Variability of Sentinel Lymph Node Location in Patients with Trunk Melanoma.

(1) Background: Melanoma is one of the most aggressive types of neoplasia, and the management of this pathology requires a correct staging, as well as a personalized modern oncological treatment. The main objective of the study is to determine the variability of the lymphatic drainage for patients with melanomas located on the trunk and, secondarily, to determine the features of individuals who underwent sentinel lymph node biopsy (SLNB) depending on the exact location on the trunk. (2) Methods: This retrospective, observational, single-center study included 62 cases of trunk melanoma operated between July 2019 and March 2023, in which SLNB was performed and a total of 84 lymph nodes were excised. (3) Results: Patients had a median age of 54.5 (33-78) years, with 58.1% being male; the melanomas had a median Breslow index of 2.3 (0.5-12.5) mm. Approximately 64.3% of the cohort had melanoma on the upper part of the trunk (54 cases) and 35.7% had it on the lower part (30 cases). The type of anesthesia chosen was general anesthesia in 53 cases and spinal anesthesia in 9 cases (85.5% vs. 14.5%, p < 0.001). The number of sentinel lymph nodes excised was 54 for melanomas located on the upper part of the trunk (8 cervical and 46 axillary) and 30 sentinel lymph nodes for melanomas of the lower part of the trunk (16 at the axillary level and 14 at the inguinal level). Out of the 54 LNs identified in patients with melanoma on the upper part of the trunk, 13 were positive, with a total of 12 positive lymph nodes (LNs) from the axillar basin, and only one from the cervical region. Additionally, the incidence of patients with a minimum of two identified sentinel lymph nodes was 32.2%, with a total of seven having LN involvement in two basins, and only one of these cases showed positivity for malignancy. (4) Conclusions: SLNBs were more frequent in the axillary region overall, and had more positive SLNs. Moreover, melanoma on the upper part of the trunk had a higher rate of positive SLNs compared to the lower part. Tumors located on the lower part of the truck had more positive SLNs in the axillary region than in the inguinal one.

Cardiac surgery-associated acute kidney injury and perioperative plasma viscosity: is there a relationship?

Plasma viscosity (PV) is a key factor in microcirculatory flow resistance and capillary perfusion during hemodilution, we hypothesized a possible relationship between cardiac surgery-associated acute kidney injury (CSA-AKI) and PV. We conducted a prospective, observational, single-center study on 50 adult cardiac surgery patients with cardiopulmonary bypass (age 64 years, male sex 80%, baseline serum creatinine 1.04 mg/dL). We assessed perioperative characteristics, management, short-term outcomes, blood analysis, PV, serum creatinine, and diuresis. CSA-AKI was identified using KDIGO criteria. Data were collected at 10 time points during the first perioperative week. CSA-AKI occurred in 17 patients (34%): 12 (24%) stage 1, 1 (2%) stage 2, and 4 (8%) stage 3. Most patients (88%) developed CSA-AKI within 48 h post-surgery. Patients with CSA-AKI had higher body mass index (BMI), more frequent chronic kidney disease (CKD), and lower hemoglobin and hematocrit levels. The median baseline PV for the entire cohort was 1.50 cP on EDTA and 1.37 cP on citrate. No significant differences in PV levels were found between patients with CSA-AKI and normal kidney function, both at baseline and at the 48-h. Logistic and Cox regression analyses showed no significant relationship between PV and CSA-AKI. However, CSA-AKI was related to increased BMI, lower hemoglobin and hematocrit levels, and pre-existing CKD. The present study found no significant association between PV and CSA-AKI. Nevertheless, more research is needed to validate this finding and to investigate the role of PV in other clinical settings.

Clinical characteristics and factors associated with ICU mortality during the first year of the SARS-Cov-2 pandemic in Romania: A prospective, cohort, multicentre study of 9000 patients.

BACKGROUND: The epidemiology of critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be different worldwide. Despite similarities in medicine quality and formation, there are also significant differences concerning healthcare and ICU organisation, staffing, financial resources and population compliance and adherence. Large cohort data of critically ill patients from Central and Eastern Europe are also lacking. OBJECTIVES: The study objectives were to describe the clinical characteristics of patients admitted to Romanian ICUs with SARS-CoV-2 infection and to identify the factors associated with ICU mortality. DESIGN: Prospective, cohort, observational study. SETTING: National recruitment, multicentre study, between March 2020 to March 2021. PATIENTS: All patients with SARS-CoV-2 infection admitted to Romanian ICUs were eligible. There were no exclusion criteria. INTERVENTION: None. MAIN OUTCOME MEASURE: ICU mortality. RESULTS: The statistical analysis included 9058 patients with definitive ICU outcome. The multivariable mixed effects logistic regression model found that age [odds ratio (OR) 1.27; 95% confidence interval (CI), 1.23 to 1.31], male gender (OR 1.21; 95% CI 1.05 to 1.4), medical history of neoplasia (OR 1.74; 95% CI, 1.36 to 2.22), chronic kidney disease (OR 1.54; 95% CI, 1.27 to 1.88), type II diabetes (OR 1.23; 95% CI, 1.06 to 1.43), chronic heart failure (OR 1.24; 95% CI, 1.03 to 1.49), dyspnoea (OR 1.3; 95% CI, 1.1 to 1.5), SpO2 less than 90% (OR 3; 95% CI, 2.5 to 3.5), admission SOFA score (OR 1.07; 95% CI, 1.05 to 1.09), acute respiratory distress syndrome (ARDS) on ICU admission (OR 1.35; 95% CI, 1.1 to 1.63) and the need for noninvasive (OR 1.8, 95% CI, 1.5 to 1.22) or invasive ventilation (OR 28; 95% CI, 22 to 35) and neuromuscular blockade (OR 3.5; 95% CI, 2.6 to 4.8), were associated with larger ICU mortality.Higher GCS on admission (OR 0.81; 95% CI, 0.79 to 0.83), treatment with hydroxychloroquine (OR 0.78; 95% CI, 0.64 to 0.95) and tocilizumab (OR 0.58; 95% CI, 0.48 to 0.71) were inversely associated with ICU mortality. CONCLUSION: The SARS-CoV-2 critically ill Romanian patients share common personal and clinical characteristics with published European cohorts. Public health measures and vaccination campaign should focus on patients at risk.

Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery: A Randomized Controlled Clinical Trial.

Background and Objectives: The erector spinae plane block (ESPB) is a multimodal opioid-sparing component, providing chest-wall analgesia of variable extent, duration, and intensity. The objective was to examine the ESPB effect on perioperative opioid usage and postoperative rehabilitation when used within a Nociception Level (NOL) index-directed anesthetic protocol. Materials and Methods: This prospective, randomized, controlled, open-label study was performed in adult patients undergoing on-pump cardiac surgery in a single tertiary hospital. Eighty-three adult patients who met eligibility criteria were randomly allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 40) and received general anesthesia with NOL index-directed fentanyl dosing. Preoperatively, group 2 also received bilateral single-shot ultrasound-guided ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Postoperatively, both groups received intravenous paracetamol (1 g every 6 h). Morphine (0.03 mg/kg) was administered for numeric rating scale (NRS) scores ≥4. Results: The median (IQR, 25th−75th percentiles) intraoperative fentanyl and 48 h morphine dose in group 2-to-group 1 were 1.2 (1.1−1.5) vs. 4.5 (3.8−5.5) µg·kg−1·h−1 (p < 0.001) and 22.1 (0−40.4) vs. 60.6 (40−95.7) µg/kg (p < 0.001). The median (IQR) time to extubation in group 2-to-group 1 was 90 (60−105) vs. 360 (285−510) min (p < 0.001). Two hours after ICU admission, 87.5% of ESPB patients were extubated compared to 0% of controls (p < 0.001), and 87.5% were weaned off norepinephrine compared to 46.5% of controls (p < 0.001). The median NRS scores at 0, 6, 12, 24, and 48 h after extubation were significantly decreased in group 2. There was no difference in opioid-related adverse events and length of stay. Conclusions: NOL index-directed ESPB reduced intraoperative fentanyl by 73.3% and 48 h morphine by 63.5%. It also hastened the extubation and liberation from vasopressor support and improved postoperative analgesia.

Perioperative trajectory of plasma viscosity: A prospective, observational, exploratory study in cardiac surgery.

OBJECTIVE: Plasma viscosity is one of the critical factors that regulate microcirculatory flow but has received scant research attention. The main objective of this study was to evaluate plasma viscosity in cardiac surgery with respect to perioperative trajectory, main determinants, and impact on outcome. METHODS: Prospective, single center, observational study, including 50 adult patients undergoing cardiac surgery with cardiopulmonary bypass between February 1, 2020 and May 31, 2021. Clinical perioperative characteristics, short term outcome, standard blood analysis, plasma viscosity, total proteins, and fibrinogen concentrations were recorded at 10 distinct time points during the first perioperative week. RESULTS: The longitudinal analysis showed that plasma viscosity is strongly influenced by proteins and measurement time points. Plasma viscosity showed a coefficient of variation of 11.3 ± 1.08 for EDTA and 12.1 ± 2.1 for citrate, similarly to total proteins and hemoglobin, but significantly lower than fibrinogen (p < .001). Plasma viscosity had lower percentage changes compared to hemoglobin (RANOVA, p < .001), fibrinogen (RANOVA, p < .001), and total proteins (RANOVA, p < .001). The main determinant of plasma viscosity was protein concentrations. No association with outcome was found, but the study may have been underpowered to detect it. CONCLUSION: Plasma viscosity had a low coefficient of variation and low perioperative changes, suggesting tight regulation. Studies linking plasma viscosity with outcome would require large patient cohorts.

Ten Tumors in the Heart: Papillary Fibroelastoma With Triple Valve Involvement.

Cardiac papillary fibroelastoma (CPF) is a benign tumor of endocardial origin, most frequently solitary, which commonly affects the aortic valve. We report the case of a 62-year-old woman with 10 separate tumors that developed on the mitral, tricuspid, and pulmonary cusps; atrioventricular valve chordae; and left ventricular endocardium. Surgical treatment included valve-sparing resection of the pulmonary cusp tumors and bioprosthetic replacement of the mitral and tricuspid valves, which exhibited extensive tumor invasion. The postoperative course was unremarkable. The high number of CPFs and triple-valve tumor involvement are both exceptional. CPF should be considered whenever multiple cardiac masses are discovered.

The Prognostic Role of Early Postoperative Troponin I in Lung Transplantation-A Retrospective 7-Year Analysis.

OBJECTIVES: Postoperative cardiac troponin I concentration is predictive of worsened outcomes in cardiac surgery. Lung transplantation (LT) surgery shares common features with cardiac surgery, but postoperative troponin has yet to be investigated. The authors aimed to evaluate the association between early postoperative troponin concentration and the 1-year mortality after transplantation. DESIGN: A retrospective, observational, single-center study. SETTING: At a tertiary care, university hospital. PARTICIPANTS: Patients who underwent lung transplantation from January 2011 to December 2017 INTERVENTIONS: For each patient, preoperative, intraoperative, and postoperative data were collected, as well as the troponin I measurement at the moment of postoperative intensive care unit admission. MEASUREMENTS AND MAIN RESULTS: Two hundred twenty LT procedures were analyzed. Troponin I was elevated in all LT patients, with a median of 3.82 ng/mL-1 (2-6.42) ng/mL-1 significantly higher in non-survivors than in survivors with 5.39 (2.88-7.44) v 3.50 ng/mL (1.74-5.76), p = 0.005. In the multivariate analysis, the authors found that only the Simplified Acute Physiology Score II score (hazard ratio [HR] 1.03; 95% confidence interval [CI] [1.001; 1.05]; p = 0.007) and the need to maintain extracorporeal life support at the end of surgery (HR 2.54; 95% CI [1.36; 4.73]; p = 0.003) were independently associated with the 1-year mortality. The multiple linear regression model found that troponin levels were associated with the need for extracorporeal life support (ECLS) (p = 0.014), the amount of transfused packed red blood cells (p = 0.008), and bilateral LT (p < 0.001). CONCLUSION: Early postoperative troponin serum levels were not independently associated with 1-year mortality. Early postoperative troponin I levels were correlated to bilateral LT, the need for ECLS, and intraoperative blood transfusion.

Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery.

With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.

Perioperative Trajectory of Haemoglobin, Predictors of Blood Transfusion and Tailoring Targets for Patient Blood Management Interventions: A Single-centre, Retrospective Study of Non-emergent Cardiac Surgery Patients.

Background: Anaemia and blood transfusion are two independent contributing factors to perioperative morbidity in cardiac surgery. While preoperative treatment of anaemia has been shown to improve outcomes, in real life, logistical difficulties remain substantial, even in high-income countries. The adequate trigger for transfusion in this population remains controversial, and there is a wide variability in transfusion rates among centres. Objectives: To assess the impact of preoperative anaemia on perioperative transfusion in elective cardiac surgery,todescribe the perioperative trajectory of haemoglobin (Hb), to stratify outcomes based on preoperative presence of anaemia and to identify predictors of perioperative blood transfusion. Materials: and Methods: We included a retrospective cohort of consecutive patients who underwent cardiac surgery with cardiopulmonary bypass in a tertiary centre of cardiovascular surgery. Recorded outcomes included hospital and intensive care unit (ICU) length of stay (LOS), surgical re-exploration due to bleeding, packed red blood cell (PRBC) transfusion pre-, intra- and postoperatively. Other record perioperative variables were preoperative chronic kidney disease, duration of surgery, use of rotation thromboelastometry (ROTEM) and cell saver, and fresh frozen plasma (FFP) and platelet (PLT) transfusion. Hb values were recorded at four distinct time points: Hb1 - at hospital admission, Hb2 - last Hb recorded preoperatively, Hb3 - first Hb recorded postoperatively and Hb4 - at hospital discharge. We compared the outcomes between anaemic and non-anaemic patients. Transfusion was decided by the attending physician on a case-by-case basis. Results: Of the 856 patients operated during the selected period, 716 underwent non-emergent surgery and 710 were included in the analysis. Also, 40.5% (n = 288) of patients were anaemic preoperatively (Hb <13 g/dl); 369 patients (52%) were transfused PRBCs, with differences found between anaemic and non-anaemic patients regarding the percentage of transfused patients perioperatively (71.5% vs 38.6%, p < 0.001) and in the total median number of units transfused (2 [IQR 0-2] vs 0 [IQR 0-1], p <0.001). We built a multivariate model, and logistic regression analysis showed that preoperative Hb <13 g/dl (odds ratio [OR] 3.462 [95% CI 1.766-6.787]), female sex (OR 3.224 [95% CI 1.648-6.306]), age (1.024 per year [95% CI 1.0008-1.049]), hospital LOS (OR 1.093 per day of hospitalisation [95% CI 1.037-1.151]) and FFP transfusion (OR 5.110 [95% CI 1.997-13.071]) are associated with PRBC transfusion. Conclusions: Untreated preoperative anaemia leads to more transfusion in elective cardiac surgery patients, both as a ratio of transfused patients and as the number of units of PRBCs per patient, and this is associated with an increased use in FFP.

Brachial Mycotic Pseudoaneurysms Due to Prosthetic Valve Infective Endocarditis: A Case Report and Review of the Literature.

Brachial mycotic pseudoaneurysms (BMPA) are a rare complication of infective endocarditis (IE), but potentially could be a limb-threatening condition. We present the case of a 38-year-old male referred to our department, complaining of the sudden onset of a painful pulsatile mass 5 x 10 cm in the right antecubital fossa that slowly progressed over time. Two years before this, he underwent aortic and mitral valve replacement with mechanical prosthetic valves and tricuspid annuloplasty for IE with methicillin-susceptible Staphylococcus aureus after a six-week course of intravenous antibiotherapy with oxacillin. Clinical examination of the right upper limb revealed a pulsatile and compressible mass with a normal temperature and without other clinical signs of inflammation. Pulse of the axillary artery, brachial and radial arteries were palpable. He was diagnosed by Doppler ultrasonography and digital subtraction angiography with BMPA. Furthermore, transesophageal echocardiography (TEE) revealed normal function of the aortic and mitral prosthetic valve with no signs of prosthetic valve endocarditis and no feature of congestive heart failure. Considering these clinical findings, surgical treatment was planned. He underwent re-section of the brachial pseudoaneurysm and arterial reconstruction. One year after the pseudoaneurysm resection, evolution was excellent. This manuscript presents this rare, uncommon complication after IE and also reviews the available surgical management strategies for this pathology.

Unusual Location of a Posterior Lipoma Originating From the Left Atrial Roof: Case Report and Review of the Literature.

Lipomas are the most common type of soft tissue tumors. They mainly are located in subcutaneous tissue in the body, including the heart. The cardiac location of lipomas is rare, mostly asymptomatic, and can cause life-threatening complications by rapid growth. The clinical symptoms, when present, occur in evolution with the growth in size, depending upon the location and degree of invasion in the endocardium. We present the case of a 63-year-old male patient with a large intrapericardial lipoma with an unusual location, originating from the left atrial roof. The initial symptoms of the patient were shortness of breath, dizziness, and mild dyspnea. Transthoracic echocardiography (TTE) was the first line diagnosis method, followed by computed tomography (CT); both showed a large posterior intrapericardial mass. Resection of a 12/8/5 cm lipomatous tumor mass was performed via median sternotomy, under cardiopulmonary bypass (CPB) on the beating heart. Histopathologic examination revealed the presence of diffuse proliferation of large- and medium-sized mature adipocytes consistent with the diagnosis of pericardial lipoma. The patient was discharged at home on the seventh postoperative day, with a marked improvement of his clinical state and effort tolerance. He did not present evidence of recurrence at his 1-year follow up.

Perioperative management of antiplatelet therapy in noncardiac surgery.

PURPOSE OF REVIEW: Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. RECENT FINDINGS: Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. SUMMARY: Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.

Transseptal Approach for Mitral Valve Replacement in Dextrocardia with Situs Inversus Totalis: A Case Report and Review of the Literature.

We consider mitral valve disease requiring surgery in a patient with dextrocardia and situs inversus totalis to be an exceptional finding. The transseptal approach for mitral valve surgery in dextrocardia represents a technical challenge owing to its anatomic particulars. We present the case of a 56-year-old female patient who had been diagnosed with situs inversus totalis in childhood and with chronic atrial fibrillation in adulthood and was under oral anticoagulant treatment. She was referred to our hospital for increasing dyspnea and palpitation. Transthoracic echocardiography detected severe mitral regurgitation associated with moderate tricuspid regurgitation, with normal left and right ventricular function. Contrast chest computed tomography (CT) and preoperative abdominal CT showed both dextrocardia and situs inversus totalis, with normal continuity of the inferior vena cava. Biatrial cannulation was performed with the surgeon standing on the right side of the patient, and mitral valve replacement using a transseptal approach was performed with the surgeon standing on the left side of the patient. In this case report, we emphasize the rarity of mitral valve disease in a patient with dextrocardia and the inherent potential difficulty that can appear in this particular anatomic condition.

The value of a superior vena cava collapsibility index measured with a miniaturized transoesophageal monoplane continuous echocardiography probe to predict fluid responsiveness compared to stroke volume variations in open major vascular surgery: a prospective cohort study.

Superior vena cava collapsibility index (SVC-CI) and stroke volume variation (SVV) have been shown to predict fluid responsiveness. SVC-CI has been validated only with conventional transoesophageal echocardiography (TEE) in the SVC long axis, on the basis of SVC diameter variations, but not in the SVC short axis or by SVC area variations. SVV was not previously tested in vascular surgery patients. Forty consecutive adult patients undergoing open major vascular surgical procedures received 266 intraoperative volume loading tests (VLTs), with 500 ml of gelatine over 10 min. The hSVC-CI was measured using a miniaturized transoesophageal echocardiography probe (hTEE). The SVV and cardiac index (CI) were measured using Vigileo-FloTrac technology. VLTs were considered 'positive' (≥ 11% increase in CI) or 'negative' (< 11% increase in CI). We compared SVV and hSVC-CI measurements in the SVC short axis to predict fluid responsiveness. Areas under the receiver operating characteristic curves for hSVC-CI and SVV were not significantly different (P = 0.56), and both showed good predictivity at values of 0.92 (P < 0.001) and 0.89 (P < 0.001), respectively. The cutoff values for hSVC-CI and SVV were 37% (sensitivity 90%, specificity of 83%) and 15% (sensitivity 78%, specificity of 100%), respectively. Our study validated the value of the SVC-CI measured as area variations in the SVC short axis to predict fluid responsiveness in anesthetized patients. An hTEE probe was used to monitor and measure the hSVC-CI but conventional TEE may also offer this new dynamic parameter. In our cohort of significant preoperative hypovolemic patients undergoing major open vascular surgery, hSVC-CI and SVV cutoff values of 37% and 15%, respectively, predicted fluid responsiveness with good accuracy.

Continuous Noninvasive Hemoglobin Monitoring Reflects the Development of Acute Hemodilution After Consecutive Fluid Challenges.

BACKGROUND: Consecutive fluid challenges (FCs) are frequently administered to maximize the stroke volume (SV) as part of a goal-directed therapy (GDT) strategy. However, fluid administration may also cause acute hemodilution that might lead to an actual paradoxical decrease in oxygen delivery (DO2). The aim of this study was to examine whether continuous noninvasive hemoglobin (SpHb) monitoring can be used to detect the development of acute hemodilution after graded fluid administration. METHODS: In 40 patients who underwent major vascular or gastrointestinal surgery, an FC, consisting of 250 mL colloid solution, was administered. When the SV increased by ≥10%, the FC was repeated up to a maximum of 3 times. Laboratory-measured hemoglobin concentrations (BHb), SpHb, SV, cardiac output (CO), and DO2 values were recorded after each FC. RESULTS: All 40 patients received the first FC, 32 patients received the second FC, and 20 patients received the third FC (total of 750 mL). Out of the 92 administered FCs, only 55 (60%) caused an increase in SV ≥10% ("responders"). The first and the second FCs were associated with a significant increase in the mean CO and DO2, while the mean SpHb and BHb decreased significantly. However, the third and last FC was associated with no statistical difference in CO and SV, a further significant decrease in mean SpHb and BHb, and a significant decrease in DO2 in these patients. Compared to their baseline values (T0), BHb and SpHb decreased by a mean of 5.3% ± 4.9% and 4.4% ± 5.2%, respectively, after the first FC (T1; n = 40), by 9.7% ± 8.4% and 7.9% ± 6.9% after the second FC (T2; n = 32), and by 14.5% ± 6.2% and 14.6% ± 5.7% after the third FC (T3; n = 20). Concordance rates between the changes in SpHb and in BHb after the administration of 250, 500, and 750 mL colloids were 83%, 90%, and 100%, respectively. CONCLUSIONS: Fluid loading aimed at increasing the SV and the DO2 as part of GDT strategy is associated with acute significant decreases in both BHb and SpHb concentrations. When the administration of an FC is not followed by a significant increase (≥10%) in the SV, the DO2 decreases significantly due to the development of acute hemodilution. Continuous noninvasive monitoring of SpHb does not reflect accurately absolute BHb values, but may be reliably used to detect the development of acute hemodilution especially after the administration of at least 500 mL of colloids.

Giant Aortic Syphilitic Aneurysm of The Ascending Aorta with Erosion in the Chest Wall: Case Report.

Since the discovery of penicillin, the incidence of tertiary syphilis dramatically has decreased. However, cases of cardiovascular complications of syphilis still are present. Ascending aortic aneurysms are some of the most devastating complications. Nonetheless, syphilitic aortitis (SA) can appear and should be suspected in patients with syphilis and aortic aneurysm. We report a case of a 57-year-old patient with a large ascending aortic aneurysm with cartilage and rib erosion. The purpose of this article is to discuss the particular surgical aspects of this unusual case.

Case Report: Aberrant Left Vertebral Artery Management in Traumatic Transection of the Aortic Isthmus.

Association of elective debranching and endovascular thoracic aortic repair (TEVAR) with aberrant left vertebral artery (AVA) revascularization and supra-aortic left carotid-subclavian bypass in post-traumatic pseudoaneurysm of the distal aortic arch are extremely rare procedures that can minimize unnecessary neurologic complications. The patient was a 42-year-old man, stable, with a post-traumatic transection of the aortic isthmus, with origin of the AVA between the left common carotid artery (LCCA) and left subclavian artery (LSA). Preoperative planning and proper sizing of the stent-grafts were evaluated by means of computed tomography angiography (CT scan) images. The patient underwent a hybrid procedure that included TEVAR with landing zone 2, covering the origin of both the AVA and LSA and concomitant supra-aortic reimplantation of the AVA in the LCCA and left carotid-subclavian bypass combined with both ligation of the AVA and LSA proximally. Postoperative arteriography images confirmed the exclusion of the aneurysm and the patency of all arch vessels, including the AVA. No endoleak was reported.