To the Editor, The term porcelain aorta, defined as an extensive calcification of the aorta, increases the complexity of cardiac surgery. Although usually seen in the elderly population, we report a rare and unprecedented finding of a porcelain aorta incidentally discovered in a patient in his twenties. A 29-year-old male patient with prior Bentall surgery in 2014 for ascending aorta aneurysm and aortic regurgitation (AR) presented with suprasternal swelling [Figure 1] and fever, revealing calcification of bilateral common carotid artery and arch of the aorta in chest X-ray (CXR) posterior-anterior (PA) view [Figure 2]. Contrast-enhanced computed tomography (CECT) thorax revealed dense peripheral wall calcification of bilateral common carotid artery, arch of the aorta, and descending thoracic aorta; also, aneurysmal dilation of the aortic arch and right subclavian artery; and narrowing of descending thoracic aorta. The patient was taken for emergency exploration because the swelling was increasing with an associated drop in hemoglobin. Intraoperatively, the patient was found to have a mediastinal abscess draining into subcutaneous space and drained under femoral bypass. The patient was shifted to the intensive care unit on vasopressor support and was extubated on postoperative day one, but later, he succumbed to sepsis.Figure 1: Suprasternal swellingFigure 2: CXR PA view showing bilateral carotid artery, aortic arch calcification and intercoastal drain in situ (for hydropneumothorax)Porcelain aorta is challenging because it precludes aortic cannulation and cross-clamping due to the risk of injury and release of thromboembolic material, causing stroke. Peripheral arterial cannulation, intraluminal balloon occlusion of the aorta, hypothermic circulatory arrest to avoid cross-clamping, and slow aortic clamping with flushing through the open aorta can minimize this risk.[1] Vascular calcification has been reported in younger patients with chronic kidney disease (due to altered mineral metabolism), systemic lupus erythematosus (SLE), and Takayasu arteritis due to systemic inflammation and immune mechanisms.[2] Our patient had a normal renal function test and no history of claudication, joint pain, or skin rashes. Tests for SLE were not performed. He fulfilled one major criterion (fever) and three minor criteria (previous history of AR, descending thoracic aorta narrowing, and high ESR, 40 mm/hr in our case) of the Sharma criteria for diagnosis of Takayasu arteritis, but using fever as a major criterion is dubious in the background of mediastinal abscess.[3] Boudagh et al.[3] had reported a similar case of Takayasu arteritis in a young patient with severe AR and atypical presentation. Unfortunately, the focus was on determining the reason for suprasternal swelling, and other findings on CECT were not thoroughly investigated. CT angiography, which depicts luminal changes and is a reliable tool in the diagnosis of Takayasu arteritis, was not performed, and rheumatology consultation was also not sought. Genetic predilection and chronic inflammation post-cardiac surgery might have led to accelerated vascular fibrosis and calcification in this patient, or he might have some underlying vasculitis that remained undiagnosed and Takayasu arteritis should also be kept in mind as a cause of AR and aortic aneurysm in young patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

ABSTRACTWhole lung lavage (WLL) for pulmonary alveolar proteinosis, performed under one-lung ventilation (OLV), illustrates the dynamic interplay between alveolar expansion and pulmonary vascular responses. Instillation of warm saline into the nonventilated lung compresses pulmonary vessels, mimicking hypoxic pulmonary vasoconstriction and enhancing oxygenation. Conversely, drainage of the saline relieves vascular compression, worsens ventilation–perfusion (V/Q) mismatch, and leads to a decline in oxygenation. This cyclical pattern underscores the physiological shifts that influence oxygenation during WLL.

Complex aortic aneurysms, including thoracoabdominal, juxtarenal, and pararenal aneurysms, pose significant challenges due to their involvement with vital branch vessels. Fenestrated endografts have emerged as a promising alternative to traditional open surgery. These devices are available in two types: custom-made and off-the-shelf. Custom fenestrated endografts are tailored to individual anatomy, offering precision but requiring longer preparation times and higher costs. Off-the-shelf fenestrated endografts provide a standardized approach with shorter deployment times and lower costs but may not suit highly complex cases. The aim of this review is to assess the role of custom and off-the-shelf fenestrated endografts in treating complex aortic aneurysms, focusing on clinical outcomes, complications, cost-effectiveness, and advancements in technology. We conducted a systematic search of PubMed, Scopus, and Google Scholar for studies published between 2000 and 2024 using keywords such as "complex aortic aneurysms," "fenestrated endograft," "custom endograft," and "off-the-shelf endograft." Data on outcomes, complications, and technological advancements were extracted and analyzed. This review seeks to provide insights into the advantages and challenges of both approaches, guiding clinicians in optimizing treatment strategies for complex aortic aneurysm patients.

Assessment of LV diastolic dysfunction (LVDD) poses challenges due to the dynamic changes of loading conditions in the perioperative course. Diastolic strain-based measures showed to be less load dependent, but data in aortic valve replacement (AVR) surgery remains sparse to date. Therefore, we aimed to explore the feasibility to assess these measurements and to describe the intraoperative course in this patient population. Prospective observational study including 30 adult patients. Intraoperative transesophageal echocardiography (TEE) was performed after induction of anesthesia [T1], after termination of cardiopulmonary bypass [T2], and after sternal closure [T3]. TEE assessment included the evaluation of peak longitudinal strain rate during isovolumetric relaxation (SR-IVR), early (SR-E) and late (SR-A) LV filling, as well as of conventional echocardiographic measurements and LVDD grading algorithms. Diastolic strain analysis was feasible in 27 (90%) AVR patients at all time points of assessment. LV diastolic strain improved significantly after AVR [T1 vs T3] as measured by SR-IVR (0.31 s-1 (IQR 0.22; 0.38) vs. 0.4 s-1 (IQR 0.33; 0.43); P = 0.01), SR-E (1.13 s-1 (IQR 0.89;1.28) vs. 1.35 s-1 (IQR 1.10;1.52); P = 0.035), and E/SR-IVR (2.2 m (IQR 1.7;2.8) vs. 1.6 m (IQR 1.3;2.2); P = 0.013). In contrast, conventional echocardiographic measurements and grading algorithms were not able to detect these changes in the same period. Assessment of LV diastolic strain was feasible in our group of selected AVR patients. LV relaxation and filling improved during the intraoperative course of AVR as measured by diastolic strain, while most conventional grading algorithms were not able to detect these alterations.

Extravascular lung water (EVLW) in children undergoing cardiac surgery may affect the outcomes after surgery. The study aimed to evaluate if extravascular lung water assessed by ultrasound could serve as a predictor of short-term postoperative outcomes in pediatric cardiac surgery. This is a prospective observational study conducted at a tertiary care facility involving children aged 6 months to 12 years who were scheduled for cardiac surgery. A lung ultrasound assessment was carried out before the operation (T0), immediately after the surgery (T1), 6 to 8 hours after surgery (T2), and 18 to 24 hours postoperatively (T3). A score was assigned based on the presence of extravascular lung water indicated by B lines. Pearson's correlation analysis was performed to examine the relationship between the lung ultrasound score of extravascular lung water and the duration of mechanical ventilation and the length of stay in the intensive care unit, with fluid balance, inotrope score, and oxygenation status being analyzed secondarily. The EVLW score demonstrated a positive relationship with the duration of mechanical ventilation across all time points, with correlation coefficients of r = 0.56 at T0, r = 0.70 at T1, r = 0.40 at T2, and r = 0.52 at T3. The most pronounced correlation occurred at T1, where r = 0.7 was observed. A moderate positive correlation with the duration of ICU stay was noted at the time points T0, T1, and T3. The EVLW score at T1 proved to be significant in linear regression analysis for prediction of both the duration of mechanical ventilation and the length of stay in the ICU. The EVLW score measured at T1, which is immediately after surgery, can serve as an indicator of short-term postoperative outcomes in pediatric cardiac surgery related to the duration of mechanical ventilation.

Lung isolation is essential for optimal surgical exposure and prevents contamination of normal lung. It is challenging in pediatric patients due to the anatomical and physiological differences. The most common methods of achieving lung isolation include the use of double-lumen endotracheal tubes (DLTs) or bronchial blockers (BBs). However, in pediatric patients, the size of the airways often restricts the use of DLTs, and in some cases, specific BBs may not be available or feasible due to the anatomy. Here, we report a case of right lower lobectomy in a two-and-half-year-old child using a pulmonary artery (PA) catheter to isolate the lung.

This was a prospective, longitudinal study, of 40 children who had open heart surgery, on account of congenital heart diseases, at our study center, between April 2020 and June 2022. Plasma samples were assayed for cystatin-C using the enzyme-linked immunosorbent assay method, while quantification of creatinine was done using a Roche automated analyzer (Cobas C311). Mean plasma concentrations of cystatin-C at 0, 4, 8, 12, 24 and 48 hours were 0.49±0.11 ng/dL, 0.75 ± 0.19 ng/dL, 0.96 ± 0.23 ng/dL, 0.79 ± 0.20 ng/dL, 0.66 ± 0.15 ng/dL, and 0.60 ± 0.14 ng/dL, respectively, versus 48.98 ± 11.6 μmol/L, 59.65 ± 13.06 μmol/L, 63.00 ± 16.53 μmol/L, 64.90 ± 17.65 μmol/L, 68.50 ± 19.99 μmol/L, and 70.78 ± 21.86 μmol/L, respectively, of creatinine. Plasma cystatin-C peaked earlier at 8 hours compared to creatinine, which peaked at 48 hours. The ROC curve showed that cystatin-C had an AUC of 0.983. This study showed that cystatin-C has a better sensitivity and specificity than creatinine in predicting CSA-AKI in children who had open heart surgery for congenital heart diseases.

Patients are administered anaesthesia to avoid pain and discomfort while performing different medical procedures. It is the responsibility of anesthesiologists and surgeons to make patients aware of the potential risks during anaesthesia. This is predominantly because once patients are aware of potential anaesthesia risks, they can make informed choices about their care and be an active part of the shared decision-making process. Acknowledging the need to educate patients on anaesthesia risks, there is a definite need to plan and implement targeted interventions for the benefit of the patients and the healthcare facilities. In conclusion, it is the responsibility of healthcare providers to inform patients about anaesthesia risks to empower them to make informed decisions about the procedure and the recovery process. However, considering that there are multiple patient and healthcare provider-related barriers, we must take into account all these factors and implement targeted interventions to benefit patients.

This chest X-ray (CXR) image [Figure 1] was obtained after placing a left internal jugular (IJ) central venous catheter (CVC). The CVC was inserted easily under ultrasound guidance using a modified Seldinger technique, with pressure transduction confirming venous placement. However, the CXR revealed that the catheter did not cross the midline and instead took an abnormal lateral course. It also did not follow the course of the aorta. A blood gas sample was then drawn from the catheter confirming venous placement. A CT scan was then performed and revealed that the CVC terminated in the pericardiophrenic vein [Figure 2]. This abnormal placement was likely due to an occluded left brachiocephalic vein in our patient, which prevented the CVC from crossing the midline [Figure 3].Figure 1: Bedside CXR showing a left IJ CVC not crossing the midline and instead taking an abnormal lateral course (white arrows) with the tip projecting over the left heart. A CT confirmed the CVC to be placed in the left pericardiophrenic veinFigure 2: CT with contrast. The left image is an axial CT plane with a white arrow pointing to the CVC that appears as a filling defect within a dilated pericardiophrenic vein. The right image is a coronal CT plane with a white arrow also pointing to the dilated pericardiophrenic veinFigure 3: CT with contrast. The left image is an axial CT plane with a white arrow pointing to the chronically occluded left brachiocephalic vein that does not opacify with contrast. The right image is a coronal CT plane with a white arrow also pointing to the chronically occluded left brachiocephalic veinThe correct location for a CVC tip should be at the superior vena cava (SVC)—right atrial junction or the upper right atrium, distal to the last venous valve located at the junction of IJ and subclavian vein.[1,2] The right IJ is generally preferred over the left due to its straight path to the SVC and the higher risk of malposition associated with left-sided cannulation. This increased risk is likely due to the longer course and more oblique path of the left brachiocephalic vein, as well as the presence of small tributaries in the area.[3] Potential venous locations for a misplaced left IJ CVC tip that does not cross the midline include the left pericardiophrenic vein, left subclavian vein, left internal mammary vein, left superior intercostal vein, the accessory hemiazygos vein, or persistent left SVC in patients with abnormal anatomy.[2,3] For a left IJ CVC that crosses the midline or a right IJ CVC, potential atypical venous locations also include the right internal mammary vein, right pericardiophrenic vein, and azygos vein[2,3] [Figure 4]. Arterial and extravascular placement, such as in the pericardial and pleural spaces, are also potential sites for CVC misplacement.[1,3]Figure 4: Potential sites for IJ misplacement. 1: left pericardiophrenic vein, 2: left internal mammary vein, 3: left superior intercostal vein, 4: accessory hemiazygos vein through potential connection with the superior intercostal vein,[ 2 ] 5: persistent left SVC in some patients with abnormal anatomy. Left SVC typically regresses during fetal development. It drains the left jugular and subclavian veins to the coronary sinus,[ 2 ] 6: right internal mammary vein, 7: right pericardiophrenic vein and 8: azygos veinThe pericardiophrenic veins carry venous drainage from the pericardium, pleura, and diaphragm and are not a suitable location for a CVC because of their small size and the increased risk of thrombosis.[2] Consequently, we removed the CVC once adequate venous access was established. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.