Background. Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged, many articles have been published on airway management for coronavirus disease 2019 (COVID-19) patients. However, there is a lack of clear and concise conceptual framework for working with infected patients without respiratory failure undergoing general anaesthesia compared to noninfected patients. The aim of this article is to review current literature data on new challenges for anaesthesia providers, compare standard airway management techniques protocols with new data, and discuss optimisation potential.Materials and methods. Literature search was performed in Google Scholar and PubMed databases using these keywords and their combinations: anaesthesia, preoxygenation, airway management, difficult airway, SARS-CoV-2, COVID-19. The following nonsystematic review is based on a comprehensive literature search of available data, wherein 41 articles were chosen for detailed analysis. Summarised and analysed data are presented in the article.Results. SARS-CoV-2 has unique implications for airway management techniques in patients without respiratory failure undergoing general anesthesia. Main differences with the standard practice include: institutional preparedness, team composition principles, necessary skills, equipment, drugs, intubation and extubation strategies. Failed or difficult intubation is managed with predominance of emergency front of neck access (FONA) due to increased aerosol generation.Conclusions. Airway management techniques in COVID-19 patients without respiratory failure are more challenging than in noninfected patients undergoing general anaesthesia. Safe, accurate and swift actions avoid unnecessary time delay ensuring the best care for patients, and reduce risk of contamination for staff. Appropriate airway strategy, communication, minimisation of time for aerosol generating procedures and ramped-up position aid to achieve these goals. During the pandemic, updated available literature data may change clinical practice as new evidence emerges.
We aimed to evaluate (i) the effectiveness of combined surgery (coronary artery bypass grafting with restrictive mitral valve annuloplasty) and (ii) the late gadolinium enhancement cardiovascular magnetic resonance-based predictors of ischaemic mitral regurgitation (IMR) recurrence.The prospective analysis included 40 patients with multivessel coronary artery disease, IMR >II° and left ventricular (LV) dysfunction undergoing combined surgery. The degree of IMR and LV parameters were assessed preoperatively by transthoracic echocardiography, 3D transoesophageal echocardiography and cardiovascular magnetic resonance and postoperatively by transthoracic echocardiography. The effective mitral valve repair group (n = 30) was defined as having recurrent ischaemic mitral regurgitation (RIMR) ≤II° at the end of follow-up (25 ± 11 months).The surgery was effective: freedom from RIMR >II° at 1 and 2 years after surgery was 80% and 75%, respectively. Using multivariable logistic regression, 2 independent predictors of RIMR >II° were identified: ≥3 non-viable LV segments (odds ratio 22, P = 0.027) and ≥1 non-viable segment in the LV posterior wall (odds ratio 11, P = 0.026). Using classification trees, the best combinations of cardiovascular magnetic resonance-based and 3D transoesophageal echocardiography-based predictors for RIMR >II° were (i) posterior mitral valve leaflet angle >40° and LV end-systolic volume index >45 ml/m2 (sensitivity 100%, specificity 89%) and (ii) scar transmurality >68% in the inferior LV wall and EuroSCORE II >8 (sensitivity 83%, specificity 78%).There is a clear relationship between the amount of non-viable LV segments, especially in the LV posterior and inferior walls, and the recurrence of IMR after the combined surgery.
Meningiomas occurring outside the cerebrospinal axis can be primary at an extracranial site (nasal cavity, paranasal sinuses, and nasopharynx) or secondary extending from an intracranial lesion. Magnetic resonance imaging findings of an 8‐year‐old child with primary meningioma before and after surgery have been reviewed and compared to computed tomography and histological evaluation. The child had difficulty breathing through the left nostril and tearing of the left eye. After physical and radiological examination, a tumor comprising the left lower, middle turbinate, and ethmoidal cells was found and radically extirpated. On histological examination, the tumor was identified as meningothelial meningioma. On the basis of the clinical, radiological, and histological features, the tumor was diagnosed as extracranial meningioma of the sinonasal tract. A follow‐up examination 6 months later revealed no evidence of recurrence of the tumor.
This article presents the case of a 54-year-old male with evidence of myocardial ischemia at rest. In our case, by means of cardiovascular magnetic resonance, myocardial ischemia at rest in theoretical left anterior descending artery territory was proved, myocardial scar was excluded, and need for revascularization was validated.
Abstract PurposeMyocardial fibrosis in aortic stenosis (AS) is associated with worse survival following aortic valve replacement (AVR). We assessed myocardial fibrosis in severe AS patients, integrating echocardiographic, cardiovascular magnetic resonance (CMR) and histological data. MethodsA total of 83 severe AS patients (age 66.4 ± 8.3, 42% male) who were scheduled for surgical AVR underwent CMR with late gadolinium enhancement (LGE) and T1 mapping and global longitudinal strain (GLS) analysis. Collagen volume fraction (CVF) was measured in myocardial biopsies (71) that were sampled at the time of AVR. ResultsCVF correlated with imaging and serum biomarkers of LV systolic dysfunction and left side chamber enlargement and was higher in the sub-endocardium compared with midmyocardium (p<0.001). CVF median values were higher in LGE-positive versus LGE-negative patients [28.7% (19-33) vs 20.7% (15-30), respectively, p=0.040]. GLS was associated with invasively (CVF; r=-0.303, p=0.013) and non-invasively (native T1; r=-0.321, p<0.05) measured myocardial fibrosis. GLS and native T1 correlated with parameters of adverse LV remodelling, systolic and diastolic dysfunction and serum biomarkers of heart failure and myocardial injury. ConclusionOur data highlight the role of myocardial fibrosis in adverse cardiac remodelling in AS. GLS has potential as a surrogate marker of myocardial fibrosis, and high native T1 and low GLS values differentiated patients with more advanced cardiac remodelling.
Abstract Background: Increasing demand for aortic dilatation imaging and complicated use of multiplanar image reconstructions (MPR) from 3D images for less experienced users inspired research of unenhanced 2D-MRI in order to reduce need for aortic MPR. Purpose: To research robustness of unenhanced 2D-MRI with no need for MPR from 3D images by comparing maximal axial measurements of thoracic aorta in unenhanced “dark blood” (DB) and “bright blood” (BB) 2D-MRI images vs. contrast enhanced 3D-T1 MR angiography (ce3D-MRA) both in patients with tricuspid (TAV) and bicuspid (BAV) aortic valves. Material and Methods: Prospective study. 68 subjects underwent MRI and US examinations of aorta and were divided into 2 groups: 1) TAV patients: 26 patients, age: 53.3±8.1 years, 14 males and 12 females; 2) BAV patients: 42 patients, age: 30.8±9.8, 31 males and 11 females. Results: Strongest correlation between repeated MRI studies for TAV thoracic aorta segmental measurements was in BB (AS R=0.94, AA R=0.94) as well between BB and US (AS R=0.9, AA R=0.86). Unenhanced techniques in BAV patients revealed statistically significant correlation in all segments (p˂0.05) with strongest correlation in AA (R=0.96) and weakest correlation in AS (R=0.86, influenced by asymmetry of sinuses in BAV). Conclusion: BB correlated better with ce3D-MRA than measurements performed in DB both in TAV and BAV cohorts, especially in the AA. Comparing aortic measurements between US and MRI unenhanced sequences - BB had the strongest correlation in TAV. Our results suggest that there is no strict need for intravenous contrast administration and MPR for routine MRI evaluation of thoracic aorta’s maximal diameters, except for AS in BAV.
Abstract Tatton-Brown–Rahman syndrome (TBRS) is a rare congenital genetic disorder caused by autosomal dominant pathogenic variants in the DNA methyltransferase DNMT3A gene. Typical TBRS clinical features are overgrowth, intellectual disability, and minor facial anomalies. However, since the syndrome was first described in 2014, a widening spectrum of abnormalities is being described. Cardiovascular abnormalities are less commonly reported but can be a major complication of the syndrome. This article describes a family of three individuals diagnosed with TBRS in adulthood and highlights the variable expression of cardiovascular features. A 34-year-old proband presented with progressive aortic dilatation, mitral valve (MV) regurgitation, left ventricular (LV) dilatation, and ventricular arrhythmias. The affected family members (mother and brother) were diagnosed with MV regurgitation, LV dilatation, and arrhythmias. Exome sequencing and computational protein analysis suggested that the novel familial DNMT3A mutation Ser775Tyr is located in the methyltransferase domain, however, distant from the active site or DNA-binding loops. Nevertheless, this bulky substitution may have a significant effect on DNMT3A protein structure, dynamics, and function. Analysis of peripheral blood cfDNA and transcriptome showed shortened mononucleosome fragments and altered gene expression in a number of genes related to cardiovascular health and of yet undescribed function, including several lncRNAs. This highlights the importance of epigenetic regulation by DNMT3A on cardiovascular system development and function. From the clinical perspective, we suggest that new patients diagnosed with congenital DNMT3A variants and TBRS require close examination and follow-up for aortic dilatation and valvular disease because these conditions can progress rapidly. Moreover, personalized treatments, based on the specific DNMT3A variants and the different pathways of their function loss, can be envisioned in the future.
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