Search

Background Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. Case presentation A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. Conclusion CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

The formation of an intraperitoneal pseudocyst as a complication of ventriculoperitoneal shunts is well known. However, the formation of a pseudocyst at the subcutaneous extraperitoneal abdominal space is unusual and likely secondary to the migration of the peritoneal catheter. We present a 53-year-old male who had placement of a ventriculoperitoneal shunt for hydrocephalus secondary to a vestibular schwannoma. Five months later, he presented with an enormously distended abdomen. Investigations showed the peritoneal catheter in the extraperitoneal space within a large right lower quadrant abdominal wall pseudocyst. The patient was taken to the operating theatre, and the shunt was externalised at the original abdominal incision. Approximately 3 L of cerebrospinal fluid were aspirated from the distal peritoneal catheter. After negative cultures, a new peritoneal catheter was placed intraperitoneally at the contralateral lower abdominal quadrant. The contralateral quadrant was utilised to prevent fluid accumulation into the old extraperitoneal cavity.

Abnormal communications between the systemic and pulmonary venous systems are rare but can present as a opacity on chest radiograph. A solitary vessel communicating as a fistula directly between the systemic arterial circulation and the pulmonary venous system is not widely described. These may have significant implications in the long-term cardiovascular health of an individual acting as a left to right shunt. There is no clear consensus as to the management, but surgical management and endovascular embolisation have been successfully used. We present a case where a systemic arteriaopulmonary fistula originating from the abdominal aorta and connecting to the right inferior pulmonary vein manifested as an incidental finding on a chest radiograph and was further evaluated on cross-sectional imaging in a young patient. Chest radiographs are non-specific and it is important to be aware of the less frequent but important pathologies that can be picked up on plain chest radiographs, which inturn should warrant further investigation. This is presented in conjunction with a review of the available literature along with a discussion regarding the differential diagnosis and management applicable to the general clinician.

Atrial septal defect (ASD) is the most common congenital heart disease observed in adult. Several ECG findings are considered sensitive for the diagnosis of ASD. We describe a 50 years old man who displayed Crochetage sign, incomplete right bundle branch block (IRBBB) and right ventricular strain pattern on ECG. Crochetage sign is highly specific for ASD and it correlates with shunt severity. The diagnostic specificity for ASD increases if the R waves have both Crochetage patterns and IRBBB. It is important not to confuse Crochetage signs with IRBBB abnormalities on ECG. Our patient was ultimately diagnosed with a large ASD measuring 3 cm with bidirectional shunt and concomitant pulmonary thrombosis. This illustrates that high suspicion of the ASD with the use of good-old ECG signs remains relevant in this modern era. This also reminds us that patients with Eisenmenger syndrome are at higher risk for pulmonary thrombosis.

Background The Fontan procedure, the last of a series of palliative operations for patients born with single ventricles, is associated with a significant late burden of complications. There are other strategies for patients who are suboptimal candidates for Fontan completion; however, the long-term outcomes of these different surgical options have not been clearly elucidated. We performed a systematic literature review to establish the current role of other treatment approaches besides the Fontan procedure. Methods The MEDLINE and Embase databases were systematically searched for articles describing the long-term outcomes of patients with single ventricles who have not received the Fontan procedure. Results A total of 36 articles met all inclusion criteria. There is a scarcity of contemporary data on the non-Fontan cohort. Historical studies provided a significant contribution. Conclusions Long-term survival of unoperated patients with single ventricles is possible under the rare conditions of having balanced hemodynamics. As many as half of patients may survive on only a systemic-to-pulmonary artery shunt or bidirectional cavopulmonary shunt for more than 20 years with reasonable functional status. In patients with a failing single ventricle, the bidirectional cavopulmonary shunt is an excellent bridge to heart transplantation and may provide better posttransplant survival than patients with a Fontan circulation. Currently, the Fontan procedure continues to be the best definitive palliation for patients born with single ventricle lesions. However, for those with borderline indications, other strategies should be carefully considered.

We report a clinically significant right-to-left intracardiac shunt through a patent foramen ovale, diagnosed during investigations for hypoxemia and left ventricular dilation on the late postoperative period of a HeartMate3 implantation. We discuss diagnostic pitfalls and haemodynamic influences in this scenario, as well as the possibility of successful percutaneous treatment.

OBJECTIVE The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. METHODS The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. RESULTS The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98–1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. CONCLUSIONS This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.

Overdrainage of cerebrospinal fluid is one of the most notorious complications after ventriculoperitoneal shunt implantation. Siphon effect plays a major role in the development of overdrainage. Various overdrainage-preventing devices have been invented to counteract the siphon effect. Though some of the devices are designed to reduce the flow instead of providing antisiphoning effect, they are generally called antisiphon devices (ASDs). The basics of siphoning, the mechanisms and physical properties of currently available devices are described in this article. The clinical efficacy, shunt survival, and considerations on patient factors are also discussed. There are three kinds of ASD design, diaphragm, gravitational, and flow reducing devices. Flow reducing ASD is always open and the flow it controls is relatively stable. On the other hand, it may not provide sufficient flow in nocturnal intracranial pressure elevations. Diaphragm and gravitational devices are sensitive to the position of the patients. Diaphragm device is sensitive to the external pressure and the relative position of the device to the mastoid process. The gravitational device is sensitive to the angle between the axis of the device and the head. Many studies showed encouraging results with gravitational devices. Studies regarding diaphragm devices either showed better or similar outcomes comparing to differential pressure valves. Clinical studies regarding flow-reducing devices and head-to-head comparison between different mechanisms are warranted. This review aims to provide a useful reference for clinical practice of hydrocephalus.

Lumboperitoneal or ventriculoperitoneal shunt insertion is a standard therapy for hydrocephalus that diverts cerebrospinal fluid from the subarachnoid space into the peritoneal cavity. Gastrointestinal perforations due to this procedure occur rarely; however, accepted treatment strategies have not yet been established. Hence, the most common treatment approaches are open surgery or spontaneous closure without endoscopy. We report the case of a small intestinal perforation in a 73-year-old-woman that occurred after the insertion of a lumboperitoneal shunt. A positive cerebrospinal fluid culture and high cerebrospinal fluid white blood cell count indicated a retrograde bacterial infection, and computed tomography revealed that the peritoneal tip of the shunt catheter was located in the lumen of the gastrointestinal tract. We repaired the perforation endoscopically using an over-the-scope clip, and the patient’s recovery was uneventful. Use of an over-the-scope clip could be an effective and minimally invasive treatment for intestinal perforations caused by lumboperitoneal or ventriculoperitoneal shunt insertion.

The Blalock–Taussig–Thomas Shunt (BTTS) procedure was first introduced by Alfred Blalock, Hellen B. Taussig, and Vivien Thomas in 1944. The procedure is performed by making a connection between the subclavian artery to the pulmonary artery to augment pulmonary blood flow. BTTS is used to palliate neonates born with restrictive pulmonary blood flow disorders (cyanotic congenital heart disease). The modified BTTS (MBTTS) procedure is still seen as high risk and has quite high morbidity and mortality rates, especially in the neonatal group. Recent studies suggest a mortality of up to 15% in the single ventricle group and 3% in the biventricular group. Based on a literature search, several risk factors such as patient weight, shunt size/body weight ratio, underlying cardiac malformations, use of mechanical ventilator support, sternotomy approach and use of CPB machines have been shown to increase mortality. Current perioperative risk assessment methods and recommendations are also covered. In addition, our review article specifically discusses perioperative strategies including strategies for surgeons using the MBTTS procedure (surgical approach, determining shunt size and anastomosis techniques) and postoperative strategies (anticoagulation management and strategy to deal with undershunting/overshunting problems). Resumen: El procedimiento de derivación de Blalock-Taussig-Thomas fue introducido por primera vez por Alfred Blalock, Hellen B. Taussig y Vivien Thomas en 1944. El procedimiento se realiza al hacer una conexión entre la arteria subclavia y la arteria pulmonar para aumentar el flujo sanguíneo pulmonar. El procedimiento de derivación de Blalock-Taussig-Thomas se utiliza para paliar a los recién nacidos que nacen con trastornos restrictivos del flujo sanguíneo pulmonar (cardiopatía congénita cianótica). El procedimiento MBTTS todavía se considera un procedimiento de alto riesgo y tiene tasas de morbilidad y mortalidad bastante altas, especialmente en el grupo neonatal. Estudios recientes sugieren que hay una mortalidad de hasta el 15% en el grupo de un solo ventrículo y del 3% en el grupo de anomalías cardíacas biventrículos. Según la búsqueda bibliográfica, se ha demostrado que varios factores de riesgo, como el peso del paciente, la relación tamaño de la derivación/peso corporal, malformaciones cardíacas subyacentes, uso de asistencia respiratoria mecánica, abordaje de esternotomía y uso de máquinas de CEC, aumentan la mortalidad. También se tratan los métodos y recomendaciones actuales de evaluación de riesgos perioperatorios. Además, nuestro artículo de revisión analiza específicamente las estrategias perioperatorias, incluidas las estrategias para los cirujanos en el procedimiento MBTTS (abordaje quirúrgico, determinación del tamaño de la derivación y técnicas de anastomosis) y las estrategias postoperatorias (manejo de anticoagulación y estrategia para lidiar con problemas de sobrecapacidad/sobrecadencia).

It is crucial to have an adequate-size unobstructed branch pulmonary artery architecture to achieve an ideal cavopulmonary circulation. Branch pulmonary artery distortion, stenosis, or hypoplasia is a common problem following the stage I Norwood procedure for infants with hypoplastic left heart syndrome regardless of the shunt type. This technical review describes the surgical principle and techniques of the extensive hilum to hilum branch pulmonary artery reconstruction at the time of stage II palliation, bidirectional cavopulmonary shunt in infants with hypoplastic left heart syndrome.

Knotting or twisting of the peritoneal catheter around a bowel segment, causing bowel obstruction and necrosis, is extremely rare. Only six cases have been reported in the literature. This report described the second case of an adult patient with spontaneous knotting of the peritoneal catheter around a small-bowel segment, causing bowel obstruction and necrosis. The presentation of a knotted ventriculoperitoneal shunt around a bowel loop is stereotypical. Treatment and general recommendations have been made to help guide clinicians when encountering such cases. Evidence of small-bowel obstruction in a twisted, coiled or knotted peritoneal catheter may need surgical intervention. In the setting of progressive abdominal manifestations, knotting of the peritoneal catheter around bowel loops may cause bowel obstruction and may present with acute life-threatening manifestations. Efficient and expedite diagnosis should be made to coordinate multispecialty intervention and follow-up appropriately.

Serratia species are opportunistic, gram-negative, motile bacteria classified in the large family Enterobacteriaceae and differentiate from Klebsiella spp. with slow fermenting lactose and DNAase positive (1,2). One of the characteristics of Serratia bacteria that distinguishes them from other bacteria is to synthesize the red pigments, prodigiosins. It can cause nosocomial infections especcialy in newborns and patients in intensive care units. Serratia spp.; responsible for approximately 2% of nosocomial infections; has been reported as the responsible agent especially in respiratory tract infections, urinary tract infections and bacteremia. An outbreak of S. marcescens blood stream infection has been identified in patients receiving contaminated parenteral nutrition bags (2). It has been reported to cause S. marcescens meningitis, wound infections, arthritis and outbreaks in pediatric wards (3). In this text we aimed to present a three and a half year old girl case of acute bacterial meningitis due to Serratia spp. with ventriculo-peritoneal shunt.

Persistent anhydramnios after placement of a vesicoamniotic shunt is a rare but potentially serious concern in a patient in utero. We present the case a male fetus who at 32 weeks gestation had bilateral hydroureteronephrosis, a distended bladder, and anhydramnios. A vesicoamniotic shunt was placed, but the anhydramnios persisted. Postnatally, the child was found to have a migrated shunt, left grade V vesicoureteral reflux (VUR) and posterior urethral valves (PUV). He underwent a PUV ablation and removal of the migrated shunt. The patient is now two years old and is doing well with no urinary tract infections or renal deterioration.

BACKGROUND The interatrial communication, one of the most frequent congenital heart defects, represents an important intracardiac shunt between systemic and pulmonary circulations. Direction and magnitude of the interatrial shunting depends upon several features, including defect size, shape and location, pressure difference between right and left atrium, and difference in right and left ventricular compliance. METHODS In this review article, the presence or absence of interatrial communication, and its role, have been analyzed, as they can have a critical impact on the cardiovascular physiopathology, and the interatrial communication can prove to be either clinically harmful, useful or indispensable. Accordingly, the utility and role of the interatrial communication in modern congenital, pediatric and adult, disease has evolved, with modification of the indications to close, maintain patency, or create an interatrial communication. RESULTS The interatrial communication and shunting can be manipulated to maximize the oxygen delivery to the tissues, accordingly with the underlying congenital heart defect. While not always relevant to patients with bi-ventricular circulations, this becomes extremely important in children and adults with complex congenital heart defects. CONCLUSIONS With improving long-term survival for the vast majority of congenital heart patients, an advanced understanding of the role and utility of the interatrial communication, and of all the possibilities of its manipulation, is essential to improve the patient outcomes.

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

BACKGROUND Hepatic encephalopathy (HE) is a frequent and debilitating complication of chronic liver disease. Recurrent HE is strongly linked with spontaneous portosystemic shunts (SPSSs). Intrahepatic arterioportal fistulas (IAPFs) occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension. Herein, we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF. CASE SUMMARY A 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo. SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography. The patient did not respond well to medical treatment. Therefore, simultaneous embolization of SPSS and IAPF was scheduled. After embolization, the symptoms of HE showed obvious resolution. CONCLUSION The presence of liver vascular disorders should not be neglected in patients with chronic liver disease, and interventional therapy is a reasonable choice in such patients.

Background Systemic to pulmonary shunt (Shunt) is offered for children with duct dependent pulmonary circulation to augment pulmonary flow. Recently patent ductus arteriosus (PDA) stent (Stent) is widely used as an alternative method. We aimed to compare post intervention outcomes in children underwent either procedure. Methods Infants under 3 months who had an initial palliation by Shunt or Stent were retrospectively reviewed between 2008 and 2016, then followed till the second intervention or 1 year whichever earlier. Results 187 patients (110 Shunt and 77 Stent) were included. Initial weight and pulmonary artery (PA) branches size were similar between the groups. Shunt patients had more shock preoperatively and required more emergency intervention. Stent group showed less ICU stay 4 (1–8) vs 13 (7–23) days, p < 0.0001 and less positive pressure ventilation days 1 (0–2) vs 5.5 (3–11), p < 0.0001. However, Stent group had more symptomatic arterial and deep venous thromboses. In Stent patients the branch PAs growth was better and more homogeneous. At follow-up, no difference between groups regarding cumulative readmission days to hospital, hemoglobin levels and the weight percentile for age. Mortality was not different with a tendency to be higher in the Shunt group (13%) compared to the Stent group (5%), p 0.1. Conclusions The implantation of PDA stent in patients with duct dependent pulmonary circulation results in a smoother ICU course and a shorter hospital stay, with higher risk of vascular injury. Shunt and Stent procedures have a good outcome for PA growth, somatic growth and survival.

Objective. To evaluate the results of treatment of prehepatic portal hypertension (PPH) in children by method of side-to-side splenorenal bypass. Methods. A retrospective, monocentric analysis of 114 patients with prehepatic portal hypertension was carried out in the period from 2000 to 2018. The age of the patients was from 6 months up to 18 years, the average age 10,1±3,8 years (M±σ). All patients underwent side-to-side splenorenal shunt. In the postoperative period, on the 7th day, ultrasound examination of the abdominal organs with Doppler sonography (US) was performed to assess the volume of the spleen, the rate of portohepatic perfusion, the rate of blood flow along the side-to-side splenorenal shunt, as well as to assess its diameter. Control US was performed after the 1st, 3rd, 6th, 12th months; to assess the regression of esophageal and gastric varicose veins, the control esophagogastroduodenoscopy (EYD) was performed after 3rd , 6th, 12th months and then once a year. Subsequently, the control examination of the patients was carried out once a year. The follow-up was 2-18 years. Results. Out of 114 patients who underwent side - to - side splenorenal shunt, 5 (4,4%) patients had recurrent bleeding from the esophageal variceal vein at the follow-up period (2-18 years). One patient had intra-abdominal arrosive bleeding from side-to-side splenorenal shunt provoked by severe postoperative pancreatitis. The average diameter of the shunt was 12±1.9 mm. The spleen volume decreased by 39.7±10.3%. Portohepatic perfusion reduced by 39% in comparison with the indicators before surgery. The blood flow rate along the side -to-side splenorenal shunt was 2403±557.3 ml/min. in 95,4% of patients the regression of variceal vein was noted. Hypersplenism syndrome was arrested in 73.6% of children. Conclusion. Side -to- side splenorenal shunt is considered to be an effective method of portal decompression with the effectiveness inpreventingboth esophageal and gastricvariceal veins bleeding in 95,4% of patients. What this paper adds The results of treatment of the prehepatic portal hypertension by method of side-to-side splenorenal shunt have been firstly analyzed, and the effect of this variant of portosystemic shunt on portohepatic perfusion has been assessed. It has been established that this option of shunt is effective for the portal system decompression and occupies an intermediate position between selective and total variant of portosystemic shunt.

Ventricular shunting is a well-recognised and commonly practiced method of reducing increased intracranial pressure in patients with neurologic pathology. There are possible complications related to shunt implantation, where the rarest is intracardiac migration of the distal shunt catheter. We present a case where the distal catheter migrated into the right ventricle, causing extrasystoles and was complicated with acute right ventricle failure during the endovascular shunt evacuation procedure.

Childhood priapism is a rare entity and there is currently no consensus regarding its contemporary management. The use of perioperative anticoagulation and open distal corpora-glandular shunt procedure in the management of childhood priapism has not been reported in the literature. We present a stuttering case of a 13-year-old boy who presented with idiopathic ischaemic priapism lasting 13 h in duration, which recurred despite corporal aspiration and alpha-adrenergic agonist injections, percutaneous distal shunt surgery, and revision of percutaneous distal shunt surgery. He was eventually successfully managed with perioperative subcutaneous enoxaparin, oral aspirin and clopidogrel in conjunction with an Al-Ghorab shunt, which led to sustained detumescence but with spontaneous morning erections. In paediatric patients with sustained childhood priaprism failing stepwise treatments, an Al-Ghorab shunt with perioperative anticoagulation is a viable option.

Background and Objectives: To assess the outcome of Endoscopic Third Ventriculostomy (ETV) versus Ventriculoperitoneal Shunt (VPS) in Obstructive Hydrocephalus in terms of infections, foreign bodies, cost-effectiveness, and length of hospital stay. Materials and Methods: It was a Randomized Controlled Trial study, in which 30 patients with Obstructive Hydrocephalus were divided into two groups one was treated with (ETV) and the other was treated with VP Shunt and the patients were followed up for 1 year. Results: Patients were divided into 2 groups, 15 were treated with ETV, and 15 were treated with VP Shunt. Length of stay for VP shunt was 7 ± 0.85 days and for ETV mean stay was 2.93 ± 1.1 days. The complication was observed in 4 (26.7%) treated with VP Shunt and in 3 (20%) patients with Endoscopic Third Ventriculostomy. In ETV, 3 (20%) patients had recurrence whereas in VP shunt in 1 (6.67%) had an infection and in 3 (20%) patients had recurrence (upper-end blockage) and the overall success rate was 76% in both the procedures and in VP Shunt 73.3% and ETV 80%. Overall there were no complications found in 23 (76.6%) patients, in 3 (10%) patient’s complications were found at 1st month, in 3 (10%) complications were observed at 3rd month, and in 1(3.3%) complication was recorded at 6th month. Conclusion: ETV was found better in terms of length of hospital stay, cost-effectiveness as well as minimal complication rate as compared to VP shunt.

Background Cerebrospinal fluid (CSF) leak through petrosal air cells is a known complication after drilling the posterior wall of the internal acoustic canal (IAC) for resection of vestibular schwannoma (VS). Whereas mild pneumocephalus is common after retrosigmoid craniotomy, tension pneumocephalus has been rarely documented. Objective To testify a case of fatal tension pneumocephalus after VS resection in a patient with ventriculo-peritoneal (VP) shunt and to propose possible recommendations to limit the risk of this dramatic complication. Methods A case of fatal tension pneumocephalus after VS resection in presence of hidden CSF fistula is illustrated with pre- and post-operative images. Results In the uneventful situation of concomitant post-operative CSF fistula in presence of VP shunt, tension pneumocephalus may occur. The negative pressure created by the shunt system and the presence of osteo-dural defect allow the air to enter and, at the same time, prevent the outflow. Conclusion After VS resection, tension pneumocephalus can occur as a consequence of CSF fistula from petrosal air cells in the presence of functioning VP shunt. Precautions as pre-operative increase to 'virtual-off' the pressure of the valve, subsequences CT scans after surgery and sealing of the petrous air cells are recommended to avoid such as fatal complication.

Shunt dysfunction is a common event, especially in children who have this intervention performed early in life. The consequences of chronic shunt overdrainage can be multiple since the cerebral hydrodynamics is altered. A thrombotic event with consequent symptoms of intracranial hypertension is discussed in this article. We performed a detailed review of cerebral hydrodynamics and intracranial pressure compensation mechanisms and how this can alter cerebral venous circulation. Next, we report the case of a 4-year-old child with such a clinical presentation that was conducted by our team. A child with a history of hydrocephalus treated with a ventriculo-peritoneal (VP) shunt in his early childhood presented with symptoms of intracranial hypertension, initial computed tomography (CT) demonstrating reduced-sized ventricles. Complementary investigation showed bilateral papilledema, cranial suture closure, changes compatible with Chiari type I, and venous sinus thrombosis (transverse and sigmoid, bilaterally). The case was managed conservatively with full anticoagulation with enoxaparin. Four months after the onset of symptoms, there was an improvement in the clinical and imaging status. A condition of severe headache in a patient with an apparently functioning shunt and small ventricles on initial CT should open up a range of diagnostic possibilities, with pseudotumor cerebri syndrome and cerebral venous sinus thrombosis being suggested. The therapeutic approach in these cases must be individualized.

Background Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. Case presentation A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. Conclusions PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

Hydrocephalus is the most common neurosurgical disorder in children, and cerebrospinal fluid (CSF) diversion with shunt placement is the most commonly performed pediatric neurosurgical procedure. CT is frequently used to evaluate children with suspected CSF shunt malfunction to assess change in ventricular size. Moreover, careful review of the CT images is important to confirm the integrity of the imaged portions of the shunt system. Subtle shunt disruptions can be missed on multiplanar two-dimensional (2-D) CT images, especially when the disruption lies in the plane of imaging. The use of volume-rendered CT images enables radiologists to view the extracranial shunt tubing within the field of view as a three-dimensional (3-D) object. This allows for a rapid and intuitive method of assessing the integrity of the extracranial shunt tubing. The purpose of this pictorial essay is to discuss how volume-rendered CT images can be generated to evaluate CSF shunts in the pediatric population and to provide several examples of their utility in diagnosing shunt disruption. We also address the potential pitfalls of this technique and ways to avoid them.

The authors report the clinical case of secondary Takotsubo syndrome developed after transcatheter aortic valve replacement that was performed in compassionate manner in female patient with combination of congenital ventricular septal defect and acquired severe aortic stenosis. In the teams view, Takotsubo syndrome was triggered with profound changes of intracardial hemodynamics subsequent to iatrogenic impairment of preexisting interventricular shunt.Авторы приводят клиническое наблюдение вторичного синдрома Такоцубо после транскатетерной имплантации аортального клапана, предпринятой в качестве паллиативного вмешательства у пациентки с сочетанием врожденного дефекта межжелудочковой перегородки и приобретенного клапанного аортального стеноза. По мнению авторов, триггером синдрома Такоцубо в данном случае послужило критическое изменение внутрисердечной гемодинамики при ятрогенном воздействии на степень межжелудочкового шунтирования крови.

Multifocal ventriculoperitoneal shunts with Y-connections (MVPS with Ys) are widely used in many centers when neuroendoscopic procedures on entrapped ventricles are not feasible; however, their use is not frequent. This study aimed to confirm the stability of an MVPS with Y and, for the first time, identify the factors that influence stability. We studied 33 consecutive patients who underwent initial conversion to MVPS with Ys. The one-year overall shunt survival rate was calculated and compared with the historical outcome of single ventriculoperitoneal shunts (VPSs). The factors influencing the one-year overall shunt survival rate were also investigated. The one-year survival rate for proximal catheters in each location was further investigated, and the rates were compared among locations. The factors affecting proximal catheter survival were determined. The one-year overall shunt survival rate of MVPS with Y was 70%, which was not much different from that of previously reported single VPSs, including our institution. We found no significant factor influencing overall shunt survival, but when an additional catheter was inserted into the fourth ventricle, the survival rate was exceptionally low at 40% (p = 0.21). When we investigated the one-year survival rate of each proximal catheter, we found that the location of the proximal catheter showed a certain trend toward significance (p = 0.07), especially in the case of the fourth ventricle, which had the lowest survival rate at 57% and an odds ratio of 15.64 (p = 0.013) in multivariate analysis. However, when the catheter was sufficiently inserted parallel to the brain stem using navigation, the survival was relatively well maintained (1,995 to 2,547 days). The stability of MVPS with Y was similar to that of single VPSs. However, the malfunction rate of the proximal catheter inserted at the fourth ventricle in the Y-connection was higher than that at other locations. The transcerebellar vertical approach or transtentorial approach parallel to the brain stem may decrease the malfunction rate.

In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival.Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated.Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006).Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

Background : Ventriculo-peritoneal shunt (VPS) is usually placed inside the peritoneal cavity for cerebrospinal fluid drainage. Rarely, it can migrate to various pelvic visceral organs. Inside the pelvis, the distal end of the shunt can perforate anywhere from the uterus or adnexa to the vulva and migration through the uterus is extremely rare. Case : A three-and-a-half-year-old girl presented with CSF leak through the vagina following uterine perforation by VPS. The diagnosis was made with an ultrasound. Her symptoms resolved following revision surgery. Conclusion : In a patient with a VPS in situ, presenting with a watery fluid leak through vagina, perforation of fornix or uterus must always be kept in mind. Timely diagnosis and intervention can result in the prevention of complications.

Ventriculoperitoneal (VP) Shunt is a commonly performed surgical procedure and offers a good result in the treatment of hydrocephalus. In general, 25% of the complication rate of this surgical procedure is abdominal complications. Anal extrusion of a peritoneal catheter is a rare complication ranging from 0.1 to 0.7% of all shunt surgeries. This study presents a rare case of anal extrusion of ventriculoperitoneal shunt in a 1-year-old female child who was asymptomatic. The physical examination revealed swelling and redness along the shunt tract on the retro auricular region, soft abdomen, and no catheter was observed in the anal. This study found several contributing factors affecting the complications in the anal extrusion of a peritoneal catheter, that are thin bowel wall in children and sharp tip and stiff end of VP shunt. The shunt should be disconnected from the abdominal wall, and the lower end should be removed through the rectum by colonoscopy or sigmoidoscopy/proctoscopy or by applying gentle traction on the protruding tube. This study concludes that due to potentially life-threatening consequences and case rarity, thorough anamnesis, physical examination, and objective investigation are needed to determine the appropriate management for anal extrusion of ventriculoperitoneal shunt.Â

Background The ventriculoperitoneal shunt (VPS) procedure is still the most used technique for management of hydrocephalus. This article reports a case of hepatic cerebrospinal fluid (CSF) pseudocyst as a rare, but important, complication of the VPS insertion. Case Description An 18-year-old male presented to the hospital complaining of temporal headache and visual turbidity for approximately 3 months with a history of VPS insertion for treatment of hydrocephalus and revision of the valve in adolescence. The diagnosis was based on abdominal imaging, demonstrating an extra-axial hepatic CSF pseudocyst free from infection. Following the diagnosis, the management of the case consisted in the removal and repositioning of the catheter on the opposite site of the peritoneum. Conclusion The hepatic CSF pseudocyst is an infrequent complication of VPS procedure, but it needs to be considered when performing the first evaluation of the patient. Several techniques are considered efficient for the management of this condition, the choice must be made based on the variables of each individual case.

Hydrocephalus is a neurological disorder caused by excessive accumulation of the cerebrospinal fluid (CSF) in the ventricles of the brain. It can be treated by diverting the extra fluid to different parts of the body using a device called a shunt. This paper reviews different shunt devices that are used for this purpose.Shunts have high failure rates either due to infection or mechanical failure, therefore there is still ongoing work to address these two main handicaps. They require additional devices for performance assessment. Here, the paper also reviews different approaches for assessing shunt limitations. Moreover, future prospects are also discussed.This study shows that shunt devices still remain an important treatment option for hydrocephalus. However, further efforts are required to design more advanced shunts, to eliminate high failure rates in clinical use. Sophisticated sensor systems that can accurately detect and regulate changes in CSF drainage to optimize drainage for individual needs. Moreover, shunt infection problem is still present despite recent improvements such as antibiotic impregnated catheters.

Vascular injuries to the upper or lower limb in the context of significant soft tissue loss, fractures, or other life-threatening injuries are associated with a high amputation rate. Complex extremity vascular injuries in which acute arterial insufficiency combined with severe or prolonged shocks are unacceptable because warm, warm, skeletal muscle time is often exceeded before adequate revascularization, and are associated with extended ischemia periods or fractures or soft tissue wounds. Revascularizing the limb is essential for the success of the limb rescue. Selective intravascular temporary shunting hence allows better overall care of the patient and can therefore be predicted to increase both limb rescue and patient survival rates. The aim of this article was to review and summarize results of previous literature regarding effectiveness on intravascular shunting as management of limb trauma as well as reviewing its potential complications.

A 54-year-old man suddenly developed impaired consciousness and left hemiplegia due to a right thalamic hematoma. Emergent ventricular drainage for acute hydrocephalus improved the level of consciousness, but macrosquare-wave jerks (MSWJ) consisting of a right-ward intrusive saccade and corrective saccade appeared. The MSWJ disappeared on day 2 when follow-up CT revealed improvement of hydrocephalus. However, on day 36, after ventricular drainage was clamped, the MSWJ reappeared. After ventriculoperitoneal shunt, MSWJ again subsided. In this patient, hydrocephalus may have stretched the superior colliculus, thereby decreasing activity of the fixation neurons and then omnipause neurons, and eventually resulting in the reversible MSWJ.

Resonant structural vibrations are a common source of disruptive noise, and suppressing these vibrations is often the most direct way to reduce the noise levels. Elastic metamaterials (EMMs) consist of distributed resonant substructures, at a scale which is small compared to the wavelength of vibration. This allows these materials to be used in applications where space is limited, and more traditional vibration suppression techniques would be impractical. Tuned resonators can be designed through selection of geometry or material properties, but an alternative approach, which requires significantly less prototyping, is through the use of shunted electrodynamic inertial actuators. In this paper, a novel electrodynamic metamaterial (EDMM) is proposed consisting of an array of mass-produced inertial actuators, each connected to a tuned shunt impedance. It is considered impractical to measure the dynamic and electrical parameters of a large number of actuators, and so the effect of uncertainties in the actuators is investigated on both the performance and the stability of the EDMM.

Right heart catheterisation is a frequently used procedure in cardiology and intensive care medicine, especially for the differential diagnosis of pulmonary hypertension, shunt diagnostics and accurate calculation of the important haemodynamic parameters. Various catheters are available for the examination; the most common and safest is the use of a Swan-Ganz catheter. The complete examination includes probing of the right atrium, right ventricle, pulmonary artery and pulmonary capillary bed. In this "step-by-step" article, the authors discuss the practical aspects of this method.

Hydrocephalus is caused by the disruption of the normal flow of cerebrospinal fluid (CSF), which results in a buildup of CSF. Hydrocephalus comprises two key categories: communicating and noncommunicating. Normal-pressure hydrocephalus, a type of communicating hydrocephalus, currently has no cure; the main treatment option is ventriculoperitoneal shunt (VPS) placement surgery. This procedure is performed to reestablish the balance between CSF production, flow, and absorption. Recently, general surgeons have begun assisting the neurosurgeon by placing the distal or abdominal end of the shunt using a laparoscopic technique. This article briefly reviews the pathophysiology and treatment options for hydrocephalus; presents a thorough review of the laparoscopic-assisted VPS placement procedure, as well as the expected perioperative course and care considerations; and concludes with a case study of a 68-year-old patient who undergoes a laparoscopic-assisted VPS placement.

Inadequate absorption of cerebrospinal fluid (CSF) in the setting of high CSF production is a relatively rare cause of shunt malfunction. We present the unique case of a 3-year-old boy who developed sterile ascites and abdominal distension in a delayed fashion after shunt placement. The shunt was externalized, and the patient was noted to have high CSF output. Bilateral choroid plexus cauterization resulted in a significant decrease in CSF production and enabled the shunt to be re-inserted into the abdomen.

Postoperative bowel complications after non-shunt-related neurosurgical procedures are relatively rare. In an effort to identify the primary risk factors, we evaluated postoperative bowel complications in cranial, endovascular, and spinal procedures in neurosurgery patients using our own institutional case series along with a literature review. We identified severe postoperative bowel complications that occurred at our institution after non-shunt-related neurosurgical procedures between July 2016 and December 2018. We also completed a systematic review of PubMed/MEDLINE using search terms related to bowel complications. At our institution, 7 patients (average age 49.7 ± 9.5 years, range 34–60; no apparent sex predilection) had severe postoperative bowel complications after undergoing a total of 10 neurosurgical procedures. Diagnosis was on average 1 week postoperatively (range 5–13 days), and the time between radiographic/clinical diagnosis and either surgery or death was 1.3 ± 1.4 days (range 0–4 days). Bowel perforation occurred in 4 patients. Five of the patients died, 3 as a direct result of the bowel complication. In the literature review, we identified 6487 spine and 66 cranial and/or endovascular bowel complications after neurosurgical procedures. Our case series and literature review demonstrate that severe postoperative bowel complications after non-shunt-related neurosurgical procedures, while rare, carry significant morbidity/mortality despite prompt and aggressive management. These can also happen without direct injury to bowel tissue, instead occurring as sequelae of inflammatory processes, as well as from delayed mobility, extended use of opiate narcotics, and lack of standardized protocols to ensure early bowel movements that likely stems from unfamiliarity with this potentially devastating complication.

Tunnelled hemodialysis catheters are well accepted and widely used devices to provide vascular access for dialysis in patients when an arteriovenous shunt is not feasible or dysfunctional. In the literature complications after implantation are well documented but fatal or near-fatal events during implantation are seldom reported. In this article 3 such cases from a single tertiary center over a period of more than 10 years are presented and discussed. The (near) fatal complications occurred despite experienced surgeons and the use of ultrasound and fluoroscopy during implantation. Although the incidence is estimated to be much less than 1% at this centre, implantation of a tunnelled hemodialysis catheter is demanding, a thorough evaluation of vascular structures in advance is mandatory and experiencend professionals with high index of suspicion are essential. Performing the procedure with the patient under conscious sedation has benefits compared to general anesthesia. If the patient indicates atypical pain, the procedure should be stopped immediately and re-evaluated for any cause. If a perforation with relevant vascular damage is suspected, we recommend leaving the dilator/introducer/catheter in place to reduce major hemorrhage until the vascular or cardiothoracic surgeon can fix the problem.Die Einlage eines großlumigen, tunnelierten zentralen Venenkatheters zur Hämodialyse ist eine akzeptierte und weit verbreitete Alternative, wenn die Anlage eines arteriovenösen Shunts zur Dialyse nicht möglich oder ein solcher Shunt dysfunktional ist. Typische Komplikationen wie Infekte oder Nachblutungen sind gut bekannt und wiederholt beschrieben. Ernsthafte Zwischenfälle bei der Einlage solcher großlumigen Systeme werden jedoch kaum berichtet. Über einen Zeitraum von mehr als 10 Jahren wurden an einem schweizerischen Krankenhaus der Maximalversorgung 3 vital bedrohliche Zwischenfälle im Rahmen der Einlage eines großlumigen tunnelierten Kathetersystems beobachtet und hier diskutiert. Trotz größter Vorsichtsmaßnahmen verstarb ein Patient letztlich an den aus der Einlage resultierenden Komplikationen. Die Inzidenz von tödlichen respektive beinahe tödlichen Zwischenfällen beträgt an diesem Zentrum weniger als 1%. Die Indikation für den Eingriff muss auch unter diesem Aspekt umsichtig gestellt und der Patient sorgfältig aufgeklärt werden. Da bei dem für diese Prozedur vorgesehenen Patientenkollektiv das Gefäßsystem durch vorgängige Interventionen oft alteriert ist, ist präoperativ eine Evaluation des Venensystems durch einen Angiologen zur Festlegung des optimalen Zugangsorts eine zwingende Voraussetzung. Zu dem von uns empfohlenen Standard für die Einlage zählen die Verwendung von Bildverstärker und Ultraschall perioperativ sowie die Ausführung durch Fachärzte mit Erfahrung in endovaskulärer Instrumentierung. Bei kooperativen Patienten ist die Intervention unter Lokalanästhesie und Sedation nach Bedarf einer Prozedur in Allgemeinanästhesie vorzuziehen. Vermeldet der Patient untypische Schmerzen, so sollte die Prozedur sofort gestoppt und nach möglichen Ursachen gesucht werden. Wird eine gröbere Gefäßverletzung vermutet, so wird empfohlen den gelegten Dilatator, Introducer oder Katheter in situ zu belassen (analog dem Management von Pfählungsverletzungen), um eine größere Blutung zu vermeiden, bis sich ein entsprechend ausgebildeter Chirurg der Lazeration und deren Versorgung annehmen kann.

BACKGROUND: One of the most common causes of extrahepatic portal hypertension in children is portal vein thrombosis. The causes of this disease are different and, in most cases, remain unrecognized. Along with this, the mesoportal shunt (Rex shunt) proved itself and today is considered the gold standard to treat extrahepatic portal hypertension in children. The restoration of hepatopetal blood flow eliminates gastroesophageal bleeding, splenomegaly, hypersplenism, and many other complications. For the results of mesoportal shunt to be successful, several conditions must be met, one of which is the patency of the umbilical portion of the left portal vein. Despite the importance of preoperative diagnostics of the patency of this area, the most optimal instrumental research method has not yet been found. AIM: This literature review aims to highlight the main issues of extrahepatic portal hypertension etiopathogenesis, surgical treatment methods, and the most effective preoperative diagnostic methods to assess the patency of the left portal vein. RESULTS: The authors analyzed the sources of domestic and foreign literature on the etiology, pathogenesis of HSV in children, and laboratory and instrumental diagnostic methods to assess the patency of the PVI to plan the mesoportal shunting operation. CONCLUSIONS: Extrahepatic portal hypertension is a polyetiological disease with a possible hereditary predisposition to a thrombotic process under the influence of various triggers. The most common causes of portal vein thrombosis are omphalitis and umbilical vein catheterization in the neonatal period. Unfortunately, to date, none of the existing instrumental diagnostic methods can reliably answer the question about left portal vein patency. Due to the small number of works, the lack of a unified view on the problem of preoperative diagnosis of patients with extrahepatic portal hypertension, we could not reliably determine the specificity, sensitivity, and accuracy of each instrumental method. Therefore, we could not identify the gold standard method. Nevertheless, with further improvement of the methods for preoperative assessment of the left portal vein patency, surgeons will be more likely to predict the successful outcome of mesoportal shunting, which will generally affect the surgical treatment quality of extrahepatic portal hypertension in children.

BACKGROUND: Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients develop hydrocephalus (HCP). The rate of cerebrospinal fluid diversion in these patients varies significantly in literature, from 52% to 92%. MMC repair conventionally occurs in the post-natal period. With the technological advances in surgical practice and fetal surgeries, intra uterine MMC repair IUMR is adopted in some centers. Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing. There is also good evidence to suggest that the IQs of patients with MMC who do not undergo shunt placement are higher than that of their shunt treated counterparts. AIM: In this study, we are trying to identify strong clinical and radiological predictors for the need of ventriculoperitoneal (VP) shunt insertion in patients with MMC who underwent surgical repair and closure of the defect initially. This will decrease the overall rate of shunt placement in this group of patients through applying a strict policy adopting only shunt insertion for the desperately needing patient. METHODS: Prospective clinical study conducted on 96 patients with MMC presented to Aboul Reish Pediatric Specialized Hospital, Cairo University. After confirming the diagnosis through clinical and radiological aids, patients are carefully examined, if HCP is evident clinically and radiologically a shunt is inserted together with MMC repair at the same session after excluding sepsis or cerebrospinal fluid (CSF) infection, (GROUP A). If there are no signs of increased ICP, MMC repair shall be done alone (GROUP B). Those patients shall be monitored carefully postoperatively and after discharge and shall be followed up regularly to early detect and promptly manage latent HCP. Multiple clinical and radiological indices were used throughout the follow-up period and statistical significance of each was measured. RESULTS: Shunt placement was required in 45 (46.88%) of the 96 patients. Eighteen patients (18.75%) needed the shunt as soon as they presented to us (GROUP A), because they were having clinically active HCP. Twenty-seven (28.13%) patients were operated on by MMC repair initially without shunt placement because they did not have signs of increased ICP at the time of presentation. Yet, they developed latent HCP requiring shunt placement during the follow-up period (GROUP B2). Fifty-one patients of the study population (53.13%) underwent surgical repair of the MMC without the need of further VP insertion and they were followed up for 6 months period after the repair without developing latent HCP (GROUP B1). Patients of GROUP B were the study population susceptible for the development of latent HCP. Out of 78 patients in GROUP B, only 27 patients (34.62%) needed a VP shunt. CONCLUSION: In our study, we found that the rate of shunt insertion in patients with MMC is lower than the previously reported rate in the literature. A more thorough evaluation of the patient’s post-operative need for a shunt is mandatory. We suggest that we could accept postoperative (after MMC repair) ventriculomegaly provided it does not mean any deterioration in the patient’s clinical or developmental state. We assume that reduction of shunt insertion rate will eventually reduce what has previously been an enormous burden for a significant proportion of children with MMC.

Intraoperative transesophageal echocardiography is a well-established modality for the evaluation of the adequacy of the surgical repair of complex congenital heart lesions. This case report highlights the important role played by real-time transesophageal echocardiography during the evaluation of the patency of a left modified Blalock-Taussig shunt in a child with pulmonary atresia, nonconfluent pulmonary arteries, and borderline hemodynamic/ventilator parameters. Changes observed in the pulmonary venous blood flow pattern provided reassurance to the surgical team about the patency of the shunt and thereby avoided its reconstruction.