Kemal Tolga Saracoglu

Missing atrioventricular echogenic mass during paediatric HeartWare® implantation

To the Editor, While awaiting for heart transplantation, left ventricular assist device implantation has become a well-established treatment for children with end-stage heart failure [1] During the implantation, a left or right atrial mobile mass may be visualized by transesophageal echocardiography [2]. Even the differential diagnosis can be challenging, mostly consisting of a primary or metastatic cardiac tumour, vegetation or a thrombus [3]. However, determination of a new atrial mobile mass with irregular borders typically raises concern of a thrombus which carries the risks of systemic embolization [4]. A 5-year-old boy with a history of several surgeries, including the Senning procedure for correction of transposition of the great arteries, pulmonary artery banding, ventricular septal defect surgery, and tricuspid valve ring annuloplasty, presented with multiple organ dysfunction syndrome. During a transthoracic echocardiography, left ventricular ejection fraction was assessed at 10%. The patient underwent implantation of a HeartWare® continuous-flow left ventricular assist device. Transesophageal echocardiography demonstrated an echogenic mass formation in the right atrium (Fig. 1) and the left ventricle (Fig. 2). The echo probe was in place throughout the procedure and continuous images were acquired. After 15 minutes time, first the atrial and then the ventricular thrombus-like images just vanished in an instant, without observing any changes or stages of resolution. The images were recorded following the implantation of an assist device. Immediately after the surgery, no thromboembolic complications were observed. A Doppler ultrasound examination of the blood circulation in the upper and lower extremities showed no thrombus formation. In conclusion, we have come across a highly unusual case of echogenic mass formation both in the right atrium and left ventricle that developed during implantation of an isolated permanent continuous-flow left ventricular assist device (HeartWare®). Although this could have been an artefact, acute systemic embolization may be a life-threatening condition and should be excluded in the early postoperative period.

Silicone stents save lives without surgery in postintubation subglottic stenosis

A B a recent study by Patel et al. [10] demonstrated that the CLT or a combination of the CLT with laryngeal parameters failed to accurately predict PES. Moreover, the probability that the CLT can increase the risk of oropharyngeal and subglottic secretions into the airway during cuff deflation and mechanical ventilation does exist and cannot be denied. Extubation of intensive care unit (ICU) patients is potentially a high risk procedure. There is no single test that can reliably predict post-extubation stridor. We believe that a combination of tests should be performed (as suggested by Patel et al. [10]) in addition to a fibreoptic laryngoscopy prior to extubation so as to exclude any new onset of anatomical defects similar to our case. This, in turn, can somewhat reduce the incidence of post extubation upper airway obstruction.

Air leak without subcutaneous emphysema in an adult patient due to thyroidectomy

1Department of Respiratory Diseases, Istanbul Bilim University Medical School, Turkey 2Department of Anesthesiology and Reanimation, Istanbul Marmara University Medical School, Turkey 3Department of Anesthesiology and Reanimation, Istanbul Bilim University Medical School, Turkey 4Department of Respiratory Diseases, Yedikule Teaching Hospital for Pulmonology and Thoracic Surgery, Istanbul, Turkey

VivaSight: a new era in the evolution of tracheal tubes

STUDY OBJECTIVE To evaluate the available data describing the use of single and double lumen VivaSight tubes. DESIGN Systematic review. SETTING The use of VivaSight tubes for elective surgeries including advantages, disadvantages, and possible complications. PATIENTS Systematic review of randomized controlled trials from databases including Medline, Web of Knowledge, Google Scholar, and Cochrane Central Register of Controlled Trials. INTERVENTIONS Comparison of VivaSight single and double-lumen tubes with conventional tubes during normal airway and expected difficult airway management. The effectiveness of the devices was also evaluated during 1-lung ventilation for patients undergoing thoracic surgery. MEASUREMENTS Intubation time, success rate, the requirement for fiberoptic bronchoscope, and the rate of complications. MAIN RESULTS Following a VivaSight double-lumen tube, a flexible bronchoscope is still needed. It is difficult to agree that VivaSight tube reduces the need or use of a bronchoscope. According to the current literature, it is unclear if there is any advantage of the VivaSight compared with using flexible bronchoscopy to direct a blocker into the correct lung. The cost may be another issue. Studies comparing VivaSight tubes with standard double lumen tubes reported faster tracheal intubation rate and higher success rate at first attempt for VivaSight. However, VivaSight tubes may cause soft tissue trauma such as bleeding, hematoma, edema, and erythema. Sore throat and dysphonia are other reported complications. Due to the outer thickness, smaller-sized double-lumen tube may be necessary. It has been reported to have the disadvantages, such as melting due to the heat of light source before insertion and sudden shutdown without warning. CONCLUSIONS Problems such as overheating and melting on the distal end of the tube due to the light source and potential breakdowns of the cable should be solved by the manufacturer. This will probably require a redesign and necessitate further studies.

The importance of maintaining an optimal hemodynamic state during minimally invasive fetal surgery

Minimally invasive fetal surgery has become an accepted treatment option for several fetal life-threatening congenital malformations [1]. Fetoscopic surgery is mainly performed in the presence of congenital diaphragmatic hernia, neural tube defects, twin-to-twin transfusion syndrome, and cardiac malformations [2]. Prenatal repair of myelomeningocele reduces the need for shunting and improves motor outcomes [3]. In order not to compromise maternal and fetal health, a goaldirected therapy is mandatory. Besides, pregnancy induces physiologic changes that may include alterations in both drug pharmacokinetics and pharmacodynamics [4]. Therefore, perioperative fluid, vasopressor, and inotropic agent titration with the assessment of pulmonary vascular permeability and fluid contents are the key points of perioperative anesthesia management. Hemodynamic monitoring, airway management, and postoperative pain therapy are other major elements that make up the secrets of anesthesia [5]. In this case series, we aimed to share our results of the first four pregnant patients who underwent minimally invasive fetal repair for spina bifida aperta. All patients were at 26 weeks of pregnancy. The mean age was 33.3 ± 4.3 years. Preoperatively, the mean pulmonary arterial pressure was 25.3 ± 1.0 mmHg, and themean ejection fraction was 61.0% ± 2.0%. Other parameters that were measured three times during the perioperative period are shown in Table 1. The PICCO2 monitor was used for the measurement of parameters. Preoperative and postoperative hemodynamic data of the patients showed no significant differences. There were also no significant differences in umbilical artery trace and systolic/ diastolic blood pressure rates. The surgeries were all successful, and the infants have no any neurologic deficit.