Double Lumen Research Articles

Tracheal rupture following double lumen tracheal intubation: A case report

Tracheal rupture following double lumen tracheal intubation: A case report

Ultra-Low-Field Portable MRI and Extracorporeal Membrane Oxygenation: Preclinical Safety Testing.

Conventional MRI is incompatible with extracorporeal membrane oxygenation (ECMO) cannulas and pumps. Ultra-low-field portable MRI (ULF-pMRI) with 0.064 Tesla may provide a solution, but its safety and compatibility is unknown. ULF-pMRI does not cause significant displacement and heating of ECMO cannulas and does not affect ECMO pump function. ECMO cannulas in various sizes were tested ex vivo using phantom models to assess displacement force and heating according to the American Society for Testing and Materials criteria. ECMO pump function was assessed by pump flow and power consumption. In vivo studies involved five female domestic pigs (20-42 kg) undergoing different ECMO configurations (peripheral and central cannulation) and types of cannulas with an imaging protocol consisting of T2-weighted, T1-weighted, FLuid-Attenuated Inversion Recovery, and diffusion-weighted imaging sequences. Phantom models demonstrated that ECMO cannulas, both single lumen with various sizes (15-24-Fr) and double lumen cannula, had average displacement force less than gravitational force within 5 gauss safety line of ULF-pMRI and temperature changes less than 1°C over 15 minutes of scanning and ECMO pump maintained stable flow and power consumption immediately outside of the 5 gauss line. All pig models showed no visible motion due to displacement force or heating of the cannulas. ECMO flow and the animals' hemodynamic status maintained stability, with no changes greater than 10%, respectively. ULF-pMRI is safe and feasible for use with standard ECMO configurations, supporting its clinical application as a neuroimaging modality in ECMO patients.

Successful Coronary Interventions with the Ingenious Vector\(\circledR\) Balloon in Chronic Total Occlusion (CTO): A Preliminary Study

Aims: To assess the safety and plausibility of successful coronary interventions in Chronic Total Occlusion (CTO) with the innovative Vector\(\circledR\) balloon through balloon-assisted crossing technique. Study Design: Observational, prospective study. Place and Duration of Study: Department of Cardiology, King Edward Memorial Hospital and Seth G. S. Medical College, Mumbai. The study was carried out between the months of March and June, 2024. Methodology: A total of 20 patients were included in the study. All patients with chronic coronary syndrome were being planned for Percutaneous Coronary Intervention (PCI) for CTO. During PCI, the standard protocol of intervening CTO lesions was followed. When the operator was not able to cross the lesion with standard CTO guidewires, Vector\(\circledR\) balloon-assisted crossing was planned. This technique was used in a total of seven (35%) patents. Success was defined as the possibility of advancing the guidewire further to the target lesion and being able to deploy a drug eluting stent. Safety was assessed as reporting complications like kinking or rupture of the balloon shaft, loss of balloon inside the guide or the coronary artery and the balloon burst rate after inflation exceeding the Rated Burst Pressure (RBP) according to the manufacturer’s reference table. Results: The mean age of the patients was 58.1 ± 3.6 years. The balloon-assisted crossing was successful in all seven patients. The most commonly used diameter of the balloon was 1.25 mm (42.85%). Conclusion: The novel Vector\(\circledR\) balloon catheter showed excellent result when deployed to treat the CTO after the usual strategy of guidewire escalation had failed. The proximal shaft with polytetrafluoroethylene (PTFE) coating brings the flexibility to navigate complex and tortuous vascular pathways with ease due to its laser welded core-wire. A study with a larger sample size and a comparator arm would rather clarify if such a balloon-assisted crossing technique in CTO would decrease the need of costly devices like double lumen microcatheters.

Vascular Access for Renal Replacement Therapy in Neonates and Infants: A Single Center Experience

IntroductionNeonatal renal replacement therapy (RRT) is a treatment modality used for severe kidney failure. Historically, its use has been limited in small infants due to circuits with large extra-corporeal volumes that require large double lumen vascular catheters. We sought to review our institution's experience with vascular access and overall survival in infants who receive RRT. MethodsA retrospective chart review of infants less than 5 kg (kg) was performed at our free-standing children's hospital from January 2016 to July 2023. We assessed the number of catheters used per patient, location of catheter placements, size of catheter, duration of treatment, reasons for line removal, and mortality. ResultsA total of 93 neonatal patients were identified who underwent RRT. Thirty-two patients (34.4%) required more than one catheter, with a total of 145 catheters placed for this cohort. The median (IQR) weight at insertion was 3.3 kg (2.7–4.0). The most common location for placement was the right internal jugular vein (n = 114, 78.6%). Patients required catheters for RRT for a median (IQR) of 16 days (7–39). Six patients underwent catheter placement at a weight of less than 2 kg. Nineteen total patients went on to peritoneal dialysis (20.4%). Fifty-three patients died during their admission (57.0%). ConclusionTo our knowledge this is the largest review of catheter use for RRT in infants within an intensive care unit and it reveals the success in treating renal failure in even the smallest infants. Level of EvidenceIV, Treatment Study.

101 Beyond guidelines: a case report of combined FBS and VLS use for awake double lumen tube positioning

101 Beyond guidelines: a case report of combined FBS and VLS use for awake double lumen tube positioning

CAT Study: Pediatric Catheter-Associated Thrombosis: A Retrospective Electronic Record Review

Highlights CAT is a significant problem in pediatric patients with CVCs and other risk factors. CAT was found in 4% of the sample with estimated 0.23 events per 1,000 CVC days. Incidence of CAT was lower than anticipated but consistent with published evidence. Median LOS was substantial in the CAT group suggesting increased disease burden. Specific clinical modifiers and CVC factors were more common in the CAT group. Findings provide valuable foundation for future CAT research and risk models. Clinicians and researchers should collaborate to reduce CAT incidence. Abstract Background: Catheter-associated thrombosis (CAT) is a serious condition, especially among pediatric surgical patients. This study describes the CAT incidence rate and clinical, demographic, and central venous catheter (CVC)-specific risk factors that may be associated with CAT, for a cohort of pediatric surgical patients. Methods: An electronic record review of 124 pediatric surgical patients with indwelling CVCs receiving parenteral nutrition (PN) cared for in a single pediatric hospital between 2016 and 2018 was performed. Results: Of the 297 CVCs, 4% of patients (n = 5) developed CAT, resulting in an estimated incidence rate of 0.23 events per 1,000 CVC days (95% confidence interval 0.15–0.31). Patients diagnosed with CAT had a higher burden of anemia, blood product administration, chronic lung disease, congenital heart disease, sepsis, prolonged mechanical ventilation, extracorporeal membrane oxygenation use, increased surgical complexity, and longer hospital stays. They also had a higher frequency of peripherally inserted central catheters, small caliber size CVCs, double lumen CVCs, extended PN and lipid course, lack of ethanol prophylaxis, higher rates of intravenous antibiotics, lower rates of treatment-dose heparin, and prolonged CVC duration. Conclusion: The incidence of CAT in this study was consistent with published rates for hospitalized pediatric patients with CVCs. The study provides additional foundational evidence about clinical, demographic, and CVC-specific risk factors associated with CAT in pediatric surgical patients with CVCs. It can help guide future research and collaborative efforts to develop risk assessment and other preventative strategies to reduce CAT incidence and improve patient care outcomes.

Use of a novel configuration of ports for patients needing intermittent long-term apheresis.

In patients with a need for frequent but intermittent apheresis, vascular access can prove challenging. We describe the migration of the use of a Vortex LP dual lumen port (Angiodynamics, Latham, NY) to one Powerflow and one ClearVUE power injectable port (Becton Dickinson, Franklin Lakes, NJ) in a series of patients undergoing intermittent apheresis. All patients had a need for long-term intermittent apheresis. Eight had double lumen Vortex port (pre) and were exchanged for one Powerflow port and one conventional subcutaneous venous port with 90° needle entry (post) while 12 did not have any port in place and received the same configuration. IRB approval was granted. We recorded the treatment time, flow rate, and tissue plasminogen activator (tPA) use for five treatment sessions after placement. When available, we compared five treatments with the Vortex port and the new configuration. The mean treatment time is reduced with the new configuration (P = 0.0033). The predicted mean treatment time, adjusting for gender, race, BMI and age and accounting for correlations within a patient is 91.18 min pre and 77.96 min post. The flow rate is higher with the new configuration (P < 0.0001). The predicted mean flow rate in mL/min is 61.59 for the Vortex port and 71.89 for the new configuration. tPA use was eliminated in the population converted from Vortex ports and had a 48% reduction when compared to all other configurations in the study. The introduction of a novel device configuration of venous access ports for intermittent apheresis resulted in higher flow rates and less total time for treatment. Use of tPA was greatly reduced. These results suggest that the new configuration could result in less expense for the hospital and better throughput in a busy pheresis practice. Clinical trial registration with ClinicalTrials.gov: NCT04846374.

Methicillin-Sensible Staphylococcus aureus (MSSA) Pericardial Effusion Causing Cardiac Tamponade: A case report

Background: Methicillin-Sensible Staphylococcus aureus (MSSA) as the pathogen of the pericardial space is an uncommon case that can be fatal if untreated. The underlying disease accompany with infection that lead to cardiac tamponade can increase mortality rate of the patient. Case description: We present a 29 years old male patient with severe dispnea who was found to have cardiac tamponade secondary to a purulent pericardial effusion. He was also had end stage renal disease with regular hemodialysis. The diagnosis was suggested by clinical context, imaging, pericardial fluid analysis and was confirmed by culture. MSSA were isolated from 2 times pericardial fluid, peripheral blood and double lumen catheter exit site swab that were growth in blood agar only. Identification and susceptibility to antibiotics was assessed by Vitek2 Compact automated system (BioMerieux), represent sensitive to penicillin, cephalosporin, quinolone, aminoglycoside except macrolides. Administration of cefazolin intravenous for 5 days and also pericardial drainage result in a full recovery for the patient. Discussion: Purulent pericardial effusion is a rare condition that carries a high mortality rate as it can rapidly progress into cardiac tamponade. In developing countries, Mycobacterium tuberculosis is the most frequent cause of acute pericarditis followed by Haemophilus, Staphylococcus and Streptococcus. Prior to the advent of antibiotics, Staphylococcus aureus takes role as the predominant pathogen, this event was common as the result of hematogenous seeding such as catheter related hemodialysis in this patient. Conclusion: Prompt diagnosis of purulent pericardial effusion also initiation of appropriate antibiotic and pericardial drainage treatment are the mainstays of successful management of this rare but potentially lethal case.

Comparison of Auscultation Method Versus Lung Ultrasound Technique to Evaluate the Accuracy of Positioning of Left Double Lumen Tube in Patients Undergoing Cardiothoracic Surgery

Comparison of Auscultation Method Versus Lung Ultrasound Technique to Evaluate the Accuracy of Positioning of Left Double Lumen Tube in Patients Undergoing Cardiothoracic Surgery

Effect of patient position on the success rate of placing triple-cuffed double lumen endotracheal tubes: a two-center interventional observational study.

Double-lumen endotracheal tubes (DLT) are essential for one-lung ventilation during thoracic surgery. Bronchoscopy is crucial for correct placement of a DLT to avoid complications such as hypoxemia. This study evaluated the effectiveness of the triple-cuffed DLT (tcDLT) in the supine and lateral positions for correct placement without bronchoscopic guidance. This prospective observational study included 167 patients scheduled for elective thoracic surgery requiring one-lung ventilation. The incidence of successful placement of left-sided tcDLTs was compared between the supine and lateral decubitus positions under bronchoscopic surveillance. Successful tcDLT placement was defined as the placement of the proximal end of the bronchial cuff within 5 mm of the carina. Among 153 patients who completed the study, the successful tcDLT placement rate in the lateral position (70.6%) was significantly higher than that in the supine position (50.3%). The rate of difference was 20.3% (95% confidence interval [CI], 10.6-29.9%). The extended successful placement rate, including slightly deeper placements, showed no significant differences between the positions (88.9%; 95% CI, 83.9‒93.9% in supine, 86.3%; 95% CI, 80.8‒91.7% in lateral). tcDLT facilitates correct tube placement in both the supine and lateral positions, with a higher lateral success rate. This finding supports the idea that tcDLTs offer a reliable alternative for lung separation when bronchoscopy is not feasible.

Initial Experience with the Eclipse Double-Lumen Balloon Catheter for Embolization of Cranial Vascular Malformations

Double lumen balloon catheters (DLBCs) have emerged as a potential alternative to single lumen balloon catheters (SLBCs) for endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs). This study describes our preliminary experience with the Eclipse 2L DLBC in treating AVMs and dAVFs. Patients who underwent embolization of cranial dAVFs or AVMs at our institution from August 2021 to March 2024 were included. Spinal vascular malformations were excluded. Descriptive statistics were used to analyze procedural outcomes, technical nuances and post-operative outcome on follow-up. 25 patients who underwent 38 embolization procedures (15 AVMs and 23 dAVFs) met criteria for inclusion in this study. The mean age of the cohort was 52.44 (standard deviation (SD)= 17.26), and 48% of the overall cohort (n= 13) was female. The average procedure times for AVMs and dAVFs were 80.4 minutes and 96.73 minutes, respectively. There was one instance of catheter entrapment. Two patients in the AVM cohort experienced mortality and one experienced post-operative rupture. Our preliminary experience using the Eclipse 2L balloon catheter for Onyx embolization reported procedural outcomes comparable to other DLBCs despite relatively higher procedure times and radiation doses. Further long-term studies on its efficacy as primary modality in treating AVMs and dAVFs are encouraged.

P-771 Does follicle size impact effect of follicular flushing on oocyte retrieval rate and embryology outcomes?

Abstract Study question Is the effect of follicular flushing on oocyte retrieval rate (RR) and embryology outcome influenced by follicular size? Summary answer Flushing improved RR in discordant growth with smaller(8-12 mm) follicles and larger(&amp;gt;22mm) follicle. Flushing did not impact embryological outcomes adversely. It increased top quality embryo What is known already Follicular flushing is done in poor responder for improving retrieval rate. There are very few studies in normal or hyper responders. Studies show controversial results of flushing, some showing benefits, while others, a detrimental effect because of increased intra-follicular pressure, increased procedure time, and change in paracrine milieu of oocytes by dilution with flushing medium No study has addressed whether increased retrieval rates with flushing are dependent on follicular size and indirectly maturity of oocyte. Most studies flushed with fixed volume of 1-2ml as size of follicle was not taken into account, making volume inadequate for completely flushing larger follicles. Study design, size, duration Prospective cohort study conducted from September 2022 to August 2023. Group 1: Study group- follicles were flushed after aspiration. Total patients were 120. They were divided into 3 groups according to follicular size and fluid volume aspirated with sample size calculated as A:306 small follicles 8-12 mm(&amp;lt;1.0ml), B:467 medium follicles 13-22 mm (1.0-6.0ml) C:102 large follicle &amp;gt; 22 mm (&amp;gt;6.0 ml). Group 2- Control group where follicles aspirated without flushing in 280 patients, 2572 follicles. Participants/materials, setting, methods Ethical approval taken. Inclusion - patients 21-40years of age undergoing oocyte retrieval for IVF/ICSI cycle with antagonist protocol Exclusion of oocyte of indeterminate origin ie one aspirate have two oocytes Group1 After aspiration of follicle with double lumen oocyte retrieval needle, follicle flushed with media volume equivalent to follicular volume. Group2 only follicular aspiration and volume measured Analysis done using SPSS-25 version. Primary outcome retrieval rate(RR) of oocytes. Secondary outcome: fertilization rate, percentage of top quality embryos(TQE)on day3&amp;5, blastocyst rate. Main results and the role of chance Flushing follicle significantly increased RR in smaller follicles(8-12mm) compared to controls 159/311 (51.12%)vs 176/780 (22.56%) p = &amp;lt;0.001 and also in larger follicles(&amp;gt;6ml) 76/109 (69.72%)vs 116/219 (52.96%) p = &amp;lt;0.01 No difference seen in optimum size follicles (13-22mm) 337/470 (71.7%)vs 1099/1573(69.86%) p = 0.44. Overall, there was statistically significant increase in RR with flushing 567/890 (63.7%)vs 1391/2572 (54.08%) p = &amp;lt;0.001. Significantly more time was taken for flushing vs control groups 16.50vs 12.15 minutes p = &amp;lt;0.001. Secondary outcomes like fertilization rate was not different with flushing 476/567 (83.95±15.01%)vs 1125/1391(80.88±19.01 %) p = 0.21. Percentage of TQE (day 3) were significantly more in flushing group 321/476 (67.43±25.41%)vs control 642/1125 (57.07±25.94%)p = &amp;lt;0.01. TQE (day 5) were significantly more in flushing group 142/476 (29.83±11.02)vs control 251/1125 (22.31±12.11%)p=0.04. Blastocyst rate remained similar in both groups 196/476 (41.18±16.73 %) vs 403/1125 ( 35.82±13.90 %) p = 0.12. Subgroup analysis showed that younger women (&amp;lt;35yrs)had a significantly higher RR with flushing 66.33±16.29%vs controls 57.88±13.68% (p = &amp;lt;0.01), compared to older women &amp;gt;35 years 60.29±16.37%vs 56.35±17.30% (p = 0.38). Women with higher AMH had better RR with flushing 63.71±15.11%vs controls 56.50±14.33 (p = 0.01) compared to women with lower AMH (&amp;lt;1 ng/ml) where flushing made no difference 63.47±19.59%vs 60.62±14.93(p = 0.79). Normal and hyper responders had significantly higher RR with flushing 66.16±15.11vs controls 57.53±13.85%(p = &amp;lt;0.001) compared to poor responders (&amp;lt;5 oocytes) 51.07±18.07vs 56.24±27.47(p = 0.55). Limitations, reasons for caution Although RR was better with flushing in small and large follicles we could not translate the advantage to pregnancy rate(PR) PR could not be calculated as some patients wanted 2 embryos transferred. Since patient had one each embryos from small and optimum follicles both were transferred. Further RCT required. Wider implications of the findings Practice of follicular flushing needs re-evaluation Women with discordant growth should be taken for flushing as it increases RR in small and large follicles Role of flushing should be widened beyond poor responders to younger women, with normal or hyper response increasing oocyte yield which may increase cumulative pregnancy rate Trial registration number not applicable

Clinical application study of midline catheter in vasopressor therapy

To evaluate the safety and necessity of vasopressor infusion through midline catheter. A convenient sampling method was used for a controlled study. A total of 88 adult patients who used vasopressors admitted to respiratory intensive care unit (RICU) of Fenyang Hospital in Shanxi Province from June 2022 to June 2023 were enrolled as the research subjects. A total of 44 patients who were infused with vasopressors through peripherally inserted central venous catheter (PICC) from June to December 2022 were enrolled as the PICC group, and 44 patients who were infused with vasopressors through midline catheter from January to June 2023 were enrolled as the midline catheter group. Both groups of patients used the modified Sedinger technique under the guidance of B-ultrasound for puncture and catheter placement. The middle 1/3 site between the cubital fossa and the axilla was selected. The catheters were 5 Fr double lumen. After catheter placement, the patients were followed until catheter removal, death, or 30 days (whichever came first). Based on the Infusion therapy standards of practice revised by American Infusion Nurses Society (INS), and combined with the results of previous preliminary tests, the safety evaluation was conducted on incomplete catheter obstruction, catheter-related bloodstream infection (CRBSI), phlebitis, thrombus within the catheter during extubation, redness of the puncture site (but no infection), and exudation of the puncture site in the two groups of patients. There were no statistical differences in gender, age, catheter indwelling time, and primary disease between the two groups, indicating that the baseline data of the two groups were balanced and comparable. No CRBSI or phlebitis occurred in both groups during the observation period after catheterization. One patient in both groups had exudation at the puncture site [both were 2.27% (1/44)]. Compared with the PICC group, the incidence of incomplete catheter obstruction, thrombus within the catheter during extubation, redness of the puncture site (but no infection) in the midline catheter group were lowered [incomplete catheter obstruction: 4.55% (2/44) vs. 6.82% (3/44), thrombus within the catheter during extubation: 0% (0/44) vs. 2.27% (1/44), redness of the puncture site (but no infection): 0% (0/44) vs. 4.55% (2/44)], the overall incidence was significantly decreased [6.82% (3/44) vs. 15.91% (7/44), P < 0.01]. Administering vasopressor through a midline catheter can reduce the incidence of catheter-related complications, decrease the rate of central venous catheterization, and reduce the financial burden on patients.

Anesthetic management of broncho- alveolar lavage in pulmonary alveolar proteinosis: A case report

: Pulmonary alveolar proteinosis (PAP) is a very rare, life threatening, noninflammatory, diffuse lung disorder characterized by dense accumulation of lipo-proteinaceous material within the alveoli causing hypoxemia, restrictive lung disease leading to respiratory failure. Whole lung lavage (WLL) is considered as the treatment of choice which includes infusing warm saline in the lungs and draining it out with the lipo-porteinaceous materials thereby clearing the obstruction. WLL requires good team co-ordination between the anaesthesiologists, pulmonologists and physiotherapists. The procedural course is challenging in many aspects like hypoxaemia and hemodynamic fluctuations. Post procedure short term mechanical ventilation is commonly required.: A 45 year old female, diagnosed case of PAP presented with dyspnea at rest with increasing oxygen requirement. After clinical examination and investigations, due to severity of the disease, broncho-alveolar lavage (BAL) of left lung was planned with subsequent right lung BAL after few days. During the procedure, desaturation upto 78% was noted. With meticulous corrective measures, saturation picked up and the procedure was completed uneventfully. Post-operatively patient was mechanically ventilated and extubated after 32 hours.: WLL is the treatment of choice for PAP which involves multidisciplinary approach with mulitple challenges. Pre-oxygenation, adequate lung isolation with left sided double lumen tube (DLT), one lung ventilation with positive end expiratory pressure (PEEP), vigilant intra-operative monitoring, cautious use of positional manoeuvres and recruitment manoeuvres with a good teamwork is the key for successful outcome.

Clinical procedures for in vitro maturation treatment

To demonstrate clinical techniques for invitro maturation (IVM) treatment, including stimulation recommendations, small follicle pick-up procedures, and compact cumulus-oocyte complex (COC) search practice. This video utilizes live-action footage from surgery and embryology practice for a representative IVM treatment cycle, with step-by-step instructions and recommendations for practice procedures. Invitro fertilization (IVF) clinic. Patients undergoing IVM treatment. The patient(s) included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites, and other applicable sites. Identification of treatment cohorts, IVM definitions, and recommendations for stimulation treatments. A visual demonstration of COC extraction techniques from small antral follicles includes tubing, needle types, considerations when using double lumen or sheath needles, needle pressure, ultrasound, needle flushing, and aspiration technique. Visual demonstration of oocyte search and IVM preparation, including filtering follicular aspirate, prevention of COC cooling, identification of compact COCs, and general parameters of different IVM approaches. Clinical techniques for small follicle ovum pick up and compact COC identification for IVM treatment. Successful IVM treatment of patients can be achieved using minimal ovarian stimulation, effective small follicle retrieval, and efficient compact COC identification with flexibility in approach depending on clinical constraints and preference. Invitro maturation treatment is an efficacious and safe treatment for high ovarian reserve and hyper-responding patients undergoing IVF treatment, in which the retrieval of multiple immature COCs and their exvivo maturation can be achieved with little to no invivo stimulation. Practice procedures vary between treatment centers and IVM techniques. This video provides practice recommendations paired with a visual demonstration of techniques to assist in standardizing the approach and expanding the practice to more centers.

Thoracotomy: An Overview of Perioperative Anaesthetic Management

Background: The anesthesiologist's role during open thoracotomy includes using a double lumen tube (DLT) for lung isolation, maintaining oxygenation with one-lung ventilation (OLV), and providing postoperative analgesia. This study aims to describe patient demographics, comorbidities, perioperative anesthetic management, complications, and the effectiveness of epidural catheter analgesia. Methods: In this prospective, observational study, patients who underwent open thoracotomy for decortications were evaluated. Thoracotomy was done under general anaesthesia, OLV with DLT, and epidural analgesia. Postoperatively, all the patients were shifted to the intensive care unit. Collected data included patient demographics, associated co-morbidities, severity of lung diseases, complications, and postoperative recovery. Postoperative analgesia was assessed by the visual analogue scale (0-10). Result: Of 20 patients, 16 were male, and 4 were female, with a mean age of 35 years (range 15-60) and a mean weight of 52 kg (range 36-66). History of hypertension (N=5), hypertension with diabetes (N=3), obstructive lung disease (N=6), restrictive lung disease (N=11), and both combined (N=3) were noted on pre-anesthetic check-ups. Intraoperative complications were hypotension (N=3), desaturation (N=3), respiratory acidosis (N =7), and metabolic acidosis (N=3). Postoperative analgesia was managed with an epidural catheter (N=18) &amp; systemic analgesia (N=2). All patients had uneventful postoperative courses except one patient who had pulmonary edema and did not survive. Conclusion: Patients undergoing open thoracotomy had an increased risk for adverse perioperative outcomes. The incidences of perioperative morbidity are high in patients with associated comorbidities. Proper OLV strategy helps to correct intraoperative desaturation. Epidural analgesia plays a key role in postoperative recovery.

MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY

Abstract The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.

Individualized rotation of left double lumen endobronchial tube to improve placement success rate: a randomized controlled trial

BackgroundIn conventional practice, the left double lumen tube (DLT) is rotated 90° counterclockwise when the endobronchial cuff passes glottis. Success rate upon the first attempt is < 80%, likely owing to varying morphology of the bronchial bifurcation.MethodsWe conducted a randomized controlled trial to compare 90° counterclockwise rotation versus individualized degree of rotation in adult patients undergoing elective thoracic surgery using left DLT. The degree of rotation in the individualized group was based on the angle of the left main bronchi as measured on computed tomography (CT). The primary outcome was the first attempt left DLT placement success rate.ResultsA total of 556 patients were enrolled: 276 in the control group and 280 in the individualized group. The average angle of the left main bronchi was 100.6±9.5° (range 72° to 119°). The first attempt left DLT placement success rate was 82.6% (228/276) in the control group versus 91.4% (256/280) in the individualized group (P=0.02, χ2 test). The rate of carina mucosal injury, as measured at 30 min after the start of surgery under fibreoptic bronchoscopy, was significantly lower in individualized group than control group (14.0% versus 19.6%, P=0.041). The individualized group also had lower rate of postoperative sore throat (29.4% versus 44.0%, P<0.001) and hoarseness (16.8% versus 24.7%, P＜0.05).ConclusionsIndividualized rotation of left DLT based on the angle of the left main bronchi on preoperative CT increased first attempt success rate in adult patients undergoing elective thoracic surgery.Trial registrationThe trial is registered at Chinese Clinical Trial Registry (ChiCTR2100053349; principal investigator Xiang Quan, date of registration November 19, 2021).

Double lumen endobronchial tube intubation: lessons learned from anatomy

BackgroundDouble lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced clinicians. We hypothesized that airway anatomy, particularly of the glottis and proximal trachea, significantly impacts the ease or difficulty in placement of these tubes.MethodsImages from 24 randomly selected Positron Emission Tomography – Computed Tomography (PET-CT) scans were evaluated for several anatomic aspects of the upper airway, including size and angulation of the glottis and proximal tracheal using calibrated CT measurements and an online digital protractor. The anatomic issues identified were confirmed in cadaveric anatomic models.ResultsProximal tracheal diameter measurements in PET-CT scans demonstrated a mean ± standard deviation of 20.4 ± 2.5 mm in 12 males and 15.5 ± 0.98 mm in 12 females (p < 0.001), and both were large enough to accommodate 39 French and 37 French DLTs in males and females, respectively. Subsequent measurements of the posterior angulation of the proximal trachea revealed a mean angle of 40.8 ± 5.7 degrees with no sex differences. By combining the 24 individual posterior tracheal angles with the 16 angled distal tip measurements DLTs (mean angle 24.9 ± 2.1 degrees), we created a series of 384 patient intubation angle scenarios. This data clearly showed that DLT rotation to a full 180 degrees decreased the mean intubation angle between the DLT and the proximal trachea from a mean of 66.6 ± 5.9 to only 15.8 ± 5.9 degrees.ConclusionsRotation of DLTs a full 180 instead of the recommended 90 degrees facilitates DLT intubations.

A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review

BackgroundThe objective of this study was to evaluate a modern combined video laryngoscopy and flexible fiberoptic bronchoscope approach to placement of a double lumen endobronchial tube and further characterize potential strengths and weaknesses of this approach.MethodsRetrospective chart review was conducted at our single institution, academic medical center, tertiary-care hospital. Patients aged 18 years of age or older were evaluated who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. No interventions were performed.ResultsDemographics and induction and intubation documentation were reviewed for 21 patients who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. First pass success using the combined approach was 86% (18/21). The five patients with an anticipated difficult airway had successful double lumen endobronchial tube placement on the first attempt. There were no instances of desaturation during double lumen endobronchial tube placement. No airway complications related to double lumen endobronchial tube placement were recorded.ConclusionUse of a combined approach employing video laryngoscopy and a flexible fiberoptic bronchoscope may represent a reliable alternative approach to placement of double lumen endobronchial tubes.