Temporary epicardial pacing wires in isolated Coronary Artery Bypass Graft: Necessity or force of habit?

OBJECTIVE: To determine the frequency of Temporary epicardial pacing wires usage and its predictors in the immediate postoperative period in isolated coronary artery bypass graft surgery. METHODS: The longitudinal study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to August 2020, and comprised adult patients of either gender who underwent isolated coronary artery bypass graft in the Department of Cardiothoracic Surgery. Demographic, peri-operative and post-operative Temporary Epicardial Pacing Wires use data was extracted from patient's files and the institutional electronic database. Logistic regression models were built to explore predictors of Temporary epicardial pacing wires usage. Data was analysed using SPSS 22. RESULTS: Of the 322 cases evaluated, 27(8.4%) required the use of Temporary Epicardial Pacing Wires. Mean age of the patients requiring temporary epicardial pacing wires was 66.3±8.9 years compared to 58.7±8.9 years in those who did not require it (p<0.001), while the left ventricular ejection fraction percentage was 44.1±12.8 and 48.9±12.8 respectively (p=0.032). After adjusting for clinically plausible demographics and peri-operative variables, increasing age and low left ventricular ejection fraction were significantly associated with the use of temporary epicardial pacing wires in post-operative period of isolated coronary artery bypass graft patients (p<0.05). CONCLUSIONS: The frequency of temporary epicardial pacing wires usage in the post-operative period of coronary artery bypass graft was found to be low.

Untargeted metabolomic analysis of coronary artery disease patients with diastolic dysfunction show disturbed oxidative pathway.

INTRODUCTION: Left ventricular diastolic dysfunction (LVDD) is common in patients with coronary artery disease (CAD) with prevalence estimates of 34% and constitutes a predictor of all-cause mortality. Although diastolic dysfunction is induced by myocardial ischemia and has been shown to alter the clinical course, the role of coronary artery disease in the diastolic dysfunction and its progression into heart failure has not been completely elucidated. OBJECTIVE: The present study was conducted to identify possible metabolites in coronary artery disease patients that are differentially regulated in patients with diastolic dysfunction. METHODS: The serum of CAD (n = 75) patients and young healthy volunteers (n = 43) were analysed by using gas chromatography mass spectrometry (GC-MS) technique. Pre-processing of data results in 1547 features; among them 1064 features were annotated using NIST library. RESULTS AND CONCLUSION: Fifteen metabolites were found to be statistically different between cases and control. Variation in metabolites were identified and correlated with several clinically important echocardiography parameters i.e. LVDD grades, ejection fraction (EF) and E/e' values. The results suggested that metabolic products of fatty acid oxidation and glucose oxidation pathways such as oleic acid, stearic acid, palmitic acid, linoleic acid, galactose, pyruvic and lactic acids are predominantly up regulated in patients with coronary artery disease and severity of diastolic dysfunction appears to be linked to increase in fatty acid oxidation and inflammation. The metabolic fingerprints of these patients give us an insight into the pathophysiological mechanism of diastolic dysfunction in coronary artery disease patients although it did not identify validated novel markers.

Pulmonary scedosporiosis mimicking aspergilloma in an immunocompetent host: a case report and review of the literature.

A case of localized lung scedosporiosis is reported here that mimicked aspergilloma in an immunocompetent host. Through this case the importance of considering Scedosporium spp. in differential diagnosis of locally invasive lung infections and fungal ball is highlighted. As it is difficult to differentiate Scedosporium from Aspergillus on clinical grounds, microscopy, radiology and histopathology, this case is further emphasizing the significance of the definitive etiological characterization of Scedosporium through culture or molecular diagnostic tools. Accurate identification of Scedosporium, surgical resection and high-dose voriconazole has been associated with favorable outcome in most reported cases of scedosporiosis.

Innovations in cardiovascular care: Historical perspective, contemporary practice, recent trends and future directions.

Cardiovascular diseases continue to be a major cause of mortality and morbidity in the world population. First open heart procedure was performed by Gibbon in 1953, since then many advancements have been introduced to the field of cardiac surgery. Minimally invasive techniques were introduced, which include minimally invasive coronary artery bypass grafting (CABG), off-pump technique, minimally invasive valve surgery or transcatheter techniques to implant stentless or sutureless valves. The hybrid strategy to address coronary disease combines catheterisation procedures with standard surgical techniques. Cardiac imaging has also progressed to provide three-dimensional images of the heart, enabling surgeons to plan procedures with greater accuracy. Left ventricular assist devices can be used in patients suffering from cardiogenic shock or awaiting heart transplantation. Total artificial heart can be used for biventricular mechanical support. As technology becomes increasingly used for patient management, the future surgeon needs to be trained in minimally invasive surgical techniques.

Bringing efficiency into practice: A quality improvement initiative to reduce operating room turnaround time.

Operating room (OR) turnaround time (TAT) is the minimal essential time required for cleaning of OR and preparation for the next case. The TAT inversely affects OR efficiency. Several factors related to personnel, equipment and scheduling have been identified as causes of increased TAT. We conducted the study to identify factors that affect OR TAT and to propose recommendations for its reduction. The retrospective study, conducted at Aga Khan University Hospital, Karachi, comprised TAT records related to March 2014. Of the 88 cases, 22(25%) showed a delay. Upon Pareto analysis it was found that in 8(36.6%) cases there was a delay of 70% related to scheduling of OR list and 5(22.7%) related to movement of patients from wards to OR. As such, improvement in these two broad areas can take care of majority of delays. We also recommend documentation of all processes as part of continuous improvement.

Fast Track Extubation In Adult Patients On Pump Open Heart Surgery At A Tertiary Care Hospital.

BACKGROUND: Fast-track cardiac surgery programs have been established as the standard of cardiac surgical care. Studies have shown that early extubation in elective cardiac surgery patients, including coronary and non-coronary open-heart surgery patients does not increase perioperative morbidity and mortality. The objective of this observational study was to determine the success and failure profile of fast track extubation (FTE) practice in adult open-heart surgical patients. METHODS: The study was conducted at cardiac operating room and Cardiac Intensive Care Unit (CICU) of a tertiary care hospital for a period of nine months, i.e., from Oct 2014 to June-2015. All on pump elective adult cardiac surgery patients including isolated CABG, isolated Valve replacements, combined procedures and aortic root replacements were enrolled in the study. Standardized anesthetic technique was adopted. Surgical and bypass techniques were tailored according to the procedure. Success of Fast track extubation was defined as extubation within 6 hours of arrival in CICU. RESULTS: A total of 290 patients were recruited. The average age of the patients was 56.3±10.5 years. There were 77.6% male and 22.4% female patients. Overall success rate was 51.9% and failure rate was 48.1%. The peri-operative renal insufficiency, cross clamp time and CICU stay (hours) were significantly lower in success group. Re-intubation rate was 0.74%. CONCLUSION: The perioperative parameters were significantly better in success group and the safety was also demonstrated in the patients who were fast tracked successfully. To implement the practice in its full capacity and benefit, a fast track protocol needs to be devised to standardize the current practices and to disseminate the strategy among junior anaesthesiologists, perfusionists and nursing staff.

Towards excellence in cardiac surgery: experience from a developing country.

OBJECTIVE: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. DESIGN: Cross-sectional (prospectively collected data analysed and compared retrospectively). SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons' National Cardiac Database (STS-NCD). RESULTS: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). CONCLUSIONS: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world.

Mode of Coronary Revascularization and Short term Clinical Outcomes in Patients with Chronic Kidney Disease.

BACKGROUND AND OBJECTIVE: Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are two alternative methods for coronary revascularization, but it remains controversial as which one is associated with lower risks of worse clinical outcomes for chronic kidney disease (CKD) patients. We determined the mode of coronary revascularization (PCI vs. CABG) which is associated with lower risk of mortality and morbidity in CKD patients. METHODS: In this cross sectional study, 159 patients with CKD were enrolled from single center of coronary revascularization at Aga Khan University Hospital Karachi between January 2012 and August 2013. All patients with CKD underwent PCI or CABG. The primary outcome was in-hospital composite of death, myocardial infarction (MI), or stroke. We evaluated which mode of coronary revascularization was associated with reduced risks of clinical outcomes. RESULTS: Out of 159 patients with CKD, 85 (53.5%) received PCI and 74 (46.5%) received CABG. The primary finding of this study is that more patients with moderate to severe CKD underwent PCI and more patients with mild to moderate CKD underwent CABG. In both these categories, no difference was observed in clinical outcomes. There are few factors like age, ST- elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and number of coronary artery disease predicted PCI as treatment strategy in patients with moderate to severe CKD. CONCLUSION: Patients with moderate to severe CKD have similar rates of short term clinical outcomes whether they underwent PCI or CABG. Therefore, PCI can be acceptable and less invasive treatment option alternative to CABG, particularly in patients with moderate to severe CKD.

Professionalism in medical students at a private medical college in Karachi, Pakistan.

OBJECTIVE: To determine levels of professionalism in undergraduate medical students at a private medical college and assess how changes emerge during their training. METHODS: The study was conducted at Aga Khan University, a tertiary care teaching hospital, during November and December 2011. Freshmen, Year 3 and Year 5 students were requested to fill out a questionnaire. It was designed to assess the participants' levels of professionalism and how they perceived the professional environment around them by incorporating previously described scales. The questionnaire was re-validated on a random sample of practising clinicians at the same hospital. SPSS 17 was used for statistical analysis. RESULTS: The study sample comprised 204 participants. The mean score for level of individual professionalism was 7.72+/-3.43. Only 13 (6.4%) students had a score one standard deviation above the faculty mean. About 24 (11.8%) were one standard deviation and 35 (17.2%) were 2 standard deviations below the faculty mean. The remaining 130 (63.7%) were >2 standard deviations below the faculty mean. Considering the level of education, the mean score for level of professionalism was 8.00+/-3.39 for freshmen, 6.85+/-3.41 for year 3 students, and 8.40+/-3.34 for year 5 students. CONCLUSION: The currently employed teaching practices inculcating the values of professionalism in medical students are serving as a buffer to maintain the pre-training levels of professionalism from declining.

Dysregulation of metalloproteins in ischemic heart disease patients with systolic dysfunction.

Ischemic heart disease (IHD) is the leading cause of mortality worldwide. Metalloproteins have been linked to human health and diseases. The molecular functions of metalloproteins in IHD is not well understood and require further exploration. The objective of this study was to find out the role of metalloproteins in the pericardial fluid of IHD patients having normal (EF > 45) and impaired (EF < 45) left ventricular ejection fraction (LVEF). IHD patients were grouped into two categories: LVEF<45 (n = 12) and LVEF >45 (n = 33). Pooled samples of pericardial fluid were fractionated by using ZOOM-isoelectric focusing (IEF) followed by further processing using one-dimensional gel electrophoresis (1D SDS-PAGE) and filter-aided sample preparation (FASP). Tryptic peptides of each fraction and differential bands were then analyzed by nano-LC-ESI-MS/MS. Protein identification was performed through a Mascot search engine using NCBI-Prot and SwissProt databases. A total of 1082 proteins including 154 metalloproteins were identified. In the differential bands, 60 metalloproteins were identified, while 115 metalloproteins were identified in all ZOOM-IEF fractions. Twelve differentially expressed metalloproteins were selected in the intense bands according to their molecular weight (MW) and isoelectric point (pI). The 12 differentially expressed metalloprotein includes ceruloplasmin, Prothrombin, Vitamin K-dependent protein, Fibulin-1, Ribosomal protein S6 kinase alpha-6, nidogen, partial, Serum albumin, Hemopexin, C-reactive protein, Serum amyloid P-component, and Intelectin-1 protein which were all up-regulated while serotransferrin is the only metalloprotein that was down-regulated in impaired (LVEF<45) group. Among the metalloproteins, Zn-binding proteins are 36.5 % followed by Ca-binging 32.2 %, and Fe-binging 12.2 %. KEGG, pathway analysis revealed the association of ceruloplasmin and serotransferrin with the ferroptosis pathway. In conclusion, 154 metalloproteins were identified of them the Zn-binding protein followed by Ca-binding and Fe-binding proteins were the most abundant metalloproteins. The two metalloproteins, the Cu-binding protein ceruloplasmin, and Fe-binding protein serotransferrin are involved in the ferroptosis pathway, an iron-dependent form of regulated cell death that has been linked to cardiac pathology, especially in IHD patients having impaired systolic (LVEF<45) dysfunction. However, further research is required to validate these findings.

Mechanical complications following acute myocardial infarction.

OBJECTIVE: To outline the outcome and management of patients with acute myocardial infarction presenting with mechanical complications such as post-infarction ventricular septal defect, mitral regurgitation and left ventricular rupture. METHODS: The retrospective study, conducted in September and October, 2010 at the Aga Khan University Hospital, Karachi, included cases from January 1990 to December 2009. Only 18 cases were found who had presented with such complications. They were assessed for demographics as well as pre-operative, per-operative and post-operative management patterns. Data was analysed using SPSS version 17.0. RESULTS: Out of the 18 patients, 10 had post-infarction ventricular septal defect, while 8 had mitral regurgitation defects. The mean time from myocardial infarction to the diagnosis of mechanical complications was 5.28 +/- 4.07 days, and from diagnosis to repair was 2.00 +/- 1.49 days. Overall, there were 3 in-hospital mortalities. CONCLUSION: The optimal timing of surgical intervention has always remained debatable. A high-level of clinical suspicion and earlier intervention can reduce morbidities and mortalities.

Short-term complications after bilateral internal mammary artery grafting--a retrospective study.

OBJECTIVES: To analyze our experience of conducting Bilateral Internal Mammary Artery (BIMA) grafting, using both pedicled and free grafts for coronary revascularization, assessing the safety and efficacy of the procedure and comparing any differences observed between the two techniques of harvesting the grafts. METHODS: A retrospective cross sectional study was conducted in July 2010 in which all 48 patients undergoing bilateral internal mammary artery grafting for coronary bypass surgery at the Aga Khan University Hospital from 1996 to 2010 were reviewed and evaluated. The main outcome measures were perioperative mortality and early morbidity with particular reference to cerebrovascular accidents, sternal wound complications and re-opening for bleeding. Chi-square test was used to elicit any meaningful associations between patient characteristics and post-operative outcomes. RESULTS: Of the 48 patients undergoing bilateral IMA grafting, 46 were males and 2 females. The mean age was 48 +/- 9.4 years. Dyslipidaemia and smoking were the most common identifiable risk factors for coronary vascular disease. Following the 40 elective and 8 emergent surgeries, there was one hospital death. The most common post-operative complications were arrhythmias and wound infection. Diabetes and obesity were not observed to be associated with an increased risk of developing surgical site infection. CONCLUSIONS: Our study suggests that the short-term efficacy and the safety profile of bilateral IMA grafting for coronary revascularization is clinically acceptable. Long-term follow-up studies should be done to assess the cardiac event-free survival of these individuals evaluating its applicability as a routine for coronary artery bypass grafting in Pakistan.

Late presenting partially displaced atrial septal closure device: Surgical vs percutaneous correction? A case report.

INTRODUCTION: Atrial Septal Defect (ASD) is one of the most common congenital cardiac defect. Even though surgical repair of ASD is the current method of choice but percutaneous device closure is rapidly gaining popularity as it is less invasive. Dislodgment and embolization of the device may occur requiring urgent surgical retrieval. CASE PRESENTATION: We report a case of 54-years-old female patient with a history of ASD device closure 4 years ago, presenting with progressive shortness of breath for past 2 months. She had a partial dehiscence of an ASD device causing a residual ASD of 17 mm. She underwent urgent surgical repair of an ASD with a bovine pericardial patch without ASD device being explanted. CLINICAL DISCUSSION: Management of a dislodged ASD device may be percutaneous or surgical. Dislodged ASD devices that present months after deployment may become fibro-adhered to the site of embolization. Hence its retrieval can be challenging even via open surgical method. Our case describes a novel method to repair a residual ASD and prevent complications associated with dislodgement of device without completely explanting the device. CONCLUSION: In this case, the late presentation of the patient with a partially dehisced device makes it a distinctive case with a novel way on how to treat such a presentation surgically, ensuring that the device doesn't embolize further causing fatal complications.

A Comparison of AKIN, KDIGO, and RIFLE Definitions to Diagnose Acute Kidney Injury and Predict the Outcomes after Cardiac Surgery in a South Asian Cohort.

BACKGROUND: Acute kidney injury (AKI) after cardiac surgery is associated with an increased mortality and morbidity. Different definitions for AKI have been used such as Acute Kidney Injury Network (AKIN), Kidney Disease: Improving Global Outcomes (KDIGO), or risk, injury, failure, loss, end-stage kidney disease (RIFLE). Each of these definitions has their own benefits and limitations for predicting the degree of AKI and adverse outcomes following cardiac surgery. This study was aimed to compare the three AKI definitions to diagnose AKI and their predictive ability for mortality and morbidity after isolated coronary artery bypass surgery (CABG) in a South Asian cohort. MATERIAL AND METHODS: A single-center retrospective review was conducted on 1,508 patients having undergone isolated CABG surgery from January 2015 to January 2019. AKI was assessed on three definitions, and comparative receiver operating characteristics curves were built against the outcomes to assess discriminative power of each. RESULTS: Mean age of participants was 59.43 (±1.12) years, predominantly males (82.6%). Patients with AKI were elder, more likely to be diabetic and hypertensive. AKI by any definition occurred in 58.7% (885/1,508) patients. Frequency of AKI was 508 (33.7%), 517 (34.4%), and 871 (57.8%) on AKIN, KDIGO, and RIFLE criteria, respectively. The proportion of patients with RIFLE-risk 619 (41%) was greater compared with AKIN stage 1 (342 [22.7%]) and KDIGO stage 1 (330 [21.9%]), while for stages 2 and 3 the proportions were comparable across the three systems. Area under the curve (AUC) for 30-day mortality for AKIN was (0.786, [95% CI: 0.764-0.806]), KDIGO: (0.796, [95% CI: 0.775-0.816]) and for RIFLE (0.844, [95% CI: 0.825-0.862]). AUC for overall morbidity was in undesirable ranges (i.e., >0.5-≤0.7) for all three definitions. CONCLUSION: In a South Asian cohort, performance of AKIN and KDIGO criteria was comparable to diagnose AKI, while RIFLE definition, though overestimated the incidence of AKI particularly stage 1, and had an excellent discriminatory power to predict mortality compared to other two definitions.

Carotid cavernous fistula in a patient with coronary artery disease.

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting (CABG) for coronary artery disease (CAD) is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease.

T-tube management of late esophageal perforation.

Esophageal perforation is a serious condition with a high mortality rate. Management strategy of such a patient depends on the extent of perforation and the time interval between perforation and diagnosis. The use of a T tube to treat delayed esophageal perforation with complete resolution and no need for future definitive surgery has been less frequently described. We adapted this principle in successful management of a 73 year old patient with four days history of fever, shortness of breath, chest pain and radiological evidence of perforation.

Pericardial fluid proteomic label-free quantification of differentially expressed proteins in ischemic heart disease patients with systolic dysfunction by nano-LC-ESI-MS/MS analysis.

Left ventricular systolic dysfunction (LVSD) is common in patients with pre-existing ischemic heart disease (IHD) and myocardial infarction. An untargeted proteomic approach is used to improve the understanding of the molecular mechanisms associated with LVSD and to find out potential proteomic signatures in pericardial fluid. The pericardial fluid of IHD (n = 45) patients was grouped into two categories according to the left ventricular ejection fraction, LVEF ≥45 (n = 33) and LVEF <45 (n = 12), and analyzed by using nano-liquid chromatography-mass spectrometry (nano-LC-MS/MS) technique. The nano-LC-MS/MS analysis resulted in the identification of 709 pericardial fluid (PF) proteins in both normal and impaired systolic functional groups (LVEF ≥45 vs. LVEF <45). Sixteen proteins were found to be differentially expressed (p < 0.05, fold change >2) including 12 down-regulated and 4 up-regulated in the impaired systolic functional group (LVEF <45) compared to the normal group (LVEF ≥45). Among the differentially expressed proteins the inflammatory marker albumin, atherosclerosis marker apolipoprotein A-IV and hedgehog-interacting protein marker of angiogenesis were predominantly associated with the impaired LVEF <45 group. KEGG pathway analysis revealed that the hedgehog (Hh) signalling pathway is up-regulated in LVSD reflecting the underlying molecular and pathophysiological processes.

Ionomic profiling of pericardial fluid in ischemic heart disease.

Metals are essential cofactors that play a crucial role in heart function at the cell and tissue level. Information regarding the role of metals in the pericardial fluid and its ionome in ischemic heart disease (IHD) is limited. We aimed to determine the association of elements in pericardial fluid and serum samples of IHD patients and their correlation with systolic and diastolic function. IHD patients have been studied with systolic and diastolic dysfunction categorized on the basis of echocardiographic parameters. We measured concentrations of sixteen elements in the pericardial fluid and serum of 46 patients obtained during open heart surgery with IHD by ICP-MS. The levels of chromium and nickel in pericardial fluid were significantly higher as compared with serum samples of IHD patients (p < 0.05). The chromium, nickel and manganese levels in pericardial fluid were lower in patients with ejection fraction (EF) < 45% as compared to EF > 45% (p < 0.05). There was no significant difference in pericardial concentrations of elements in diastolic dysfunction grade 0-1 with 2 in IHD patients. We also found that decreased concentration of these elements in pericardial fluid is associated with decreased systolic function. These results suggest that pericardial fluid concentrations of these metals may reflect the extent of ischemic heart disease. These findings are hypothesis generating with regards to a role in the pathogenesis of the disorder.

Understanding of metals dysregulation in patients with systolic and diastolic dysfunction in ischemic heart disease.

Ischemic heart disease (IHD) is the leading cause of death and chronic disability in the world. IHD affects both the systolic and diastolic function of the heart which progressively leads to heart failure; a structural and functional impairment of filling or ejection of blood from the heart. In this study, the progression of systolic and diastolic dysfunction characterized according to their echocardiographic parameters including left ventricular ejection fraction (EF), grades of diastolic dysfunction and ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), were correlated with differential regulation of various metals in patients sera samples (n = 62) using inductive coupled plasma-mass spectrometry (ICP-MS). Chromium, nickel and selenium were found significant (p < 0.05) in patients having EF < 45% compared with EF > 45%. In patients with systolic dysfunction (EF < 45%), the level of selenium was decreased while the level of chromium and nickel was increased compared to patients with EF > 45%. Selenium level was also decreased significantly (p < 0.05) in grade 1A and 2 patients that are considered as higher grades of diastole dysfunction in comparison to grade 0-1. Overall, selenium deficiency was identified in both systolic and diastolic dysfunctions of IHD patients corresponding to the progression of disease that could be related to many metabolic and translational pathways specifically which involve selenoproteins.

Transfusion related acute lung injury--TRALI: an under diagnosed entity.

Transfusion related acute lung injury (TRALI) is a life-threatening complication of transfusion of blood and its components resembling acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). TRALI is a particular form of ARDS that follows blood transfusion and is caused by donor-derived antibodies present in the transfused products, reacting with the recipients' blood cells, inducing release of inflammatory mediators thus compromising lung functions. Anti-HLA antibodies are the most frequently indicted inducers in this category. Literature search has not revealed any documented case of TRALI from Pakistan. This in no way implies that TRALI is non existent in this part of the world but rather indicates that many clinicians may be unaware of the condition or may not recognize transfusion as the cause and like in other parts of the world, is almost certainly under-diagnosed. The lack of agreement on the definite cellular and molecular mechanisms underlying the development of TRALI renders the task of improving the safety of blood transfusion far more complex and potentially quite expensive. This review discusses the modern concepts of pathogenesis of TRALI along with its clinicopathological manifestations and management with the aim to improve awareness of our clinicians towards this dreadful and potentially fatal condition.