS group compared to 18 (IQR 9.5-29.5) for the control group (P = 0.21). There was no significant difference in TTI or VAS between stylets. The overall incidence of a Cormack-Lehane grade I or II glottic view was 98%.ConclusionsIn a group of experienced operators using the GlideScope®, the dedicated GRS and the standard malleable ETT stylet are equally effective in facilitating endotracheal intubation.RésuméObjectifLe vidéolaryngoscope GlideScope® fournit en général une excellente visualisation glottique, mais diriger une sonde endotrachéale (SET) entre les cordes vocales peut être un défi. L’objectif de cette étude était de comparer le mandrin rigide spécifique au GlideScope® au mandrin flexible standard, évalués par le temps requis pour l’intubation (TTI).MéthodeQuatre-vingts patients nécessitant une intubation orotrachéale pour une chirurgie élective ont été randomisés à être intubés à l’aide soit du mandrin rigide GlideScope® (GRS), soit du mandrin flexible standard pour faciliter l’intubation avec le GlideScope®. Le temps requis pour l’intubation a été mesuré par des évaluateurs en aveugle; les opérateurs étaient également en aveugle jusqu’à ce que la laryngoscopie soit terminée. L’opérateur a évalué la facilité d’intubation à l’aide d’une échelle visuelle analogique (EVA). Le nombre de tentatives d’intubation, le nombre d’échecs, le grade d’intubation et le recours à une manipulation laryngée externe ont été notés.RésultatsLe TTI médian était de 42,7 sec (intervalle interquartile (IQR) 38,9-56,7) pour le groupe GRS comparé à 39,9 sec (IQR 34,1-48,2) pour le groupe témoin (P = 0,07). Le score EVA médian pour la facilité d’intubation était de 20 (IQR 12,0-33,0) pour le groupe GRS comparé à 18 pour le groupe témoin (P = 0,21). Il n’y a pas eu de différence significative dans le TTI ou l’EVA entre les mandrins. L’incidence globale de la visualisation glottique selon l’échelle de Cormack-Lehane de grade I ou II était de 98 %.ConclusionDans un groupe d’opérateurs expérimentés se servant du GlideScope®, le mandrin GRS spécial et le mandrin flexible standard ont la même efficacité pour faciliter l’intubation endotrachéale.

Magnetic Resonance Imaging–Guided Transurethral Ultrasound Ablation of Prostate Tissue in Patients with Localized Prostate Cancer: A Prospective Phase 1 Clinical Trial

BACKGROUND Magnetic resonance imaging-guided transurethral ultrasound ablation (MRI-TULSA) is a novel minimally invasive technology for ablating prostate tissue, potentially offering good disease control of localized cancer and low morbidity. OBJECTIVE To determine the clinical safety and feasibility of MRI-TULSA for whole-gland prostate ablation in a primary treatment setting of localized prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS A single-arm prospective phase 1 study was performed at three tertiary referral centers in Canada, Germany, and the United States. Thirty patients (median age: 69 yr; interquartile range [IQR]: 67-71 yr) with biopsy-proven low-risk (80%) and intermediate-risk (20%) PCa were treated and followed for 12 mo. INTERVENTION MRI-TULSA treatment was delivered with the therapeutic intent of conservative whole-gland ablation including 3-mm safety margins and 10% residual viable prostate expected around the capsule. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary end points were safety (adverse events) and feasibility (technical accuracy and precision of conformal thermal ablation). Exploratory outcomes included quality of life, prostate-specific antigen (PSA), and biopsy at 12 mo. RESULTS AND LIMITATIONS Median treatment time was 36min (IQR: 26-44) and prostate volume was 44ml (IQR: 38-48). Spatial control of thermal ablation was ±1.3mm on MRI thermometry. Common Terminology Criteria for Adverse Events included hematuria (43% grade [G] 1; 6.7% G2), urinary tract infections (33% G2), acute urinary retention (10% G1; 17% G2), and epididymitis (3.3% G3). There were no rectal injuries. Median pretreatment International Prostate Symptom Score 8 (IQR: 5-13) returned to 6 (IQR: 4-10) at 3 mo (mean change: -2; 95% confidence interval [CI], -4 to 1). Median pretreatment International Index of Erectile Function 13 (IQR: 6-28) recovered to 13 (IQR: 5-25) at 12 mo (mean change: -1; 95% CI, -5 to 3). Median PSA decreased 87% at 1 mo and was stable at 0.8 ng/ml (IQR: 0.6-1.1) to 12 mo. Positive biopsies showed 61% reduction in total cancer length, clinically significant disease in 9 of 29 patients (31%; 95% CI, 15-51), and any disease in 16 of 29 patients (55%; 95% CI, 36-74). CONCLUSIONS MRI-TULSA was feasible, safe, and technically precise for whole-gland prostate ablation in patients with localized PCa. Phase 1 data are sufficiently compelling to study MRI-TULSA further in a larger prospective trial with reduced safety margins. PATIENT SUMMARY We used magnetic resonance imaging-guided transurethral ultrasound to heat and ablate the prostate in men with prostate cancer. We showed that the treatment can be targeted within a narrow range (1mm) and has a well-tolerated side effect profile. A larger study is under way. TRIAL REGISTRATION NCT01686958, DRKS00005311.

Automated Coring and Apical Connector Insertion Device for Aortic Valve Bypass Surgery

PURPOSE The technical difficulty of performing the left ventricular apical anastomosis has limited the adoption of aortic valve bypass surgery for the treatment of aortic stenosis. We report the successful use of an automated coring and apical connector device to perform aortic valve bypass surgery. DESCRIPTION A 74-year-old man, with a history of prior coronary bypass surgery with patent grafts and a porcelain ascending aorta, presented with symptomatic critical aortic stenosis. Through a left anterolateral thoracotomy, a valved conduit was anastomosed to the descending thoracic aorta. The automated coring and apical connector insertion device was used to core a plug of apical myocardium and simultaneously insert an 18-mm apical connector into the left ventricular apex. EVALUATION There were no procedural complications, cardiopulmonary bypass was not used, and estimated blood loss was minimal. The patient was discharged on postoperative day 5, and at 3-month follow-up demonstrated significant clinical and hemodynamic improvement. CONCLUSIONS The automated coring and apical connector insertion device facilitated the safe and effective performance of aortic valve bypass surgery.

Transcatheter ACURATE-TA Aortic Valve Implantation in a Patient With a Previous Mechanical Mitral Valve

Transcatheter aortic valve implantation (TAVI) in the presence of a mechanical mitral valve (MMV) prosthesis is still challenging because of the rigid mitral frame within the aortomitral curtain. Moreover, low-lying coronary ostia represent a hazardous problem of coronary obstruction, especially in narrow or porcelain aortic roots. The present case demonstrates the successful management of 2 challenging anatomical issues, the rigid cage of the MMV and the low-lying left main coronary ostium (LMCO), with the implantation of the ACURATE-TA bioprosthesis (Symetis SA, Ecublens, Switzerland). It also highlights the importance of having multiple TAVI devices in order to choose the ideal transcatheter aortic bioprosthesis to fit the unique anatomical presentation of the patient.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

Objective Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. Methods From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ±41.4 months. Results Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. Conclusions Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Giant Cystic Pheochromocytoma Containing High Concentrations of Catecholamines and Metanephrines

A 27-yr-old woman, known with neurofibromatosis type 1 and generalized anxiety disorder, presented with headaches, episodic palpitations, and pallor. Atenolol, started for hypertension by her family doctor, triggered a hypertensive crisis (226/126 mm Hg). Twentyfour-hour urine analysis demonstrated elevated excretion of metanephrine [65.7 ( 1.52; upper limit of reference range) mol/d] and normetanephrine [59.27 ( 1.95) mol/d], and to a lesser extent norepinephrine [2806 ( 569) nmol/d] and epinephrine [1222 ( 149) nmol/d]. Abdominal computed tomography (CT) scan showed a large solid and cystic lesion involving the right adrenal gland (Fig. 1A). 131-I methyliodobenzylguanidine scan showed a right adrenal tumor with prominent peripheral uptake and large central defect (Fig. 1B). After medical preparation with 3 wk of phenoxybenzamine (up to 90 mg/d), propranolol, and preoperative saline loading, the patient appeared clinically adequately blocked. However, anesthetic induction (fentanyl, propofol, lidocaine, and rocuronium) caused a hypertensive crisis (280/170 mm Hg) and prevented surgery. Phenoxybenzamine dosage was increased to 60 mg three times a day, and nifedipine SR 30 mg was added. Intravenous phenylephrine (1 mg) did not affect intraarterial blood pressure, indicating adequate -blockade. The next day, during open adrenalectomy, brittle blood pressure was noted until completion of tumor dissection. A sample of the liquefied tumor center was obtained (Fig. 2). Compared with plasma reference values (1), the cystic fluid contained extremely high concentrations of norepinephrine [65,967 ( 3.4) nmol/liter], epinephrine [51,000 ( 0.8) nmol/liter], dopamine [791.5 ( 0.21) nmol/liter], metanephrine [1,150 ( 0.3) nmol/liter], and normeta-

First North American Experience With the Engager Self-Expanding Transcatheter Aortic Valve: Insights From the London Health Sciences Centre Heart Team

The Engager aortic bioprosthesis consists of bovine pericardial leaflets mounted on a self-expandable frame with unique anatomic orientation capabilities to engage the aortic valve cusps. We report the initial North American transcatheter aortic valve implantation (TAVI) experience with the Engager device. Transapical TAVI was performed in 4 patients (mean age 80 ± 6 years, Society of Thoracic Surgeons score 5 ± 1%). The valve was anatomically oriented and successfully implanted in all patients. There were no conversions to open operation or major procedure-related adverse events. Pacemaker implantation was necessary in 1 patient. None of the patients showed paravalvular leak. The Engager device for TAVI provides anatomic orientation and anchoring that prevents coronary obstruction and paravalvular leak.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

Objective Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. Methods In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Results Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. Conclusions In patients undergoing robotic-assisted CABG, ultrafasttrack cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.