Objective: In this study we compared noninvasive arterial pressure measurement using ClearSight™ vascular-unloading-technique (Edwards Lifesciences Corp, Irvine, CA) with invasive arterial pressure measurement during induction of anesthesia undergoing mayor cardiac surgery. Design: Prospective, monocentric. Setting: University hospital. Participants: 54 patients undergoing mayor cardiac surgery. Interventions: During induction all patients were simultaneously monitored with invasive (reference method) and noninvasive arterial pressure measurement (test-method) over a mean time period of 27 minutes. Measurements and Main Results: We observed slightly lower systolic and mean arterial pressures noninvasive than invasive. For systolic arterial pressure the mean of the differences was -18,05 mmHg (p < 0,05, SD ±16,78 mmHg), the mean arterial pressure MAP -5,47 mmHg (p < 0,05, SD ±11,08 mmHg) and for diastolic pressure -1,09 mmHg (p < 0,05, SD±11,15 mmHg),. The mean of the differences in heartrate was 1,15 (p < 0,05, SD±6,9 mmHg). When considering all measured values of the invasively measured MAP and the ClearSight ™ -MAP at the same timestamp over the recording interval, an almost identical progress can be seen that indicates a sufficient mapping of the hemodynamic changes. The percentage error for mean arterial, systolic and diastolic pressure measured by ClearSight™ amounts to 25,95 %, 26,77 % and 34,16 %, respectively. Conclusions: We conclude that ClearSight ™ is a good option for hemodynamic monitoring during induction of anesthesia. Taking into account the limitations, non-invasive arterial blood pressure measurement offers sufficient security to safely initiate anesthesia, especially when MAP is of particular interest. The use of non-invasive arterial blood pressure measurement with ClearSight ™ during induction of anesthesia in patients scheduled for major cardiac surgery is reliable and easy to use.

Context: Cardiopulmonary bypass (CPB) induced acute lung injury is accounted for most of the post-operative pulmonary dysfunction which leads to decreased compliance and hypoxemia. Airway Pressure Release Ventilation (APRV) as compared to other modes of ventilation has shown to improve gas exchange in Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) lungs. Aims: We hypothesized APRV as a better primary mode of postoperative ventilation in adult post-cardiac surgery patients. Methodology: The study included 90 postoperative surgical patients, which were randomized into three groups: SIMV-PC(P), APRV(A), and SIMV-VC(V) with 30 patients in each group. Subjects and Methods: Lung compliance and serial arterial blood gas were assessed at regular intervals. PaO₂/FiO₂ ratio (a measure of oxygenation) and lung compliance were used as an indirect indicator for improvement in lung function. Hemodynamic parameters were closely observed for all the patients. Statistical Analysis Used: Statistical analysis was done using 'R' software. Results: There was a statistically significant improvement in PaO2/FiO2 ratio in the APRV group as compared to other groups. There was also an improvement in lung compliance after 6 h of ventilation and lesser duration of ventilation in the APRV group. However, it was not statistically significant. Conclusions: Our study suggests that APRV can be a useful alternative primary mode of ventilation to improve lung compliance and oxygenation in adult post-cardiac surgical patients.

Background: Postoperative delirium (POD) is a common complication in cardiac surgery especially in elderly population which can lead to a delay of weaning from ventilator and extubation. Cardiopulmonary bypass (CPB)-induced inflammation is related to POD. Anti-inflammatory effect of anesthetic agent might attenuate POD. Aims: The present study was primarily aimed to compare within-24-h POD between ketamine-based anesthesia and propofol-based anesthesia during CPB. The secondary objective was to identify risk factors associated with within-24-h POD. Setting and Design: Our study was a randomized controlled trial in patients undergoing cardiac surgery with CPB. Enrolling patients were aged >65 years, and able to comprehensive communication. Exclusion criteria were aortic surgery, cognitive disorders, cerebrovascular and carotid disease, and positive result of preoperative CAM-ICU. Materials and Methods: Patients were randomly assigned to group Ketamine infusion of 1 mg/kg/h and group Propofol infusion of 1.5-6 mg/kg/h during CPB. POD was evaluated by validated Thai version CAM-ICU at 8-24 hour after ICU arrival. Statistics: Chi-square, Fisher exact and t-test tests, univariate analysis and multivariate logistic regression were utilized. Results: Total 82 patients entered this study and 64 patients remained after exclusion (Group Ketamine = 32 and Group Propofol = 32). Within-24-h POD were 31.25% and 56.25% (P = 0.04) and mean arterial pressure (MAP) were 71.45 and 65.53 mmHg (P = 0.01) respectively in Ketamine and Propofol group. Postoperative leukocytosis was a significant risk to POD (adjusted OR 124.5). Conclusion: With limitations of the study, prevention of 24-h POD in general by ketamine was inconclusive. In comparison with propofol, ketamine leaded to less events of 24-h POD and kept higher MAP. Severity of postoperative inflammation was a significant prediction of 24-h POD.

Background: Transcatheter paravalvular leak (PVL) closure in recent times has emerged as a safe and effective alternate to redo-surgical repair. We sought to examine the clinical efficacy and safety of percutaneous PVL closure at our center. Methods and Results: A retrospective study from August 2012 to December 2019 of 19 patients who underwent 21 procedures for PVL closure. The mean age was 49.25 ± 14.72 years. The target valve was mitral in 11 (57%) and aortic in 7 (36%) cases. One (5%) patient had prosthetic valve in left atrioventricular valve with congenitally corrected transposition of great arteries. Majority of the cohort presented with heart failure without hemolysis (89%), with most of them being in NYHA functional class III (57%) or class IV (21%). A procedural success of 85% was achieved. Post procedure severity of regurgitation reduced from severe in thirteen patients and moderate in six patients to moderate in two patients and mild in fourteen patients. Symptomatic improvement was observed in all cases who had successful closure with NYHA function class improving from 3 ± 0.64 to 1.6 ± 0.94. The mean follow-up duration was 21 ± 13 months (median 24 months). There was one (4.7%) mortality with cumulative survival from all-cause mortality of 95%. Conclusion: The results of percutaneous PVL closure appear encouraging in our series with modest number of patients and offers a promising alternative to redo-surgery in this high-risk cohort.

Background: Obstructive sleep apnea (OSA) is reported in a high proportion of cardiac surgical patients, up to 73%. STOP-BANG is a validated questionnaire for screening of outpatients for OSA with high sensitivity. There is sparse literature from India regarding the prevalence of OSA in preoperative cardiovascular patients and the utility of screening tools. Aims: We sought to study the utility of the STOP-BANG questionnaire as a screening tool for OSA in cardiovascular patients validating it with ambulatory level 3 polysomnography. Materials and Methods: It was a prospective study where consecutive patients getting admitted for coronary artery bypass surgery (CABG) from August 2017–February 2019 were recruited. All the patients were screened with the STOP-BANG questionnaire. 53 patients underwent overnight level 3 polysomnography using Apnea-Link. Correlations were made between clinical symptoms, STOP-BANG score, and OSA severity, measured using Apnea hypopnea index (AHI). Results: We had 120 patients(103 males) with a mean age 60 years. Snoring was the most common sleep complaint. Our cohort had a high prevalence of vascular risk factors (DM 72.3%, hypertension 59.2%, dyslipidemia 60%) and 11.7% were obese (BMI >30). The median STOP-BANG score was 3 (IQR 2) with 83 having scores ≥3. Median AHI was 5.6 with AHI ≥5 in 28 patients and AHI 15 or above in 14 patients. Among the clinical parameters, arousals with respiratory difficulty at night, higher neck circumference, and tonsillar hypertrophy showed a significant association with PSG-proven OSA.STOP-BANG scores 3 or above had a sensitivity of 75% in predicting OSA. Conclusions: Our study shows that in cardiovascular patients less symptomatic for sleep complaints, the STOP-BANG questionnaire is a useful screening tool for OSA in outpatient settings. Among clinical parameters, airway narrowing and neck circumference can predict OSA.

Objective: We looked for a correlation between the surgically measured mitral valve size and the cardiac dimensions (left ventricle internal diameter, left atrial size, aorta size, and body surface area) measured by preoperative and intraoperative echocardiography. We also assessed to see if we could predict the mitral prosthesis size based on the correlation data obtained. Methods: The hospital records of 180 patients who underwent mitral valve replacement (MVR) with TTK Chitra valve between January 2008 and December 2012 at our hospital, were studied. The correlation between surgically measured mitral annulus size to left ventricular internal diameter systolic (LVIDS) and diastolic (LVIDD), left atrial size (linear measurement), and aorta size on echocardiography and body surface area was calculated using Pearson correlation coefficient. Mean LVIDS was calculated for each valve prosthesis size separately and the correlation was studied. Results: The correlation between mitral valve prosthesis size and left ventricular internal diameter (systolic) showed a Pearson coefficient of 3.3 with significance at the level 0.01. Mitral valve size and left atrial size showed a correlation coefficient of 2.7 with significance at the level 0.01. The correlation coefficient for mitral valve size with left ventricular internal diameter diastolic, aorta and body surface area were 2.5, 1.9, and 1.8, respectively. There was a gradual increase in the mean LVIDS with increase in the prosthetic valve size. Box plot and scatter plot showed linear correlation between valve size and mean LVIDS.

Background: Myocardial preconditioning using volatile anesthetics such as isoflurane and sevoflurane have beneficial effects in decreasing morbidity in cardiac surgical patients. Studies in animal models have indicated that reactive oxygen and nitrogen species probably play a role in mediating these effects. However, data from human studies are scarce and the differential effect of sevoflurane vs. isoflurane on reactive oxygen species (ROS) and reactive nitrogen species (RNS) has not been studied extensively. Materials and Methods: Randomized clinical control trial comparing preconditioning effects of volatile agents isoflurane and sevoflurane when administered during coronary artery bypass surgeries on cardiopulmonary bypass (CPB). Serum samples were collected at 3 time points before induction, after cross clamp release and one hour after separation from CPB. Levels of oxidative stress markers and nitric oxide were analyzed in these samples. Results: Hemodynamic indices, cardio-pulmonary bypass duration, and ICU stay were similar between the groups. CKMB values 12 hours post-op were decreased in majority of patients in the sevoflurane group compared to isoflurane. Serum malondialdehyde and nitrate levels were lower with sevoflurane (P < 0.05) when compared to the isoflurane group, but no significant differences in protein carbonyl content or protein thiol content were evident between the 2 groups. Sevoflurane also prevented the decrease in total thiols during later stages of surgery. Conclusions: Volatile anesthetics, isoflurane and sevoflurane modulate oxidative and nitrosative stress during CABG. Between the two pre-conditioning agents, isoflurane seems to provide better protection during the pre-bypass period, while sevoflurane provides protection during both pre- as well as post-bypass period.

Objectives: To evaluate the correlation between stroke volume variation (SVV) and inferior vena cava distensibility index (dIVC) as a marker for fluid responsiveness in mechanically ventilated hypotensive intensive care unit (ICU) patients. Methodology and Design: This study is designed as prospective observational study conducted in patients admitted to an ICU who were mechanically ventilated and experienced a hypotensive episode. Intervention: A fluid challenge of 10 mL/kg ringer's lactate was given over 20 min. Measurements: Hemodynamic parameters as well as SVV, IVCmax, IVCmin, dIVC, and cardiac output (CO), were recorded at a different time interval. An increase in ≥15% of CO was taken as fluid responsiveness. Results: Out of 67 patients, 67.2% responded to fluid challenge. Pearson's correlation graph at baseline showed a strong positive correlation between dIVC and SVV with r = 0.453, (P < 0.002). Non-responders also had a strong positive correlation (r = 0.474) at the baseline. Bland Altman's analysis of the correlation between dIVC and SVV post-fluid challenge showed a mean difference of – 4.444, with 1.49% of the values falling outside the limits of agreement (18.418 and -27.306). This difference was clinically significant. Pearson's correlation graph post-fluid challenge showed a moderately strong positive correlation between dIVC and SVV with r = 0.298 and P value = 0.047, which was statistically significant. Also, non-responders had a weak correlation as compared to the responder's group, r = 0.364 and P value = 0.095, which was not clinically significant. There was no significant difference in the trend of dIVC and SVV values between the non-surgical and surgical groups, nor was there any gender difference analyzed in the study. Conclusion: This study ascertains the positive correlation between dIVC and SVV and justifies its use in a clinical setting of hypotension suspected to be due to hypovolemia.

Context: In recent years, increasing awareness and early detection has made total anomalous pulmonary venous connection (TAPVC) a relatively common congenital heart condition presenting to children's heart centers in India. The condition was associated with significant morbidity and mortality in the past due to various reasons. Improvement in perioperative management has markedly changed the outcomes of TAPVC even in a developing country. Material and Methods: All patients with TAPVC operated between June 2013 and February 2018 at our center were included in the study. Post repair 30-days mortality and morbidity were analyzed. Results: A total of 166 patients were divided into supracardiac (91), infracardiac (45), cardiac (18), and mixed type (12). It also divided our cohort into obstructed and unobstructed types. The duration of inotrope usage in the obstructed group was significantly higher compared to the unobstructed group. Statistically, significant difference was noticed for the duration of ventilation 85.17 ± 80.94 h in obstructed type versus 49.23 ± 60.7 h in the unobstructed group, and in ICU stay (days) in obstructed (9.64 ± 5.96) and unobstructed group (6.29 ± 5.12). The morbidity parameters such as duration of an inotrope, ventilation, and length of ICU stay had a negative correlation between body surface area (BSA) of the patient but no correlation in respect to duration of CPB and ACC time. Mortality was found to be higher in lower BSA, infracardiac type (7/9), and obstructed variants of TAPVC (9/9) patients. Conclusions: Longer duration of inotrope usage, mechanical ventilation, and ICU stay were seen in obstructed TAPVC in comparison to unobstructed TAPVC patients. Duration of CPB or aortic cross-clamp had no effects on morbidity parameters. In our cohort of TAPVC patients, lower BSA was strongly associated with the longer requirement of inotropes, prolong ventilation time, and ICU stay. The risk factors for mortality in our study include lower BSA, infracardiac, and obstructed type of TAPVC.

Background: The optimal dose of tranexamic acid in minimizing perioperative bleeding is uncertain. We compared efficacy of two different doses of tranexamic acid in reducing post-operative blood loss and its side effects in patients with congenital cyanotic heart disease undergoing cardiac surgery. Settings and Design: Prospective observational study at a pediatric cardiac center in South India. Methods: Consecutive cyanotic patients undergoing cardiac surgery were divided into groups I and II to receive either 10 mg/kg or 25 mg/kg of tranexamic acid administered as triple dose regime after induction, during cardiopulmonary bypass, and after protamine. Post-operative blood loss at 24 hours, blood component utilization, incidence of renal dysfunction and seizures were compared. Results: Totally, 124 patients were recruited, 62 in each group. The pre-operative variables and cardiopulmonary bypass time were comparable. Patients receiving 25 mg/kg had lower post-operative blood loss compared to patients in lower dose group (8.04 ± 8.89 vs 12.41 ± 19.23 ml/kg/24 hours, P = 0.03). There was no difference in the transfused volume of packed red cells (9.21 ± 7.13 ml/kg vs 12.41 ± 9.23 ml/kg, P = 0.712), fresh frozen plasma (13.91 ± 13.38 ml/kg vs 11.02 ± 8.04 ml/kg, P = 0.19), platelets (9.03 ± 6.76 ml/kg vs 10.90 ± 6.9 ml/kg, P = 0.14) or cryoprecipitate (0.66 ± 0.59 ml/kg vs 0.53 ± 0.54 ml/kg, P = 0.5) in group II and I, respectively. Two patients developed renal dysfunction secondary to low cardiac output in lower dose group. There were no seizures. Conclusions: Tranexamic acid administered at a dose of 25 mg/kg as triple dose regime is associated with lower post-operative blood loss compared to a lower dose of 10 mg/kg in cyanotic patients undergoing cardiac surgery without causing major adverse effects.

Context: Atrial fibrillation (AF) is the most common arrhythmia in adults. For over 90% of non-valvular AF patients, the left atrial appendage is the primary site of thrombus formation. Left atrial appendage occlusion using the FDA-approved Watchman™ device has been shown to have better clinical outcomes with minimal post-procedural complications when compared to warfarin therapy for patients with contraindications to anticoagulation. Traditionally, this procedure requires an endotracheal tube (ETT) to facilitate transesophageal echocardiography (TEE) guidance. However, recently supraglottic airway (SGA) has emerged as a feasible, non-inferior alternative to ETT for procedures requiring TEE. Aims: Compare outcomes between TEE guided Watchman™ procedures performed with a SGA versus ETT. Settings and Design: A single tertiary care academic medical center. Methods and Materials: Retrospective Observational Study comparing SGA and ETT patients. Statistical Analysis Used: 1:4 propensity score matching of SGA and ETT patients. Results: 42 SGA patients were matched with 155 ETT patients. All patients underwent procedure with TEE. SGA patients had shorter operating room time (11 min difference, P = 0.00001) and considerably shorter PACU length of stays (45 min difference, P = 0.024). Statistically significant, but clinically trivial differences were seen in procedure times (P = 0.015) and fluoroscopy times (P = 0.017). Patients in the SGA group received lower fentanyl (P < 0.00001) dosages. No significant differences were observed in postoperative complications, organ-specific morbidity or 30-day mortality. Conclusions: General anesthesia with SGA is likely a safe, feasible alternative to ETT in Watchman™ procedures requiring TEE guidance. Use of SGA was associated with significant reductions in operating room time and PACU length of stay, potentially offering advantages in terms of resource utilization.

Background: Postoperative pulmonary complications in cardiac surgery increase mortality and morbidity. High flow nasal cannula oxygen therapy (HFNC) is one of the preventive measures to reduce the incidence of lung complications. HFNC can decrease dyspnea and improve physiologic parameters after extubation, including respiratory rate and heart rate, compared with conventional oxygen therapy. In this study, we evaluated the role of THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange) after extubation. Methodology: We prospectively randomized 60 adults aged between 18 and 65 years undergoing elective cardiac surgery to either High flow oxygen therapy using THRIVE (Group A) or conventional nasal cannula (group B). Arterial paO2, paCO2, pH at three points of time i.e., 1, 2, 4 hrs after extubation were evaluated using arterial blood gas analysis. Ventilation duration, the incidence of reintubation, sedation score, mortality, and other complications were also assessed. Results: Thirty adults in each group had comparable patient characteristics. There was a statistically significant decline in paCO₂ in group A at 1, 2, 4 hrs post extubation (P = 0.022, 0.02, <0.001) with a significant increase in oxygenation (P < 0.001) when compared to group B.ICU stay duration was similar between two groups. No complications were noted in both groups. Conclusion: THRIVE is safe to use following extubation in adult cardiac surgical patients.

Holt-Oram syndrome is a rare autosomal disorder with cardiac, vascular, and upper limb anomalies. Previous reports have described anesthetic and perioperative challenges including difficulty in arterial and venous cannulations, airway management and rhythm, and temperature abnormalities. There are no previous reports of absent right superior vena cava (SVC) in children with Holt-Oram syndrome. We present images of a case where the diagnosis of absent right SVC with persistent left SVC was made with intraoperative transesophageal echocardiography and discuss the anesthetic and perfusion implications of such findings.

The diagnosis of paradoxical emboli remains elusive in many cases. The causal association between the thrombotic source, the intracardiac shunt, and the final emboli location is seldom demonstrated. We present the case of a 42-year-old woman admitted to the hospital with a third stroke. The presence of a thrombus in transit through a patent foramen ovale (PFO), a deep vein thrombosis (DVT), bilateral pulmonary emboli, and an acute cerebral infarct were concurrently documented.

Severe symptomatic tricuspid regurgitation (TR) with right heart failure is associated with significant morbidity and mortality. Medical therapy is often ineffective and surgical correction is not feasible due to prohibitive perioperative risk. Transcatheter caval valve implantation (CAVI) is an evolving therapeutic option for this condition. It refers to the heterotopic placement of a valve into the inferior vena cava alone or with a second valve in the superior vena cava to restrict the backflow from the failing tricuspid valve. We hereby describe a patient with previous mitral valve surgery with chronic severe TR who underwent successful CAVI at our institute.

Percutaneous coronary intervention (PCI) is an universally accepted and standardized procedure for obstructive coronary artery diseases with minimal complication rates, including iatrogenic coronary artery perforation (CAP). Most of the coronary perforations present earlier during the time of procedure or immediately after the procedure. Delayed presentation is very rare and presents within days or weeks. The present case showed the delayed atypical presentation of stent extrusion as a swelling in the right hypochondrium three years after the procedure. This is a rare case of long standing right coronary artery stent extrusion presented atypically as a right hypochondrial swelling.

Once regarded as a rare complication, the potentially fatal bone cement implantation syndrome (BCIS) has been increasingly reported. BCIS can present as transient desaturation, hypotension, cardiac dysrhythmias, and cardiovascular collapse. Diagnosis of BCIS is often clinical and confirmed with computed tomography (CT) imaging postoperatively. However, point of care ultrasound (POCUS) examination could be a helpful and timely tool to clinch the diagnosis in a sudden cardiovascular collapse. We present a case of Grade 3 BCIS where POCUS examination revealed a massive clot in the right atrium, which supports the diagnosis.

Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals that result in leakage of excessive serum proteins and lymphocytes into the gastrointestinal (GI) tract culminating in protein-losing enteropathy. The GI loss of protein and possible antithrombin III (AT-III) loss creates a prothrombotic environment. The surgical management of congenital heart disease (CHD) in presence of PIL can present with altered heparin response and can impose problems in instituting cardiopulmonary bypass (CPB). We report a case of surgical closure of ventricular septal defect with PIL with altered heparin response. Such an association of PIL with altered heparin response in CHD has not been reported in literature.

Central venous access is useful for monitoring central venous pressure, inserting pulmonary artery catheter and administering vasoactive drugs in hemodynamically unstable patients. Central venous catheter (CVC) insertion through internal jugular vein may cause major vessel injury, inadvertent arterial catheterization, brachial plexus injury, phrenic nerve injury, pneumothorax, and haemothorax. We describe unusual presentation of hemothorax following CVC placement in a patient undergoing vestibular schwannoma excision. The patients' trachea intubated after several attempts during which thiopentone up to 600 mg administered. Thereafter, under ultrasound guidance, an 18G introducer needle placed in the right internal jugular vein but guide-wire did not advance. Meanwhile, the patient became hemodynamically unstable and a CVC placed in right subclavian vein and norepinephrine infused at 0.05 μg/kg/min; simultaneously, 1000 ml normal saline administered through CVC. The hemodynamic instability attributed to thiopentone administered during endotracheal intubation. The surgical procedure cancelled, and the patient shifted to critical care unit (CCU). Mechanical ventilation continued. In CCU, hemodynamic parameters further deteriorated and 0.1 μg/kg/min epinephrine started. Bedside lung ultrasound showed a large collection in pleural space on the right side. Chest radiograph showed a homogenous opacity obliterating costophrenic angle on the right side. A possibility of hemothorax considered, chest tube inserted and 1000 ml sanguineous fluid drained. Blood sample drawn through CVC showed air from proximal and middle lumen but distal lumen drained blood. Another CVC placed in the femoral vein and subclavian vein CVC removed. The vasoactive drug infusion transferred to CVC in femoral vein and 2 units pRBCs transfused. Hemodynamic parameters gradually stabilized and the patient recovered completely.

The anesthetic management of patients with a mediastinal mass represent a challenge due to the potential for difficult ventilation and intubation, as well as the risk of cardiovascular collapse upon induction of general anesthesia. Different strategies and alternatives have been described. We present the case of a 70-year-old man with a right para-tracheal mass extending into the anterior mediastinum with 90% mid-tracheal lumen obstruction who was successfully managed with venous-venous extra-corporeal membrane oxygenation (ECMO) during mass debulking and tracheal stent placement.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.

In the patients with stenotic upper respiratory airways tumor, the tracheal intubation during the surgical resection is sometimes impossible. In these situations, Extracorporeal Membrane Oxygenation appears to be an interesting temporarily alternative to ventilation to allow tumor removal. In this report the authors describe a case of successful resection of tracheal tumor in an 80-year-old female patient in which tracheal intubation was impossible. A circulatory assistance was used to perform the operation. Afterwards, tracheal intubation was easily performed for the rest of the operation.

The incidence aortic valve injury during percutaneous coronary intervention is scarce, mostly resulting in acute aortic regurgitation. However, rarely patients may remain asymptomatic in the immediate post-procedure period and present latter with chronic aortic regurgitation. Determining etiology of such an aortic regurgitation may be challenging. We present a case of a 51-year-old man with history of percutaneous coronary intervention for coronary artery disease and moderate aortic regurgitation scheduled for coronary artery bypass grafting and aortic valve replacement. Intra-operative transesophageal echocardiography was instrumental in deciding etiology of aortic regurgitation that change surgical management of the patient.

Marked aneurysmal dilation of the central and branch pulmonary arteries in utero in patients with tetralogy of Fallot with absent pulmonary valve can often exhibit extrinsic compression of the trachea and bronchi. The major morbidity in these patients remains postoperative ventilation issues. This case report highlights the role of intraoperative bronchoscopy in providing guidance for obtaining optimal bronchial decompression that was achieved by an initial pulmonary arteriopexy followed by an aortopexy.

Mediastinal masses carry the intrinsic potential for life-threatening perioperative complications that directly impact anesthetic management, since well-recognized cardiopulmonary failure either chronic or acute may occur. A 48-year-old patient with known airway collapse due to an anterior mediastinal mass presents for airway stent insertion, that upon manipulation of the airway, a sudden and reproducible cardiovascular collapse ensued, due to dynamic compression of the superior vena cava, witnessed via endobronchial ultrasound. Close communication with the procedural team before and during manipulation of the patient's airway plays a paramount role to assure positive clinical outcomes.

Intraoperative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for the repair of congenital heart lesions. Its ability to be used intraoperatively before and after cardiac repair makes it a unique tool. Although it is generally a safe procedure, due to the relatively large size and rigid nature of TEE probes airway complications, inadvertent extubation and insertion failures have been reported to occur predominantly in smaller patients (mean weight <7.15 kg). We would like to describe a case of complete correction of Tetralogy of Fallot in which intraoperative TEE resulted in right main bronchus compression.

The anatomical relationship between the mitral valve and the left circumflex coronary artery places this vessel at risk for occlusion during mitral valve repair or replacement. In view of the potential high morbidity and mortality of this complication, the anesthesiologist has a vital role in its prompt diagnosis. We present the case of a 47-year-old man who underwent a minimally invasive mitral valve repair, which was complicated by left circumflex coronary artery occlusion.

Intravascular leiomyoma is an uncommon disease and depending of vascular involvement and anesthetic challenge. We review a case of a 53-year-old woman who underwent vena cava leiomyoma resection under cardiopulmonary bypass using deep hypothermic circulatory arrest (DHCA). Invasive hemodynamic and neurologic monitoring, transesophageal echocardiography, and viscoelastic coagulation test were used during the procedure. Total surgical resection was accomplished with no complications and the patient was extubated 2 days after surgery without cardiac or neurologic deficit. Although uncommon, level IV intravascular leiomyoma surgery is a challenge because the total resection needs DHCA, prolonged cardiopulmonary bypass and aortic cross-clamp times. These conditions expose the patient to the risk of coagulopathy, low cardiac output syndrome, and neurologic deficit.

Myocardial abscess is a suppurative infection of myocardium, endocardium, native or prosthetic valves, perivalvular structures and cardiac conduction system. It develops in about 20% of patients with infective endocarditis. Due to avascular and fibrous structures, valvular regions are commonly involved. More precisely, aortic valve (AV) rings area; native or prosthetic valve is usually affected. Occurrence of myocardial abscess within free wall of the left ventricle (LV) without any evidence of infective endocarditis is a rare phenomenon; and infrequently reported in medical literature. We report a case of myocardial abscess cavity within the anterior wall of the LV, in a patient who underwent open heart surgery for severe AV stenosis. This was an incidental intraoperative transesophageal echocardiography (TEE) finding without any other evidence of infective endocarditis. The stenotic AV was replaced, along with surgical drainage and closure of the cavity. Postoperatively, patient was managed on empirical antibiotics according to infective endocarditis guidelines.

Electrical storm or incessant ventricular tachycardia is a life-threatening condition and is associated with high morbidity and mortality. Often patients respond to traditional anti-arrhythmia treatment. However, some patients are resistant to the drug therapy and thus, pose huge challenges in effective management. Though stellate ganglion block has been found to be effective in treating patients with electrical storm, it is still under-utilized. In this case report, we successfully managed to revert the drug-resistant arrhythmia to sinus rhythm after ultrasound-guided stellate ganglion block. Earlier utilization of the block can possibly provide effective treatment in drug-resistant ventricular arrhythmias and prevent morbidity and mortality.

Hemoptysis is a common presenting feature of tuberculosis, pulmonary parenchymal malignancy, bronchiectasis, or a cardiac pathology as mitral stenosis. Relevant clinical history, physical examination, laboratory investigations, and radiology usually identify the cause of hemoptysis in the majority of the cases. We report a case of a 50-year-old male with intermittent hemoptysis which was the presenting feature of accessory cardiac bronchus.

Hemolytic anemia and right ventricular outflow tract obstruction following device closure of ruptured sinus of Valsalva have seldom been reported in isolated case reports, and exact incidence is not known. A gentleman presented with severe delayed hemolytic anemia following the use of cocoon duct occluder for ruptured sinus of Valsalva. Right ventricular outflow tract obstruction of unclear etiology was also reported on transthoracic echocardiography, necessitating retrieval of the device and surgical closure of the defect. Intraoperative transesophageal echocardiography (TEE) showed right ventricular outflow obstruction by the cocoon device itself with a normal pulmonary valve. In this report, we emphasize that improper device selection for closure of ruptured sinus of Valsalva aneurysm, may lead to delayed leaks across the device, which can gradually progress causing hemolytic anemia and high gradient across the right ventricular outflow tract. Intraoperative TEE helped to delineate the cause of right ventricular outflow tract obstruction.