Surface Electrocardiogram Predictors of Sudden Cardiac Arrest.

BACKGROUND: Heart disease is a major cause of death in industrialized nations, with approximately 50% of these deaths attributable to sudden cardiac arrest. If patients at high risk for sudden cardiac arrest can be identified, their odds of surviving fatal arrhythmias can be significantly improved through prophylactic implantable cardioverter defibrillator placement. This review summarizes the current knowledge pertaining to surface electrocardiogram (ECG) predictors of sudden cardiac arrest. METHODS: We conducted a literature review focused on methods of predicting sudden cardiac arrest through noninvasive electrocardiographic testing. RESULTS: Several electrocardiographic-based methods of risk stratification of sudden cardiac arrest have been studied, including QT prolongation, QRS duration, fragmented QRS complexes, early repolarization, Holter monitoring, heart rate variability, heart rate turbulence, signal-averaged ECG, T wave alternans, and T-peak to T-end. These ECG findings have shown variable effectiveness as screening tools. CONCLUSION: At this time, no individual ECG finding has been found to be able to adequately stratify patients with regard to risk for sudden cardiac arrest. However, one or more of these candidate surface ECG parameters may become useful components of future multifactorial risk stratification calculators.

Transaxillary gasless robotic thyroidectomy: a single surgeon's experience in North America.

OBJECTIVE: To describe a robotic technique for transaxillary gasless thyroidectomy with the addition of intraoperative peripheral nerve monitoring in the surgical management of thyroid disease. DESIGN: Prospective study. SETTING: Academic institution. PATIENTS: Fifty patients underwent robotic transaxillary thyroidectomy from September 1, 2009, to August 31, 2010. All the patients underwent preoperative and postoperative direct laryngoscopy. The patients' demographic information, operative times, complications, postoperative hospital stay, and the surgeon's learning curve were evaluated. MAIN OUTCOME MEASURES: Feasibility of the robotic approach, patient and gland characteristics, operative time, and complications. RESULTS: Thirty-nine females and 11 males with a mean age of 48.2 (age range, 13-76) years were included in the study. A total of 37 surgical procedures were lobectomies, and 13 were total or near-total thyroidectomies. The mean nodule size (range) was 24.9 (10-72) mm. The mean operative time (range) was 122.5 (81-280) minutes, mean docking time (range) was 10.1 (6-15) minutes, and mean console time (range) was 55.5 (10-140) minutes. Mean blood loss (range) was 25 (10-100) mL. There were no conversions to conventional open surgery. One patient developed transient radial nerve neuropathy that resolved spontaneously. There were no other postoperative complications. In addition, there was no evidence of vocal cord palsy or paresis on postoperative laryngoscopy. All the patients were discharged home within 24 hours. Subjectively, the cosmetic results were considered excellent owing to the hidden anatomical location of the incision site. CONCLUSIONS: We have demonstrated the technique to be feasible, safe, and applicable for patients with thyroid disease. We believe that the use of robotic technology for endoscopic thyroid surgical procedures could overcome the limitations of conventional endoscopic surgical procedures in the surgical management of thyroid disease. To our knowledge, this is the first reported large series using this novel technique in the United States.

Motor and sensory branching of the recurrent laryngeal nerve in thyroid surgery.

INTRODUCTION: Recognition of extralaryngeal bifurcation of the recurrent laryngeal nerve (RLN) is crucial, because inadvertent intraoperative division may lead to significant morbidity. The purpose of this study was to examine the incidence of extralaryngeal bifurcation of the RLN and the distance that the initial bifurcation occurs from the cricothyroid insertion site of the RLN. We also sought to demonstrate the location of the RLN branches containing a predominance of motor fibers. METHODS: This prospective study of 220 patients with data on 310 RLNs collected the type of operation, incidence of bifurcation, distance from the cricothyroid insertion point to the point of initial bifurcation, and location of the motor fibers by assessing a stimulus response on the Medtronic NIMS as they relate to the laryngeal muscles. RESULTS: A total of 310 RLNs in 220 patients were studied. There were 133 RLNs (42.9%) that bifurcated before entering the larynx. These bifurcations occurred 51.1% on the right, 48.9% on the left, and 33.3% bilaterally. The median branching distance from the cricothyroid membrane on the right was 6.33 mm, and on the left was 6.37 mm. In all bifurcated RLNs, the motor fibers were located exclusively in the anterior branches. CONCLUSION: Extralaryngeal bifurcation was found in 42.9% of the RLNs in this case series. The motor fibers are located in the anterior branches. Great caution is therefore required after the presumed identification of the RLN to ensure there is no unidentified anterior branch.