The syndrome of the hypersensitive xiphoid.
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Disease↗
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 44-1989. A 74-year-old woman with subxiphoid pain and narrowing of the esophagus.
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Aged↗
Pediatric orogastric and nasogastric tubes: a new formula evaluated.
STUDY OBJECTIVE: We sought to compare the traditional method of determining depth of gastric tube insertion, by measuring from the external landmarks of the nose or mouth, to the earlobe, to the xiphoid process (NEX method), with a graph for determining depth of gastric tube insertion that is based on patient height (graphic method). METHODS: A prospective, randomized, double-blinded study comparing NEX and graphic methods for gastric tube depth of insertion was undertaken. This study included a convenience sample of pediatric emergency department patients in need of gastric intubation. Patients were block randomized, and their gastric tubes were placed to the depth derived from the particular method employed. Alternate depth of insertion was measured on all patients. Abdominal radiographs were used to determine the distance that the end of the tube was from the center of the stomach. RESULTS: Forty-four patients each were in the NEX and graphic groups. The mean distance from the center of the stomach was -1.12 cm (SD 1.36) for the graphic group, compared with 1.31 cm (SD 3.39) for the NEX method. The difference between the 2 methods was 2.43 cm (95% confidence interval [CI] 1.33 to 3.54). Using absolute values, the mean distance from the center of the stomach was 1.26 cm (SD 1.23) for the graphic group compared with 2.60 cm (SD 2.51) for the NEX method. Using these values, the difference between the groups is 1.34 cm (95% CI 0.50 to 2.18). CONCLUSION: When compared with the NEX method, the graphic method demonstrates a significant ability to more consistently and accurately determine the depth of pediatric gastric tube insertion.
Adolescent↗
Video-assisted subxiphoid pericardiectomy.
We report a case of malignant pericardial effusion with chronic tamponade treated by video-assisted subxiphoid pericardiectomy in a 58-year-old female. The procedure was performed under local anesthesia through a 3.5-cm midline incision over the xiphoid process using a mediastinoscope, a 5-mm telescope connected to the video camera, and an endoscopic grasper and scissors. A large piece of pericardium (5 cm x 6 cm) over the right ventricle was excised. The patient obtained immediate relief and was discharged on the second postoperative day. Follow-up at 4 months showed no recurrence of effusion. Video assistance allows generous pericardiectomy, and as the rate of recurrence has been suggested to be directly related to the extent of resection, video-assisted subxiphoid pericardiectomy offers a theoretical advantage over the conventional approach, as more pericardium can be excised. We recommend that this technique receive further investigation.
Cardiac Tamponade↗
Sub-xiphoid echocardiography--a new approach to the diagnosis and differentiation of atrioventricular defects.
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Aortic Valve↗
A prospective trial of subxiphoid pericardiotomy in the diagnosis and treatment of large pericardial effusion. A follow-up report.
OBJECTIVE: This study was designed to determine the cause of large pericardial effusions and evaluate the efficacy of subxiphoid pericardiotomy. SUMMARY BACKGROUND DATA: Despite great advances in the techniques used to diagnose pericardial effusions, much controversy remains concerning their cause and the optimal treatment of these effusions. METHODS: In a prospective consecutive case series, 57 patients underwent a thorough preoperative evaluation followed by a subxiphoid pericardiotomy. All tissue and fluid was exhaustively evaluated. Postoperatively, all patients were followed for a least 1 year. RESULTS: Surgery was performed under local anesthesia in 77% of patients, and the complications of surgery were minimal. Pericardial tissue and fluid established or aided in establishing a diagnosis in 81% of patients. Infection and malignancy were the leading causes; the condition in only 4 patients remained undiagnosed. Follow-up revealed recurrent effusion in nine (16%) patients, but only five (9%) required further surgery. The mortality rate at 30 days was 12%, and at 1 year, it was 37%. Fourteen of the 21 deaths occurred in patients with malignancies. CONCLUSIONS: These data show that the cause of most large pericardial effusions can be determined by a thorough evaluation accompanied by subxiphoid pericardiotomy. In addition, subxiphoid pericardial biopsy and window creation is safe and effective in the treatment of these effusions.
Biopsy↗
Counting ribs on CT by assessing costal attachments to the proximal xiphoid: is this method accurate?
OBJECTIVES: To evaluate the usefulness of the method of counting ribs by assessing anatomic variations of the attachments of costal cartilages to the proximal xiphoid. MATERIALS AND METHODS: From January to September 2005, 224 subjects (136 men, 88 women, age 13 to 89 years, mean age 55 years) underwent computed tomography examination of the chest. Axial images of the chest were obtained on a 16-slice multidetector computed tomography. Counting ribs was performed by using the medial clavicle as an anatomic landmark to identify the first costal cartilage. We analyzed variety and incidence of the attachment patterns of costal cartilages to the proximal xiphoid. RESULT: Out of the 224 patients, the last costal attachments to the proximal xiphoid were the sixth costal cartilages bilaterally for 2 (0.9%) subjects, one 6th and one 7th for 4 (1.8%) subjects, bilateral seventh for 191 (85.3%) subjects, one 7th and one 8th for 15 (6.7%) subjects, and bilateral eighth for 12 (5.4%) subjects. CONCLUSIONS: The method of counting ribs from the proximal xiphoid is inaccurate because the sixth, seventh, and eighth costal cartilages may each attach to the proximal xiphoid.
Adolescent↗
Blind subxiphoid pericardiotomy for cardiac tamponade because of acute hemopericardium.
OBJECTIVE: Percutaneous catheter drainage (PCD) is not always effective in a case of hemopericardium. Acute occlusion of catheter and cardiac perforation can happen more often. To perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method after finger dissection by subxiphoid approach. We report the usefulness of blind subxiphoid pericardiotomy (BSP) based on the results of a prospective control study. METHODS: We designed a study to determine a favorable management for cardiac tamponade resulting from hemopericardium. In an emergency case of cardiac tamponade because of hemopericardium, board certified surgeons should perform BSP and other emergency physicians should perform PCD, with or without local anesthesia. PCD (n = 67) and BSP (n = 16) were performed for patients with cardio-pulmonary arrest (CPA) or near CPA because of cardiac tamponade secondary to trauma (n = 7), acute aortic dissection (n = 65), and cardiac rupture following acute myocardial infarction (n = 11) in our emergency medical center from January 2000 to December 2004. RESULTS: BSP was effective in all cases but PCD was ineffective in five cases because of clotting in pericardium (p = 0.260). No complication was observed in the BSP group but five critical complications and three infeasible drainage complications were observed in the PCD group (p = 0.146). Ten patients (BSP, 4; PCD, 6; p = 0.077) survived after emergency surgery (n = 8) or conservative treatment (n = 2). CONCLUSION: BSP was safe and could be performed quickly in an emergency situation. Percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clotting in pericardium.
Cardiac Tamponade↗
Surgical techniques for implanting the automatic implantable defibrillator.
Since February 1980, the automatic defibrillator was implanted in 77 survivors of multiple cardiac arrest. The subxiphoid technique was used in 28 patients and the thoracotomy technique was used in 20 patients with previous cardiac surgery. Median sternotomy was used in 29 patients undergoing open heart procedures as well as defibrillator implantation. While the subxiphoid is the most benign procedure employed, all are safe and well tolerated. The method used is determined by the clinical picture. Survival studies indicate improved survival in this high risk population.
Adolescent↗
Comparison of subxiphoid and traditional approaches for ICD implantation.
We compared clinical and electrophysiological data in 18 patients undergoing ICD implantation via a traditional (median sternotomy or left lateral thoracotomy) with 29 patients with a subxiphoid approach. Both groups were similar in terms of age, sex, left ventricular ejection fraction, presence of coronary artery disease, and clinical indication for the device. Fifteen patients (83%) with the traditional approach had previous cardiac surgery compared with 6 patients (21%) who had a subxiphoid approach (P < 0.001). Both groups had similar patch R wave and sensing R wave measurements. Patients with the traditional approach had a lower energy for defibrillation than patients with a subxiphoid approach (13.6 +/- 6.8 J vs 17.9 +/- 4.1 J, P < 0.05). Postoperative hospital days were fewer in the subxiphoid group compared with the traditional approaches (9.8 +/- 5.3 vs 13.7 +/- 7.5 days) but the differences did not reach statistical significance, possibly due to small numbers. The subxiphoid approach appears to be a reasonable alternative approach to the traditional approach in selected patients undergoing ICD implantation.
Defibrillators, Implantable↗
Subxiphoid approach for implantable cardioverter defibrillator in patients with previous coronary bypass surgery.
From February 1988 until August 1991, 28 patients with prior coronary artery bypass grafting (CABG) received implantable cardioverter defibrillator (ICD) therapy via a subxiphoid approach. Only one patient required conversion to a median sternotomy incision. The mean defibrillation threshold was 11.9 +/- 4.4 J. The mean R wave was 8.2 +/- 3.7 mV. One perioperative death occurred due to heart failure (mortality rate 1/28 [3.50%]). No patient required reexploration for bleeding. The subxiphoid method for ICD electrode implantation is safe and reliable in patients with prior CABG surgery.
Coronary Artery Bypass↗
An epicardial subxiphoid implantable defibrillator lead: superior effectiveness after failure of standard implants.
A single epicardial implantable lead using the subxiphoid approach is described in this article. It consists of a single halo-shaped coil that is implanted under the inferior surface of the heart, including the right and left inferior ventricular surfaces. It has been implanted in four patients who could not be defibrillated with a transvenous system, even with the adjunct use of subcutaneous leads or left chest wall patch. Three of the patients had progressive heart failure due to ischemic myocardiopathy; the fourth patient had a dilated idiopathic myocardiopathy. The approach is simple and appears to be effective due to its ability to encompass the left and right ventricles. This vector seems to significantly lower the threshold for defibrillation, and may offer substantial benefit in the setting of high defibrillation thresholds with conventional leads, or when conventional systems are inadequate to achieve consistent defibrillation.
Adult↗
Automatic implantable cardioverter defibrillator: surgical approaches for implantation.
Surgical approaches for implantation of the automatic cardioverter defibrillator are sternotomy, left thoracotomy, subxiphoid, and subcostal. Although any one of these may be combined with insertion of one or more of the electrodes transvenously, surgical entry into the chest is required for every noninvestigational defibrillator implantation operation. The approaches differ in exposure provided for selecting electrode sites and for handling untoward events, in amount and location of tissue that must be divided or dissected, and in average time required. The operation is an electrical one. Its purpose is to obtain reliable rhythm sensing so that defibrillation or cardioversion shocks will occur only when necessary, and to obtain low enough defibrillation thresholds for shocks of 30 joules or less to have a 10-joule defibrillation safety margin. Many of the patients have had previous cardiac operations. They usually have low or very low ejection fractions. Intraoperative electrophysiological testing with often multiple defibrillation episodes is required. The choice of approach varies with the state of the patient, the institutional experience, and the surgeon. This article describes technique, and the advantages and disadvantages of the four approaches as used by four surgeons in four different institutions.
Defibrillators, Implantable↗
A xiphoid approach for minimally invasive coronary artery bypass surgery.
BACKGROUND: The premise for adopting minimally invasive cardiac surgery techniques for myocardial revascularization is to reduce the patient's morbidity without compromising the efficacy of conventional coronary artery bypass. However, opening the pleura has been a limitation of using these approaches. AIM: We used the xiphoid approach as an alternative to opening the pleura and to minimize pain after minimally invasive coronary artery bypass surgery. METHODS: We review our surgical experience in 55 patients who underwent minimally invasive direct coronary artery bypass (MIDCAB) surgery through a xiphoid approach between October 1997 and August 1999. Thoracoscopy (n = 31) or direct vision (n = 24) were used for internal mammary artery (IMA) harvesting. Mean patient age was 67 +/- 10 years and 65% were men. The mean Parsonnet score was 23 +/- 10. Performed anastomoses included left IMA (LIMA) to the left anterior descending (LAD) artery (n = 53), LIMA-to-LAD and saphenous vein graft from the LIMA to the right coronary artery (n = 1), and LIMA-to-LAD and right IMA (RIMA) to right coronary artery (n = 1). RESULTS: Postoperative complications included atrial fibrillation (12%), acute noninfectious pericarditis (12%), and acute renal failure (5%). Mean postoperative length of stay was 4 +/- 2 days. Angiography was performed in 16 patients and demonstrated excellent patency of the anastomoses. There was no operative mortality. Actuarial survival was 98% in a mean follow-up period of 11 +/- 5 months. CONCLUSIONS: Minimally invasive coronary artery bypass can be performed safely through a xiphoid approach with low morbidity, mortality, and a relatively short hospital stay.
Aged↗
Subxiphoid access to normal pericardium with micropuncture set: technical feasibility study in pigs.
This study was performed with approval from the ethics committee for animal research of the local government. The purpose of the study was to evaluate the technical feasibility of a technique for subxiphoid access to the normal pericardial space with a micropuncture set in 10 large white pigs. With fluoroscopic guidance, a fine needle was inserted through a subxiphoid approach into the anterior mediastinal space to puncture the pericardium, and a micropuncture set was placed in the pericardial space successfully in all animals without complications. Necropsy at 24 hours did not reveal hemomediastinum, hemopericardium, or laceration of the pericardium. Results of the experiments in animals indicated that the technique was feasible and safe.
Animals↗
Radiological appearances of the xiphoid process presenting as an upper abdominal mass.
In three patients prominent, jointed xiphoid processes were confused with abdominal masses on clinical examination. In the first case, ultrasound showed acoustic shadowing at the site of the xiphoid extension. This was interpreted as a calcified abdominal mass prior to obtaining a lateral chest radiograph, which showed it to be a jointed extension from the normal xiphoid process. In the other two cases, the mass was recognized on ultrasound as a jointed xiphoid process. Awareness of this important normal variant can prevent unnecessary surgery.
Abdominal Neoplasms↗
Arterial pulse pressure and vasopressin release during graded water immersion in humans.
Previous results indicate that arterial pulse pressure modulates release of arginine vasopressin (AVP) in humans. The hypothesis was therefore tested that an increase in arterial pulse pressure is the stimulus for suppression of AVP release during central blood volume expansion by water immersion. A two-step immersion model (n = 8) to the xiphoid process and neck, respectively, was used to attain two different levels of augmented cardiac distension. Left atrial diameter (echocardiography) increased from 28 +/- 1 to 34 +/- 1 mm (P < 0.05) during immersion to the xiphoid process and more so (P < 0.05), to 36 +/- 1 mm, during immersion to the neck. During immersion to the xiphoid process, arterial pulse pressure (invasively measured in a brachial artery) increased (P < 0.05) from 44 +/- 1 to 51 +/- 2 mmHg and to the same extent from 42 +/- 1 to 52 +/- 2 mmHg during immersion to the neck. Mean arterial pressure was unchanged during immersion to the xiphoid process and increased during immersion to the neck by 7 +/- 1 mmHg (P < 0.05). Arterial plasma AVP decreased from 2.5 +/- 0.7 to 1.8 +/- 0.5 pg/ml (P < 0. 05) during immersion to the xiphoid process and significantly more so (P < 0.05), to 1.4 +/- 0.5 pg/ml, during immersion to the neck. In conclusion, other factors besides the increase in arterial pulse pressure must have participated in the graded suppression of AVP release, comparing immersion to the xiphoid process with immersion to the neck. We suggest that when arterial pulse pressure is increased, graded distension of cardiopulmonary receptors modulate AVP release.
Adult↗
Subxiphoid surgical approach for epicardial catheter-based mapping and ablation in patients with prior cardiac surgery or difficult pericardial access.
BACKGROUND: Percutaneous epicardial mapping and ablation are successful in some patients with ventricular epicardial reentry circuits but may be impossible when pericardial adhesions are present, such as from prior cardiac surgery. The purpose of this study was to evaluate the feasibility of direct surgical exposure of the pericardial space to allow catheter epicardial mapping and ablation in the electrophysiology laboratory when percutaneous access is not feasible. METHODS AND RESULTS: In 6 patients with prior cardiac surgery or failed percutaneous pericardial access, a subxiphoid pericardial window was attempted. In all 6 patients, manual lysis of adhesions exposed the epicardial surface of the heart through a small subxiphoid incision and allowed placement of an 8F sheath into the pericardial space under direct vision. Access to the diaphragmatic surface of the heart with ablation catheters was achieved in all patients, and catheter manipulation to the lateral and anterior walls was possible in 4 patients. Three-dimensional electroanatomic voltage maps revealed low-amplitude regions in the inferior or posterior left ventricular epicardium. A total of 16 ventricular tachycardias were induced, and 14 were abolished by radiofrequency ablation. Ablation was limited by intrapericardial defibrillator patches adherent to the likely target region in 2 patients. All patients had chest pain consistent with pericarditis early after the procedure that resolved within a few days. There were no other complications. CONCLUSIONS: A direct surgical subxiphoid epicardial approach in the electrophysiology laboratory is feasible for patients with difficult pericardial access who require ablation of epicardial arrhythmia foci.
Adult↗