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3. Martinez-Ferro M, Duarte S, Laje P. Single port thoracoscopyfor the treatment of pleural empyema in children. J PediatrSurg 2004;39:1194–6.

4. Rocco G, Ucar AM, Passera E. Uniportal VATS wedge pul-monary resections. Ann Thorac Surg 2004;77:726–8.

ReplyTo the Editor:

Assouad and colleagues [1] should be commended for rightfullyaising the point of how to expand the practice of uniportalideoscopic assisted thoracic surgery (VATS). However, althoughhe indications for single-port VATS to manage pleural disease (ie,ingle incision VATS to obtain diagnosis and divide loculations)ave been known since the inception of thoracoscopic surgery,perative uniportal VATS (ie, single incision VATS pulmonaryesection) often requires interchangeability of the reciprocal posi-ion of the necessary instrumentation to address different areas inhe chest cavity [2]. Accordingly, in the description of the originalechnique of uniportal VATS pulmonary resection [2], the use of arocar was not contemplated to avoid space impediments.

In this setting, the single-incision laparoscopic surgical (SILS)ort (Covidien, Mansfield, MA) is a U.S. Food and Drug Adminis-

ration-approved device for laparoscopic use that enables theurgeon to perform single-port laparoscopic procedures whilestablishing and maintaining the pneumoperitoneum. Once again,horacic surgeons should rely on laparoscopic instruments adaptedor thoracic surgical use. Indeed, the adaptation of this laparoscopicoft port duplicates the idea of introducing more instrumentshough a single incision introduced by operative uniportal VATS2]. Along with flexing the patient’s trunk by increasing the inter-ostal space width, SILS could represent an additional protectiveactor against intercostal nerve injury—the latter significantly re-uced compared with the traditional 3-port VATS if the uniportalATS technique is carefully adhered to [3]—but I suspect it maylso hinder maneuverability [4].

I am convinced Assouad and colleagues’ contribution willelp clarify this issue in a future report of a larger institutionalxperience with SILS where more details about stapler intro-uction and specimen removal through SILS will be given. In

he meantime, I would envisage the use of SILS in uniportalATS to avoid or reduce tedious blood dripping on the thora-

oscope lens, which is common if no port is used.In conclusion, I agree with Assouad and coworkers that

pecific instruments for operative uniportal VATS should beevised because the operative uniportal VATS technique isased on a totally different intrathoracic approach to the target

esion in the chest compared with conventional 3-port VATS2–4]. Moreover, unlike 3-port operative VATS, the contributionf articulating instrumentation is fundamental for operativeniportal VATS [2–4]. In this setting, it is important to define alear-cut distinction between uniportal operative vs diagnosticATS, with the latter certainly benefitting from the use of SILS.

aetano Rocco, MD, FRCSEd

epartment of Thoracic Surgery and Oncologyivision of Thoracic Surgeryational Cancer Institute, Pascale Foundationia M Semmola, 810131 Naples, Italy-mail: gaetano.rocco@btopenworld.com

References

1. Assouad J, Vignes S, Nakad J, Grunenwald D. Single incisionvideo-assisted thoracic surgery using a laparoscopic port

(letter). Ann Thorac Surg 2011:91:2020–1. t

© 2011 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

2. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedgepulmonary resections. Ann Thorac Surg 2004;77:726–8.

3. Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: com-parison of post-operative pain and residual paraesthesia. EurJ Cardiothorac Surg 2005;28:43–6.

4. Rocco G, Romano V, Accardo R, et al. Awake single-access(uniportal) video-assisted thoracoscopic surgery for periph-eral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg 2010;89:1625–7.

Factors Associated With the Development of AcuteHeart Failure in Critically Ill Patients With SeverePandemic 2009 Influenza A (H1N1) InfectionTo the Editor:

We read with great interest the article by MacLaren and col-leagues [1] on the use of central extracorporeal membrane

xygenation (ECMO) as rescue therapy in a patient with severeardiac and respiratory failure caused by pandemic influenza AH1N1). Direct viral myocarditis was excluded by myocardialiopsy. They consider ventricular dysfunction as a consequencef protracted acute respiratory distress syndrome and sepsis.The pathophysiologic mechanism contributing to the devel-

pment of severe acute heart failure in these critically ill patientsas not yet been completely defined. Martin and colleagues [2]

dentified reversible left ventricular dysfunction in 4.9% ofatients hospitalized for H1N1 infection with a mortality of 33%.rown and colleagues [3] reported right ventricular dilatationnd systolic dysfunction in the majority of patients with life-hreatening H1N1 infection managed in the intensive care unitith concomitant left ventricular systolic dysfunction in 17% ofatients complicated with septic shock.In a case series of 4 patients admitted to the cardiothoracic

ntensive care unit in our institution during the exacerbation periodf H1N1 pandemic (December 2009 to March 2010) with acuteespiratory distress syndrome not responding to conventionalechanical ventilation, severely depressed right and left ventricu-

ar function was evident in 2 young females, aged 39 and 48 years,ith no predisposing risk factors and comorbidities. They wereoth managed with peripheral veno-arterial extracorporeal ECMOupport 1 week after the onset of symptoms. An interesting findingt the time of H1N1 diagnosis was that both patients had positiveronchial and blood cultures for Candida species accompanied byignificant myelotoxicity (ie, anemia, reduced white cell count),hich could explain susceptibility of these patients to secondarypportunistic infections. Both patients subsequently had multiplergan dysfunction syndrome (renal and hepatic failure) develop.xtracorporeal support was weaned off after 11 and 13 days,espectively. At that point left and right ventricular function wasignificantly improved. One patient survived to discharge. Severeestriction was evident on lung function tests, diffusion capacityas markedly reduced, whereas computed tomography showed

vidence of diffuse pulmonary fibrosis. At the patient’s 6-monthollow-up, lung function and diffusion capacity returned to normal,hereas radiologic evidence of diffuse pulmonary fibrosis was

table.By evaluating the clinical course of these patients, we consider

Dr Rocco discloses that he has a financial relationshipwith Covidien.

hat adverse modulation of immune response in the initial

0003-4975/$36.00