Zoya Haitov

Left Ventricular Epicardial Lead Implantation for Resynchronisation Therapy Using a Video-Assisted Thoracoscopic Approach

BACKGROUND Cardiac resynchronisation therapy using a branch of the coronary sinus is the technique of choice for left ventricular (LV) pacing in patients with poor LV function. An alternative option is the surgical implantation of an epicardial LV lead under direct vision. We describe our initial experience with epicardial LV lead implantation. METHODS The records of 10 patients undergoing epicardial LV lead implantation at our institution were retrospectively reviewed. Epicardial leads were implanted on the LV free wall using video-assisted thoracoscopic surgery techniques. RESULTS Ten patients (seven men; three women; mean age 66.9 years) underwent surgery. All 10 patients suffered from congestive heart failure (CHF) and had a mean LV ejection fraction of 25%. All patients failed endocardial LV lead implantation via the coronary sinus because of lack of adequate branches or inability to cannulate the coronary sinus. There were no intraoperative complications, intrahospital or late deaths. The mean hospital stay was 5.2 days. Follow-up showed reversal of ventricular asynchrony and improvement in functional class in all patients. CONCLUSIONS Thoracoscopic epicardial LV lead implantation is a safe and feasible procedure in a population of high risk patients who need resynchronisation therapy after endocardial LV lead placement has failed.

Bowel preparation: Comparing metabolic and electrolyte changes when using sodium phosphate/polyethylene glycol

BACKGROUND Many patients with various types of colonic pathology undergo invasive procedures that require mechanical bowel preparation. The most commonly used medications for bowel preparation include phosphate-containing drugs which are low cost and enable this procedure to be performed in an outpatient setting, as opposed to other medications, such as polyethylene glycol. Recent studies have suggested that freely using phosphate-containing drugs might lead to renal function impairment in a small group of patients. Despite this, many surgeons still use these drugs to prepare their patients. We conducted a comparative study to check the side effects of phosphate-containing drugs compared to polyethylene glycol when used for bowel cleansing. METHODS We conducted a double blind prospective randomized study that included 40 patients undergoing surgery for colonic pathology, all of whom underwent bowel cleansing (20 with sodium phosphate and 20 with polyethylene glycol). During the perioperative course, electrolyte parameters were collected from serum and urine and compared between the two groups of patients. RESULTS Changes in electrolyte and metabolic parameters were shown in both groups, but more prominently in patients prepared with sodium phosphate. In addition, early signs of renal function impairment appeared in this group. The differences in metabolic and electrolyte changes between the two groups were statistically significant. CONCLUSIONS On the basis of this study, we propose that the wide use of phosphate-containing drugs for colonic preparation might be dangerous for the specific group of patients that is prone to develop renal failure or electrolyte abnormalities.

Dextran 40 (Rheomacrodex) or Polygeline (Haemaccel) as an epidural patch for post dural puncture headache: a neurotoxicity study in a rat model of Dextran 40 and Polygeline injected intrathecally.

Background and objective: Although an epidural autologous blood patch is considered the most effective treatment for post dural puncture headache, which sometimes occurs following spinal or inadvertent spinal anaesthesia, there remains a need for alternative materials for epidural patches. We investigated the potential neurotoxicity of Dextran 40 (Rheomacrodex) and Polygeline (Haemaccel) used for this purpose in a rat model. Methods: Repeated boluses of 10% Dextran 40, 3.5% Polygeline or 0.9% saline were injected intrathecally over a period of 1 month in three groups of rats. Results: No behavioural or clinical derangements were observed in any of the three groups during this period. After sacrifice of the animals at the end of the experiment, no significant differences in the histopathological appearances of the spinal cords in the three groups were observed. No toxic effects diminishing viability of spinal cord cells were evident. Similarly, viability of renal, hepatic and peripheral blood mononuclear cells remained unaffected (98% ± 2%). Conclusions: No deleterious effects, clinical or cellular, were evident in this rat model when Dextran 40 or Polygeline were injected intrathecally. Thus, both substances can be considered as possible alternative materials for epidural patches.

RETRACTED: Accidental venous and dural puncture during epidural analgesia in obese parturients (BMI > 40 kg/m2): three different body positions during insertion

STUDY OBJECTIVE To assess the frequency of blood vessel punctures in morbidly obese parturients [body mass index (BMI) > 40 kg/m(2)] during epidural catheterization, in three different body positions. DESIGN Prospective, randomized study. SETTING Delivery room of a university-affiliated hospital. PATIENTS 347 obese parturients (BMI > 40 kg/m(2)) undergoing continuous epidural analgesia during labor. INTERVENTIONS Patients were randomized to undergo epidural catheterization in the sitting, lateral recumbent horizontal, or lateral recumbent head-down positions. MEASUREMENTS AND MAIN RESULTS A lower frequency of epidural venous cannulation was noted when this procedure was performed in the lateral recumbent head-down position (4.8%) than in the lateral recumbent horizontal (11.6%) or sitting position (18.3%) (P = 0.001). Frequency of accidental subarachnoid puncture did not differ significantly (2.5%, 2.6%, and 3.7%), respectively. CONCLUSION Adoption of the lateral recumbent head-down position for the performance of lumbar epidural blockade in labor at term reduces the frequency of lumbar epidural venous puncture in obese parturients (BMI > 40 kg/m(2)).

Morbidity and Mortality after Major Pulmonary Resections in Patients with Locally Advanced Stage IIIA Non-small Cell Lung Carcinoma Who Underwent Induction Therapy

BACKGROUND The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.

Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel.

BACKGROUND Use of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria. DESIGN/METHODS A retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011-January 2013 (the 21months preceding the 2013 Guidelines); and February 2013-October 2014 (the 21months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means. RESULTS 63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p<0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p<0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged). CONCLUSIONS Application of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.