Variante anatómica de la vía biliar durante la colecistectomía laparoscópica / Anatomical variant of the bile duct during laparoscopic cholecystectomy / Variante anatômica do ducto biliar durante colecistectomia laparoscópica

Se presenta la colangiografía intraoperatoria obtenida durante la colecistectomía laparoscópica de una paciente de 58 años con el diagnóstico de colecistitis aguda.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications.

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Intraoperative development of pulmonary thromboembolism in a bedridden patient owing to a pelvic bone fracture with negative preoperative computed tomography pulmonary angiographic findings: A case report.

RATIONALE: Pulmonary thromboembolism (PTE) is a potentially life-threatening condition with high morbidity and mortality, and computed tomographic pulmonary angiography (CTPA) is an important diagnostic tool for patients in whom PTE is suspected; however, intraoperative PTE is very difficult to diagnose and often has a rapid clinical course. We experienced a case of intraoperative PTE with persistent tachycardia refractory to conventional treatments despite negative preoperative CTPA findings. PATIENT CONCERNS: A 53-year-old man with a pelvic bone fracture who had been on bed rest for 10 days underwent open reduction and internal fixation under general anesthesia. He remained tachycardic (heart rate of 120 beats/min) despite treatments with fluid resuscitation, analgesics, and beta-blockers. DIAGNOSES: Preoperative CTPA, computed tomography (CT) venography, and transthoracic echocardiography showed no signs of deep vein thrombosis and PTE. However, the levels of D-dimer were elevated. After the start of the surgery, tachycardia (heart rate between 100 and 110 beats/min) could not be treated with fluid resuscitation. Systolic blood pressure was maintained between 90 and 100 mm Hg using continuous infusion of phenylephrine. Ninety minutes after the surgery, systolic and diastolic blood pressures suddenly dropped from 100/60 to 30/15 mm Hg with a decrease in end-tidal carbon dioxide concentration from 29 to 13 mm Hg and development of atrial fibrillation. Arterial blood gas analysis revealed hypercapnia. Under the suspicion of PTE, cardiopulmonary resuscitation (CPR) was immediately initiated. Three CPR cycles raised the blood pressure back to 90/50 mm Hg with sinus tachycardia (115 beats/min). Transesophageal echocardiography showed right ventricular dysfunction and paradoxical septal motion. However, emboli were not found. Postoperative chest CT revealed massive PTE in both pulmonary arteries. INTERVENTIONS: Immediately, surgical embolectomy was performed uneventfully. OUTCOMES: The patient was discharged from the hospital 1 month later without any complications. LESSONS: The patient with moderate risk for PTE (heart rate > 95 beats/min and immobilization, surgery under general anesthesia, and lower limb fracture within 1 month) should be closely monitored and managed intraoperatively even if preoperative CTPA findings are negative. The development of PTE needs to be expected if tachycardia is refractory to conventional treatments.

Failure of diffusion-weighted imaging in intraoperative 3 Tesla MRI to identify hyperacute strokes during glioma surgery.

Intraoperatively acquired diffusion-weighted imaging (DWI) sequences in cranial tumor surgery are used for early detection of ischemic brain injuries, which could result in impaired neurological outcome and their presence might thus influence the neurosurgeon's decision on further resection. The phenomenon of false-negative DWI findings in intraoperative magnetic resonance imaging (ioMRI) has only been reported in single cases and therefore yet needs to be further analyzed. This retrospective single-center study's objective was the identification and characterization of false-negative DWI findings in ioMRI with new or enlarged ischemic areas on postoperative MRI (poMRI). Out of 225 cranial tumor surgeries with intraoperative DWI sequences, 16 cases with no additional resection after ioMRI and available in-time poMRI (< 14 days) were identified. Of these, a total of 12 cases showed false-negative DWI in ioMRI (75%). The most frequent tumor types were oligodendrogliomas and glioblastomas (4 each). In 5/12 cases (41.7%), an ischemic area was already present in ioMRI, however, volumetrically increased in poMRI (mean infarct growth + 2.1 cm3; 0.48-3.6), whereas 7 cases (58.3%) harbored totally new infarcts on poMRI (mean infarct volume 0.77 cm3; 0.05-1.93). With this study we provide the most comprehensive series of false-negative DWI findings in ioMRI that were not followed by additional resection. Our study underlines the limitations of intraoperative DWI sequences for the detection and size-estimation of hyperacute infarction. The awareness of this phenomenon is crucial for any neurosurgeon utilizing ioMRI.

Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional cohort study.

BACKGROUND: Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. METHODS: Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke's Cognitive Examination Revised Test before and 30 days after surgical procedure. RESULTS: A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677-10.60, p = 0.027). Addenbrooke's Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001). CONCLUSION: There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. TRIAL REGISTRY NUMBER: clinicaltrials.gov , NCT02697786 14.

20 Tips to Avoid and Handle Problems in the Placement of Percutaneous Pedicle Screws.

BACKGROUND: Two-dimensional fluoroscopy-guided percutaneous pedicle screw placement is currently the most widely applied instrumentation for minimally invasive treatment of spinal injuries requiring stabilization. Although this technique has advantages over open instrumentation, it also presents new challenges and specific complications. The objective of this study was to provide recommendations developed from the experience of several spinal surgeons at different minimally invasive spine surgery reference centers to solve specific problems and prevent complications during the learning curve of this technique. METHODS: An AO Spine Latin America minimally invasive spine surgery study group analyzed the most frequent complications and challenges occurring during the placement of >14,000 two-dimensional fluoroscopy-guided percutaneous pedicle screws at different centers over 15 years. Twenty tips considered most relevant to performing this technique, excluding problems directly related to specific brands of instruments, were presented. RESULTS: The 20 tips included the following: (1) positioning; (2) clean and painless; (3) fewer x-rays; (4) check the clock; (5) beveled tip; (6) transverse-rib-pedicle; (7) double Jamshidi; (8) hammer the Kirschner wire; (9) bent tip; (10) too loose, too tight; (11) new trajectory; (12) manual control; (13) start over; (14) Kirschner wire first; (15) adhesive drape control; (16) bend the rod; (17) lower rods; (18) freehand inner; (19) posterior fusion; (20) revision. CONCLUSIONS: Implementation of these tips might improve performance of this technique and reduce the complications related to percutaneous pedicle screw placement.

Intraoperative vascular complications during 2278 cerebral endovascular procedures with multimodality IONM: relationship between signal change, complication, intervention and postoperative outcome.

BACKGROUND: Intraoperative neuromonitoring (IONM) is often used during cerebral endovascular procedures. OBJECTIVE: To investigate the relationship between intraoperative vascular complications and IONM signal changes, and the impact of interventions on signal resolution and postoperative outcomes. METHODS: A series of 2278 cerebral endovascular procedures conducted under general anesthesia and using electroencephalography and somatosensory evoked potential monitoring were retrospectively reviewed. A subset of 763 procedures also included motor evoked potentials (MEPs). IONM alerts were categorized as either a partial attenuation or complete loss of signal. Vascular complications were subcategorized as due to rupture, emboli, instrumentation, or vasospasm. Odds ratios (ORs) for new postoperative motor deficits were calculated and diagnostic accuracy was measured using sensitivity, specificity, and likelihood ratios. RESULTS: The overall incidence of new postoperative motor deficit was 1.2%; 20.4% in cases with an IONM alert and 0.09% in cases without an alert. Relative to procedures with no alerts, odds of a new deficit increased if there was partial signal attenuation (OR=210.9, 95% CI 44.3 to 1003.5, p<0.0001) and increased further with complete loss of signal (OR=1437.3, 95% CI 297.3 to 6948.2, p<0.0001). Relative to procedures with unresolved alerts, odds of a new deficit decreased if the alert was fully resolved (OR=0.039, 95% CI 0.005 to 0.306, p<0.002). Procedures using MEPs had slightly higher sensitivity (92.3% vs 85.7%) but slightly lower specificity (96.7% vs 98.2%). CONCLUSIONS: An IONM alert associated with an arterial complication is associated with a dramatic increase in odds of a new postoperative deficit; however, if there is resolution of the alert prior to closure, odds of a new deficit decrease significantly.

Iatrogenic bladder injury from port insertion during laparoscopic appendicectomy.

A 26-year-old man underwent laparoscopic appendicectomy for acute appendicitis that was carried out uneventfully after initial urethral catheterisation to empty the bladder. Postoperatively, he developed oliguria associated with high drain output and elevated drain fluid creatinine. A contrast-enhanced computed tomography urography scan showed a small amount of contrast in the intraperitoneal space. A diagnostic laparoscopy performed for a suspected bladder injury revealed that the drain (inserted via the suprapubic port) had traversed the bladder. The drain was removed, and the bladder defects were repaired. The catheter was removed 2 weeks later uneventfully. It is important to recognise and avoid the urinary bladder during suprapubic port insertion during laparoscopic appendicectomy. This complication can be minimised via initial bladder decompression and introduction of the suprapubic port lateral to the umbilical ligaments. A high index of suspicion is required to diagnose a small bladder injury.

Reliability of Preoperative Prediction of the Location of the Facial Nerve Using Diffusion Tensor Imaging-Fiber Tracking in Vestibular Schwannoma: A Systematic Review and Meta-Analysis.

The popularization and application of microscopy, the in-depth study of the microanatomy of the cerebellopontine angle, and the application of intraoperative electrophysiological monitoring technology to preserve facial nerve function have laid a solid foundation for the modern era of neurosurgery. The preoperative prediction of the location of the facial nerve is a long-desired goal of neurosurgeons. The advances in neuroimaging seem to be making this goal a reality. Many studies investigating the reliability of the preoperative prediction of the location of the facial nerve using diffusion tensor imaging-fiber tracking in vestibular schwannoma have been reported in the last 20 years. The PubMed, Embase, and Cochrane databases were searched for articles published before March 30, 2020. A comprehensive review of published studies was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Authors performed a systematic review and meta-analysis of the reported data to assess the reliability of the preoperative prediction of the location of the facial nerve using diffusion tensor imaging-fiber tracking in vestibular schwannoma. The data were analyzed using a fixed-effects model. The estimated overall intraoperative verification concordance rate was 89.05% (95% confidence interval 85.06%-92.58%). Preoperatively predicting the location of the facial nerve using diffusion tensor imaging-fiber tracking in vestibular schwannoma is reliable, but the extent to which it contributes to long-term facial nerve function is still unclear. To further verify these results, studies with larger sample sizes are needed in the future, especially prospective randomized controlled trials focusing on the long-term functional preservation of the facial nerve.

Risk Factors for Intraoperative Bladder Perforation at the Time of Midurethral Sling Placement.

OBJECTIVE: To evaluate patient-specific and perioperative factors that may be predictive of bladder perforation during midurethral sling placement. METHODS: A retrospective chart review of women who underwent a midurethral sling procedure at our institution between 2013 and 2017 was completed. All cases with bladder perforation were included. Patient demographics and perioperative factors were explored for associations with perforation. Bivariate analysis was used to compare baseline characteristics between those with and without perforation. Logistic regression modeling was used to identify predictors of perforation and associations between bladder perforation and postoperative sequelae. RESULTS: Four hundred and ten women had a urethral sling procedure at our institution between 2013 and 2017. Of these, 35 (9%) had evidence of bladder perforation on cystoscopy. This rate was higher for retropubic slings (15%) compared to transobturator slings (2%). Those with a perforation were younger (54 vs 61 years, P= .004) and had a lower average BMI (24.1 kg/m2 vs 26.3 kg/m2, P = .022). Other risk factors included lack of pre-existing apical prolapse (11% vs 4%, P = .012) and concomitant urethrolysis (27% vs 8%, P = .024). In multivariable analysis, age, BMI, and sling type were significantly associated with perforation. In univariate analysis, perforation was associated with postoperative lower urinary tract symptoms (OR 2.3, P = .21) and urinary tract infection within 30 days of surgery (OR 2.2, P = .047). CONCLUSIONS: Intraoperative bladder perforation was associated with younger patient age and lower BMI. Additionally, bladder perforation is a risk factor for postoperative urinary tract infection and lower urinary tract symptoms.

Innominate Artery Dissection Caused by Video-Mediastinoscopy.

Mediastinoscopy is considered a safe technique to biopsy mediastinal lesions. Among its complications, vascular ones are the most common. We present a rare case of intimal dissection of the innominate artery during the performance of a mediastinoscopy that caused an ischemic attack from which the patient recovered completely without long-term sequelae. We analyze the possible causes and risk factors of this complication.

The feasibility of computer-assisted 3D navigation in multiple-level lateral lumbar interbody fusion in combination with posterior instrumentation for adult spinal deformity.

OBJECTIVE: The lateral lumbar interbody fusion (LLIF) technique is used to treat many common spinal degenerative pathologies including kyphoscoliosis. The use of spinal navigation for LLIF has not been broadly adopted, especially in adult spinal deformity. The purpose of this study was to evaluate the feasibility as well as the intraoperative and navigation-related complications of computer-assisted 3D navigation (CaN) during multiple-level LLIF for spinal deformity. METHODS: Retrospective analysis of clinical and operative characteristics was performed for all patients > 18 years of age who underwent multiple-level CaN LLIF combined with posterior instrumentation for adult spinal deformity at the University of Michigan between 2014 and 2020. Intraoperative CaN-related complications, LLIF approach-related postoperative complications, and medical postoperative complications were assessed. RESULTS: Fifty-nine patients were identified. The mean age was 66.3 years (range 42-83 years) and body mass index was 27.6 kg/m2 (range 18-43 kg/m2). The average coronal Cobb angle was 26.8° (range 3.6°-67.0°) and sagittal vertical axis was 6.3 cm (range -2.3 to 14.7 cm). The average number of LLIF and posterior instrumentation levels were 2.97 cages (range 2-5 cages) and 5.78 levels (range 3-14 levels), respectively. A total of 6 intraoperative complications related to the LLIF stage occurred in 5 patients. Three of these were CaN-related and occurred in 2 patients (3.4%), including 1 misplaced lateral interbody cage (0.6% of 175 total lateral cages placed) requiring intraoperative revision. No patient required a return to the operating room for a misplaced interbody cage. A total of 12 intraoperative complications related to the posterior stage occurred in 11 patients, with 5 being CaN-related and occurring in 4 patients (6.8%). Univariate and multivariate analyses revealed no statistically significant risk factors for intraoperative and CaN-related complications. Transient hip weakness and numbness were found to be in 20.3% and 22.0% of patients, respectively. At the 1-month follow-up, weakness was observed in 3.4% and numbness in 11.9% of patients. CONCLUSIONS: Use of CaN in multiple-level LLIF in the treatment of adult spinal deformity appears to be a safe and effective technique. The incidence of approach-related complications with CaN was 3.4% and cage placement accuracy was high.

Neurophysiologic Detection of Spinal Cord Ischemia During Anterior Vertebral Tethering.

STUDY DESIGN: Case report. OBJECTIVE: The aim of this study was to present how computed tomographic angiography (CTA) and intraoperative neurophysiologic monitoring (IONM) detect spinal cord ischemia during anterior spine surgery. These data directed expedient surgical and anesthetic interventions that restored IONM signals and prevented neurologic sequalæ. SUMMARY OF BACKGROUND DATA: Anterior vertebral tethering (AVT) is a fusionless surgical treatment of adolescent idiopathic scoliosis (AIS). METHODS: AVT was performed on a skeletally immature patient with AIS. Preoperative CTA detailed location of the dominant radicular artery (DRA). Transcranial motor (tcMEP) and somatosensory (SEP) evoked potentials were monitored during operation. RESULTS: There was significant decline in tcMEP, but not SEP, after compression of the DRA during cable tensioning of AVT. There was complete tcMEP recovery following release of instrumentation. CONCLUSION: This article identifies a rare but potentially catastrophic vascular hazard associated with anterior spine operation, including AVT. Sacrifice of multiple unilateral segmental vessels may overwhelm the capacity of collateral spinal cord perfusion to compensate for DRA blood supply. This vascular risk may be eliminated by identifying the DRA in order that it may be preserved during the procedure. LEVEL OF EVIDENCE: 5.

Intraoperative Head Slippage with the Head Clamp System Can Occur During Epileptic Surgery.

BACKGROUND: During neurosurgery, we use a head clamp system for firm head fixation. However, we have encountered slippage using the head clamp system, although this has not been adequately studied. In the present study, to increase the reliability of the analysis using a more homogeneous type of patient data, we conducted a prospective study of patients who had undergone epileptic surgery. We examined the potential risk factors for head slippage and postulated that the location of the pins might be important. METHODS: We reviewed and compared the positions of the fixed head of the patients on fused preoperative and postoperative computed tomography images. We measured the distance between the corresponding head pins to determine the association with head slippage. We statistically compared the relationship between each head pin and the nasion-inion line. We also assessed age, sex, body weight, body mass index, surgical position, surgical duration, and craniotomy volume as potential risk factors for slippage. RESULTS: Head slippage was observed in 3 of 21 patients (14%) in the present prospective study. The most caudal head pin position was not associated with head slippage in the present study. However, the center point between the most caudal point and the most cranial point was significant (P = 0.014). A center point between the most caudal and most cranial pins from the nasion-inion line that was >6.5 cm was more likely to result in slippage. CONCLUSIONS: We should consider that head clamp slippage could occur intraoperatively.

Penetrating lung injury during Nuss procedure for pectus excavatum.

Life-threatening complications including cardiac perforation by the clamp or pectus bar during Nuss procedure have rarely been occurred. A rare case of lung entrapment between the pectus bar and chest wall after Nuss procedure was also reported. Thoracoscopy allows for direct visualization of the operative field, which prevents or promptly perceive these intrathoracic organ injuries. Recently, we encountered a case of penetrating lung injury during the Nuss procedure for pectus excavatum. And we agree with Mennie et al. who concluded thoracoscopic vision during Nuss procedure reduces the risk of major complication. In addition, we would like to emphasize to keep in mind what to check for routines with thoracoscopy during Nuss procedure.

Transient Retinal Ischemia During Carotid Endarterectomy Estimated by Intraoperative Visual Evoked Potential Monitoring: Technical Note.

OBJECTIVE: Carotid revascularization surgery is known to carry a risk of postoperative visual deterioration associated with retinal ischemia. We checked intraoperative visual evoked potential (VEP) monitoring in carotid endarterectomy (CEA). METHODS: Ten consecutive patients who underwent CEA in Shinshu University Hospital under total intravenous anesthesia were checked by intraoperative VEP and electroretinogram (ERG) recording in addition to somatosensory evoked potential monitoring. RESULTS: Two of 10 patients presented decreased amplitude of VEP and ERG on the ipsilateral affected side by clamping the common carotid artery and persistent attenuation of VEP and ERG during external carotid artery occlusion, using an internal carotid shunt. These findings disappeared immediately after releasing the cervical carotid artery clamping. In the other 8 patients, VEP and ERG did not change throughout the surgery. CONCLUSIONS: Transient retinal ischemia during even brief carotid artery occlusion in the CEA procedure could be estimated by intraoperative VEP and ERG monitoring.

Sodium Fluorescein for Identification of Intraoperative Urine Leaks During Partial Nephrectomy.

BACKGROUND: Rates of persistent urine leak after partial nephrectomy are reported in the range of 2-13%, of which many are technically preventable by intraoperative identification and repair of collective system injuries. We describe our technique and institutional experience utilizing intravenous sodium fluorescein, a xanthene die with rapid urinary excretion, at the time of tumor resection during partial nephrectomy for identification of collecting system injury. METHODS: Here, we present a video illustrating the utilization of sodium fluorescein for the intra-operative identification of collecting system injury. We retrospectively reviewed all patients who underwent robot-assisted partial nephrectomy with sodium fluorescein between October 2017 and May 2019 by a single surgeon (KC), and report clinicodemographic and tumor characteristics, as well as rates of post-operative urine leak. RESULTS: Over the study period, 48 patients underwent robot-assisted partial nephrectomy with intraoperative sodium fluorescein, of which 44 had follow-up data (Table 1). Patients were 66.7% male, had a median age of 65 (interquartile range [IQR] 54-72) years and median body mass index of 27.5 (IQR 24.4-35.5) kg/m2. Mean tumor nephrometry score was 7.8 (±1.45), with a mean distance of 3.3 mm (±4.0) from the collecting system. In cases performed with arterial clamping, 5 mL of sodium fluorescein (100 mg/mL) was injected intravenously by anesthesia as the clamp was removed following tumor resection. In cases performed off-clamp, sodium fluorescein was delivered after tumor resection. The video demonstrates three cases where sodium fluorescein aided in the identification and repair of a collecting system leak. There were no recorded urine leaks at time of final follow-up (median 198.6, IQR 20-289 days). CONCLUSION: Sodium fluorescein is a simple technique for identification of collecting system injuries at time of partial nephrectomy. With the aid of sodium fluorescein, intra-operative collecting system leaks can be identified and repaired, potentially mitigating postoperative urine leaks and urinomas.

Rapidly vanishing left atrial dissection following mitral valve replacement: a case report.

BACKGROUND: Left atrial dissection is an extremely rare complication of mitral valve replacement. Because of its severity, its prompt diagnosis and treatment is mandatory. The most effective treatment (i.e. surgical vs. non-surgical) for left atrial dissection has not been fully established yet. CASE PRESENTATION: Herein, we have reported left atrial dissection after mitral valve replacement in a 68-year-old obese woman. After closing the thorax, transesophageal echocardiography (TEE) revealed an atrial mass of 3 cm × 2 cm, visualized as an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Because hemodynamic conditions were stable, surgery was ruled out and conservative treatment with close observation was selected. On postoperative day 2, TEE revealed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium was normalized completely, leaving no traces of left atrial dissection. The patient recovered uneventfully. Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection. CONCLUSIONS: It is crucial to accurately define diagnosis and optimally consider therapeutic strategies for left atrial dissection based on the hemodynamic conditions of the patient and serial TEE follow-up examinations. In our case study, left atrial dissection was successfully treated with conservative treatment; therefore, we believe that TEE could be a feasible modality for the early diagnosis of this condition.

A Complex Coronary Artery Fistula as a Potential Cause of Sudden Intraoperative Hemodynamic Compromise: A Case Report.

A patient with coronary artery fistula should be considered as high risk for intraoperative hemodynamic decompensation. In this article, we report the case of a 70-year-old man affected by a complex congenital coronary artery fistula defect. The patient underwent general anesthesia for spine surgery with permissive hypotension. The development of sudden intraoperative tachyarrhythmia with hemodynamic instability required immediate resuscitation and interruption of surgery. The claim advanced is that in patients with a coronary artery fistula permissive hypotension might be considered an option only if strictly necessary and real-time cardiac monitoring including transesophageal echocardiography is available to immediately detect and treat acute cardiac impairment.