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The removal of the laryngeal mask airway (LMA®) in children may be associated with respiratory adverse events. The rate of occurrence of these adverse events may be influenced by the type of anesthesia. Studies comparing total intravenous anesthesia (TIVA) with propofol and sevoflurane are limited with conflicting data whether propofol is associated with a lower incidence of respiratory events upon removal of LMA as compared to induction and maintenance with sevoflurane. We hypothesized that TIVA with propofol is superior to sevoflurane in providing optimal conditions and improved patient's safety during emergence.In this prospective, randomized, double-blind clinical trial, children aged 6 months to 7 years old were enrolled in 1 of 2 groups: the TIVA group and the sevoflurane group. In both groups, patients were mechanically ventilated. At the end of the procedure, LMAs were removed when patients were physiologically and neurologically recovered to a degree to permit a safe, natural airway. The primary aim of this study was to compare the occurrence of at least 1 respiratory adverse event, the prevalence of individual respiratory adverse events, and the airway hyperreactivity score following emergence from anesthesia between the 2 groups. Secondary outcomes included ease of LMA insertion, quality of anesthesia during the maintenance phase, hemodynamic stability, time to LMA removal, and incidence of emergence agitation.Children receiving TIVA with propofol had a significantly lower incidence (10.8.% vs 36.2%; relative risk, 0.29; 95% CI [0.14-0.64]; P = .001) and lower severity ( P = .01) of respiratory adverse outcomes compared to the patients receiving inhalational anesthesia with sevoflurane. There were no statistically significant differences in secondary outcomes between the 2 groups, except for emergence agitation that occurred more frequently in patients receiving sevoflurane ( P.001).Propofol induction and maintenance exerted a protective effect on healthy children with minimal risk factors for developing perioperative respiratory complications, as compared to sevoflurane.

The use of left ventricular assist device (LVAD) in patients with mechanical aortic valves may result in thromboembolic events due to blood stasis around the valve and intermittent valve opening. Mechanical aortic valves encountered during LVAD implantation are managed by replacement with a tissue valve, or closure of the valve with a patch. Closure of the valve carries the risk of sudden death in cases of LVAD stoppage. Replacing the whole mechanical valve conduit is time consuming and carries a significant risk of bleeding and right ventricular (RV) failure. We describe an alternative technique of replacing a mechanical aortic valve by breaking its inner leaflets and sewing a tissue valve on top of the mechanical valve ring.

Limited studies examined the effects of pneumoperitoneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees, proving how the combination of steep Trendelenburg, lower pressure pneumoperitoneum and the extreme surgeon's experience allows to safely perform RARP using a low-impact surgery. Background: Limited studies examined effects of pneumoperiotneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of a lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees (ST). Materials and Methods: This is an institutional review board-approved, prospective, interventional, single-center study including patients treated with RARP at OLV Hospital by one extremely experienced surgeon (July 2015-February 2016). Intraoperative monitoring included: arterial pressure, central venous pressure, cardiac output, heart rate, stroke volume, systemic vascular resistance, intrathoracic pressure, airways pressures, left ventricular end-diastolic and end-systolic areas/volumes and ejection fraction, by transesophageal echocardiography, an esophageal catheter, and FloTrac/Vigileo system. Measurements were performed after induction of anesthesia with patient in horizontal (T0), 5 minutes after 8 mmHg pneumoperitoneum (TP), 5 minutes after ST (TT1) and every 30 minutes thereafter until the end of surgery (TH). Parameters modification at the prespecified times was assessed by Wilcoxon and Friedman tests, as appropriate. All analyses were performed by SPSS v. 23.0. Results: A total of 53 consecutive patients were enrolled. The mean patients age was 62.6 +/- 6.9 years. Comorbidity was relatively limited (51% with Charlson Comorbidity Index as low as 0). Despite the ST, working always at 8 mmHg with AirSeal, only central venous pressure and mean airways pressure showed a statistically significant variation during the operative time. Although other significant hemodynamic/respiratory changes were observed adding pneumoperitoneum and then ST, all variables remained always within limits safely manageable by anesthesiologists. Conclusion: The combination of ST, lower pressure pneumoperitoneum and extreme surgeon's experience enables to safely perform RARP. (C) 2017 Elsevier Inc. All rights reserved.

e u d ABNORMALITIES OF THE aortic valve morphology and function represent the most common cardiac valve lesion, ith relevant implications for medical and surgical treatent. Aortic valve sclerosis affects about one fourth of dults over 65 years of age, whereas severe aortic stenosis AS) is present in 2% to 9% of the same population.1 AS is suspected to be the result of chronic inflammation secondary to risk factors similar to the ones associated with atherosclerosis.2,3 The number of aortic valve procedures performed over the last 10 years increased if aortic valve replacement is considered alone or combined with myocardial revascularization; mitral valve surgery seemed to be constant in the same period.4 In 1968, Ross and Braunwald,5 in their classic review of the natural history of AS, re-emphasized that sudden death occurred predominantly in symptomatic patients. In asymptomatic patients with acquired severe AS, the risk of sudden death was reported to be between 3% and 5%. It was proposed that patients with acquired severe AS have surgery deferred until the onset of symptoms because the mortality increases steeply afterward (Fig 1).6,7 Surgical replacement of the aortic valve (SAVR) reduces symptoms and improves survival in patients with severe AS.8-10 Its current indications are outlined in Table 1. In the absence of serious comorbidities, the procedure is associated with low operative mortality.11,12 However, in clinical practice, at least 0% of patients with severe symptomatic AS do not undergo urgery for replacement of the aortic valve because of advanced ge, left ventricular (LV) dysfunction, or the presence of muliple coexisting medical conditions.13-16 For these patients who re at high surgical risk, a less invasive treatment may be a orthwhile alternative.17,18 Cribier et al19 reported the first successful implantation of a percutaneous aortic valve in animals in 2000. The first human implantation using the antegrade trans-septal approach followed 2 years later. The first retrograde transfemoral approach was performed in 200320 (Fig 2). At present, most of the available data for transcatheter aortic valve implantation (TAVI) are derived from studies on 2 specific devices: the Sapien valve (Edwards Life Sciences, Inc, Irvine, CA; Fig 3) and the CoreValve (Medtronic, Inc, Minneapolis, MN; Fig 4). The Sapien valve is a trileaflet bovine pericardial valve mounted with a tubular slotted balloonexpandable stent composed of a cobalt chromium alloy. It is available in 23and 26-mm sizes in the United States and 23-, 26-, and 29-mm sizes in Europe. The 23-mm valve is preferred for annular diameters of 18 to 21 mm and the