Share
array:24 [ "pii" => "S2341192917301543" "issn" => "23411929" "doi" => "10.1016/j.redare.2017.09.004" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "823" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2017;64:594-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S003493561730110X" "issn" => "00349356" "doi" => "10.1016/j.redar.2017.03.017" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "823" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2017;64:594-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 75 "formatos" => array:2 [ "HTML" => 70 "PDF" => 5 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "594" "paginaFinal" => "599" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1160 "Ancho" => 1625 "Tamanyo" => 117517 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Radiografía de tórax preoperatoria.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Fernández-Torres, A. Fernández-López, M. Congregado" "autores" => array:3 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Fernández-Torres" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Fernández-López" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Congregado" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192917301543" "doi" => "10.1016/j.redare.2017.09.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301543?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561730110X?idApp=UINPBA00004N" "url" => "/00349356/0000006400000010/v1_201711141119/S003493561730110X/v1_201711141119/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192917301579" "issn" => "23411929" "doi" => "10.1016/j.redare.2017.09.007" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "830" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2017;64:600-1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "HTML" => 3 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Response to the letter: Anaesthesia management of accidental extubation in the prone position" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "600" "paginaFinal" => "601" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentarios a la carta: Actuación ante un caso de extubación accidental con paciente en posición de decúbito prono" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Benatar-Haserfaty" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Benatar-Haserfaty" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301330" "doi" => "10.1016/j.redar.2017.04.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301330?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301579?idApp=UINPBA00004N" "url" => "/23411929/0000006400000010/v1_201711240853/S2341192917301579/v1_201711240853/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192917301506" "issn" => "23411929" "doi" => "10.1016/j.redare.2017.03.009" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "822" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2017;64:590-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Ceftazidime-induced thrombocytopenia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "590" "paginaFinal" => "593" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombocitopenia inducida por ceftazidima" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1164 "Ancho" => 1600 "Tamanyo" => 99400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evolution over time of the platelet count in relation to the antibiotic treatment administered. Preoperative, immediate postoperative and admission (day 0) levels are shown. Cef: ceftazidime; Lev: levofloxacin; Imm. Postop. Immediate postoperative; Preop: preoperative; PT: piperaziline/tazobactam; TP: Platelet transfusion; Tobram: tobramycin.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Domingo-Chiva, M. Díaz-Rangel, J.Á. Monsalve-Naharro, P. Cuesta-Montero, J.V. Catalá-Ripoll, E.M. García-Martínez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Domingo-Chiva" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Díaz-Rangel" ] 2 => array:2 [ "nombre" => "J.Á." "apellidos" => "Monsalve-Naharro" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Cuesta-Montero" ] 4 => array:2 [ "nombre" => "J.V." "apellidos" => "Catalá-Ripoll" ] 5 => array:2 [ "nombre" => "E.M." "apellidos" => "García-Martínez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301093" "doi" => "10.1016/j.redar.2017.03.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301093?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301506?idApp=UINPBA00004N" "url" => "/23411929/0000006400000010/v1_201711240853/S2341192917301506/v1_201711240853/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "594" "paginaFinal" => "599" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Fernández-Torres, A. Fernández-López, M. Congregado" "autores" => array:3 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Fernández-Torres" "email" => array:1 [ 0 => "barfertor@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Fernández-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Congregado" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitario, Virgen Macarena, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1225 "Ancho" => 1625 "Tamanyo" => 107698 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray immediately prior to the procedure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Scimitar syndrome is a congenital anomaly characterised by an abnormal drainage of the pulmonary veins of the right lung into the inferior vena cava. It is frequently associated with hypoplasia of the lung and right pulmonary artery and dextroposition of the heart. The lower lobe may receive an anomalous systemic arterial supply, usually from the infra-diaphragmatic aorta.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> The syndrome derives its name from the curved right pulmonary vein seen on chest X-ray, which resembles a Turkish sword.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical characteristics will vary, depending on both the age of presentation and the underlying complications, and include heart failure, pulmonary hypertension, and recurrent lung infections.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Patients with the adult form of this syndrome are often asymptomatic, and diagnosis is made in the context of a concomitant disease.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The presence of recurrent pneumonia may call for partial or complete resection of the affected lung, and since 1950, when Drake performed the first right lower lobectomy, pulmonary resection has been periodically described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–8</span></a> This procedure is usually successful, because from both a ventilatory and perfusion point of view this lung has little or no functionality.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, pulmonary resection of the healthy lung is rare, and to the best of our knowledge has never been reported in the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 68-year-old patient diagnosed with a left lung nodule suggestive of neoplasia was referred for pre-anaesthetic evaluation prior to left superior lobectomy. His history included smoking, pulmonary tuberculosis and chronic obstructive pulmonary disease (COPD). He reported that his dextrocardia, which was seen on the pre-operative chest X-ray, had been detected during infancy, but had never been studied (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The electrocardiogram (ECG) showed complete left bundle branch block, and laboratory tests showed no significant alterations. He reported no pulmonary symptoms, and cardiorespiratory auscultation showed marked hypoventilation in the right hemithorax and displaced heart sounds.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the functional respiratory tests performed, the pulmonologists concluded that “in terms of functional respiratory risk, we do not foresee any major problems arising from the proposed intervention”. Spirometry showed forced vital capacity of 83.3% and forced expiratory volume in the first second of 63.7%. He achieved 60<span class="elsevierStyleHsp" style=""></span>W (53%) in the cycle ergometer test, with maximum oxygen consumption (VO<span class="elsevierStyleInf">2</span> max) of 15.7<span class="elsevierStyleHsp" style=""></span>ml/kg/min, moderately affected.</p><p id="par0030" class="elsevierStylePara elsevierViewall">However, the pulmonary perfusion scan showed a hypoplastic right lung with very reduced pulmonary uptake of only 14.93%. Tracer distribution was homogeneous in the left lung, with no segmental or subsegmental perfusion defects.</p><p id="par0035" class="elsevierStylePara elsevierViewall">No endobronchial lesions were observed on fibreoptic bronchoscopy, aside from abnormal distribution of the right bronchial tree. The pulmonologist was unable to reach a definitive diagnosis, and among other possibilities, suggested that “the right upper lobe bronchus is most probably absent, with only the right middle lobe bronchus being present, with 2 segmental bronchi, and the lower right lobe bronchus has fewer basal bronchi”.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest CT showed significant loss of volume in the right lung, with the cardiomediastinal structures shifted towards the right hemithorax, narrowing of the right pulmonary artery, hypoplasia of the right atrium with anomalous venous drainage directly into the right inferior vena cava, together with compensatory hyperinflation of the left lung (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). In addition, systemic vascularisation in the lung base secondary to a wide artery arising from the coeliac trunk was also observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Due to these findings, the patient was referred to the cardiologist after pre-anaesthesia evaluation. The report received was provisional and incomplete, and describes an echocardiogram showing dextrocardia, mild aortic and mitral insufficiency, with a “slightly hypertrophic and hypocontractile left ventricle”. As this report was received late, having been performed in the patient's hospital of origin, we decided to go ahead with the surgical procedure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The PET can showed a 2<span class="elsevierStyleHsp" style=""></span>cm area of pathological tracer uptake in lingular segments of the upper left lobe, suggestive of malignancy, with no sign of other focal lesions compatible with oncological disease. If the tumour was confirmed to be malignant, it would be a T1N0M0 stage growth.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The initial surgical approach was to perform an intraoperative biopsy which, depending on the result, would be followed by thoracoscopic lobectomy. However, during preoperative assessment with the thoracic surgeons we described the difficulty involved in this procedure. We are aware that right one-lung ventilation is futile, as this lung has no functionality, and for this reason insisted that the respiratory function tests performed were of little use in assessing postoperative viability of a left lobectomy. We decided to perform wedge resection, with wide tumour margins, with the patient in apnoea if his clinical situation permitted.</p><p id="par0060" class="elsevierStylePara elsevierViewall">This meant that thoracoscopic resection could only be performed while collapse of the left lung was well tolerated and the surgical conditions were favourable. Failing this, the best alternative, in our opinion, would be wedge resection with the lung ventilated, which would require a thoracotomy. Mindful of this possibility, we placed an epidural catheter at the level of T7–T8 for continuous infusion of 0.1% bupivacaine. Anaesthesia was induced with target-controlled infusion of propofol, rocuronium and alfentanil, we introduced a 39 Fr left-sided tube and cannulated the radial artery and left internal jugular vein. After placing the patient in the right lateral decubitus position, apnoea was induced to introduce trocars. Apnoea was induced twice more to locate the nodule in the lingula, perform the atypical segmental resection with 4 endo GIA reloads, and to extract the specimen. A further 2 episodes of apnoea were induced for mediastinal sampling, removal of a small tear in segment 2, application of Coseal over mechanical sutures and placement of an Argylle drainage tube. During the 90-min intervention (55<span class="elsevierStyleHsp" style=""></span>min of surgical time), apnoea was induced 5 times, all of which were well tolerated, with SpO<span class="elsevierStyleInf">2</span> above 93% at all times. During the intervention, the patient presented mild hypotension, which was treated with ephedrine. After extubation in the operating room, the patient was transferred to the PACU, where he remained for 24<span class="elsevierStyleHsp" style=""></span>h with no clinical or radiological complications (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although the annual incidence of scimitar syndrome is 1–3 in 100,000 births, its real prevalence is unknown, since patients with the adult form often lead an asymptomatic life and are never diagnosed.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,9</span></a> The appearance of symptoms is mainly determined by the left-to-right shunt; this can increase pulmonary pressure, which is aggravated by pulmonary hypoplasia, right pulmonary artery stenosis, and the presence of an infradiaphragmatic aorto-pulmonary artery.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The fact that our patient was asymptomatic, even being a heavy smoker with a history of COPD and pulmonary TB, suggests that he was among the 77% of adult patients with a low left-to-right shunt rate and no pulmonary hypertension.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> This hypothesis is further strengthened by the echocardiography findings, which showed neither hypertrophy or dilation of the right ventricle.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although he had been monitored by his pulmonologist for many years, with clearly pathological radiographic findings, surprisingly enough, his dextrocardia and pulmonary hypoplasia had not previously been studied. Scimitar syndrome was diagnosed during the CT scan performed shortly before being referred to us for pre-anaesthesia evaluation, and indicated for the presence of a pulmonary nodule. The limited scope of the cardiac assessment, which only included evaluation with a portable echocardiograph with only a few estimates and no measurements, is also surprising.</p><p id="par0075" class="elsevierStylePara elsevierViewall">To avoid further delay of the procedure, we decided to continue on the basis of the tests described above, considering the CT scan and scintigraphy findings to be sufficient. The CT showed the anomalous venous drainage and aberrant artery, and scintigraphy showed the futility of the other respiratory function tests.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The chest X-ray did not clearly show the characteristic scimitar shape, but this only appears in 33–70% of cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–9</span></a> When scimitar syndrome is found incidentally, the diagnostic protocol begins with an ultrasound study<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>; in our case, however, this was done <span class="elsevierStyleItalic">a posteriori</span> after observing the anomalous venous drainage on CT. Magnetic resonance imaging is currently the technique of choice for the study of anomalous pulmonary venous connections,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> but we do not believe that this was essential in our patient, moreover, the findings of this study would not have changed our anaesthetic and/or surgical approach. Heart catheterisation would have provided us with detailed anatomical information, but it is rarely performed for diagnostic purposes and is reserved for patients with pulmonary hypertension and to plan the surgical correction.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,9</span></a> Pulmonary ventilation perfusion scintigraphy helps determine the functional reserves of each individual lung,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and was fundamental in our patient.</p><p id="par0085" class="elsevierStylePara elsevierViewall">There is very little information in the literature on the anaesthetic management of scimitar syndrome, and we could not find any studies describing resection of the healthy lung in patients with this syndrome. This made it extremely difficult for us to decide on the best approach, and compelled us to base our strategy on our experience, the pathophysiology of the condition, and the findings of complementary studies.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The initial suggestion to perform a lobectomy was ruled out due to the likelihood of a poor postoperative outcome in terms of both respiratory function and pulmonary circulation. Lobectomy would have involved the removal of a large volume of viable lung parenchyma, and would also have increased pulmonary pressure. This, in turn, would have affected not only the left lobe artery, but also the right pulmonary artery, and would have aggravated the right-to-left shunt. For this reason, atypical segmental resection, though not ideal from the oncological point of view, was considered the best option. We believe that if lobectomy had been the only viable option, we would have had to determine the patient's pulmonary haemodynamic patterns by catheterisation and occlusion of the left superior lobar artery.</p><p id="par0095" class="elsevierStylePara elsevierViewall">We also ruled out both intubation and selective right lung ventilation. Although we would have been able to intubate an anomalous and destructured right bronchus, it would not only have proved difficult to ventilate due to pulmonary hypoplasia, but also futile, because the shunt eliminates its functionality. Blood would only enter the aorta from the left lung, which would not be ventilated.</p><p id="par0100" class="elsevierStylePara elsevierViewall">From an anaesthetic point of view, we considered 4 option. The first was thoracoscopy with intermittent apneas. This was our first choice and the least complex procedure, given the excellent tolerance and recovery of blood oxygen levels; resection was also favoured by a surprisingly rapid lung emptying, which facilitated exposure of the surgical field. The second option was thoracotomy, performing the resection while ventilating the left lung. To prepare for this eventuality, we placed a preoperative epidural catheter and performed selective left-lung intubation. The aim was to prevent the increase in airway pressure resulting from compression of the lung during surgical manipulation from directing air flow towards the functionally non-existent right lung. The third possibility was thoracoscopic resection under selective left lung intubation and placement of a bronchial blocker in the left upper lobe. However, this option was technical extremely difficult, both from an anaesthetic and a surgical point of view. Finally, a more theoretical than practical option, given our limited experience, would be resection under pulmonary bypass.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion, this was an exceptional case not previously described in the literature. However, we believe that the different anaesthetic options described may be useful in other complex situations, such as patients undergoing pneumonectomy that require a new resection in the remaining lung. Determining which of our 4 options (thoracoscopy with intermittent apneas, thoracotomy while ventilating the left lung, bronchial blocker or pulmonary bypass) to choose first will depend on the experience of both the anaesthesiologists and thoracic surgeons. Our procedure of choice will not necessarily coincide with that of other hospitals.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols implemented in their place of work regarding the use of patient data in publications.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of all patients and/or subjects included in this manuscript. The informed consent forms can be obtained from the author for correspondence.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres945442" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec918129" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres945443" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec918128" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-18" "fechaAceptado" => "2017-03-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec918129" "palabras" => array:5 [ 0 => "Scimitar syndrome" 1 => "Anomalous drainage of pulmonary veins" 2 => "Anaesthesia" 3 => "Unipulmonary ventilation" 4 => "Unaffected lung" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec918128" "palabras" => array:5 [ 0 => "Síndrome de la cimitarra" 1 => "Drenaje venoso pulmonar anómalo" 2 => "Anestesia" 3 => "Ventilación unipulmonar" 4 => "Pulmón no afecto" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Scimitar syndrome is a rare congenital anomaly characterised by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El síndrome de la cimitarra es una rara anomalía congénita caracterizada por drenaje anómalo de las venas pulmonares derechas en cava inferior, asociado frecuentemente a hipoplasia del pulmón y arteria pulmonar derecha, dextrocardia y aporte arterial sistémico anómalo al lóbulo inferior. La resección sobre el pulmón sano resulta excepcional, y no conocemos antecedentes publicados.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Un varón con síndrome de la cimitarra es diagnosticado de nódulo pulmonar maligno del pulmón contralateral. Esta situación conlleva una enorme complejidad anestésica, fundamentalmente para la ventilación intraoperatoria. Aunque la espirometría y la prueba de esfuerzo no contraindicaban la lobectomía prevista, la gammagrafía objetivó un pulmón derecho hipoplásico con captación por debajo del 15%.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descartamos la ventilación selectiva del pulmón derecho, ya que el shunt lo hacía funcionalmente inexistente, y planteamos 4 posibilidades anestésicas. Tras la colocación de un catéter epidural e intubación selectiva izquierda, la toracoscopia con apneas intermitentes fue nuestra primera elección.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández-Torres B, Fernández-López A, Congregado M. Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto. Rev Esp Anestesiol Reanim. 2017;64:594–599.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1160 "Ancho" => 1625 "Tamanyo" => 117986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Preoperative chest X-ray.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3768 "Ancho" => 2333 "Tamanyo" => 926347 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abnormal finding on computed tomography. (A) Pulmonary artery with left and right branches (hypoplastic). (B) Left superior pulmonary vein draining into the left atrium. (C) Pulmonary nodule. Left lower pulmonary vein draining into the left atrium. (D, E, F, and G) Anomalous right pulmonary vein. (H) Anomalous right pulmonary vein draining into the inferior vena cava. Aberrant systemic artery in the right lower lobe.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2159 "Ancho" => 2261 "Tamanyo" => 229960 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagram of the abnormalities described in the patient.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1225 "Ancho" => 1625 "Tamanyo" => 107698 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray immediately prior to the procedure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scimitar syndrome. The curved Turkish sabre" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Çiçek" 1 => "A.H. Arslan" 2 => "M. Ugurlucan" 3 => "Y. Yildiz" 4 => "S. Ay" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann" "fecha" => "2014" "volumen" => "17" "paginaInicial" => "56" "paginaFinal" => "61" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breathless at the point of a sword" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Sethi" 1 => "Z.U. Rahman" 2 => "T. Forest" 3 => "T. Paul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/1947-2714.175226" "Revista" => array:6 [ "tituloSerie" => "N Am J Med Sci" "fecha" => "2016" "volumen" => "8" "paginaInicial" => "61" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27011949" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scimitar syndrome: a European Congenital Heart Surgeons Association (ECHSA) multicentric study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.L. Vida" 1 => "M.A. Padalino" 2 => "G. Boccuzzo" 3 => "E. Tarja" 4 => "H. Berggren" 5 => "T. Carrel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.109.926204" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2010" "volumen" => "122" "paginaInicial" => "1159" "paginaFinal" => "1166" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20823387" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumonectomy in scimitar syndrome: anaesthesia management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Shakuntala" 1 => "P. Shruti" 2 => "W. Dhawai" 3 => "T. Bharati" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Anesth Crit Care J" "fecha" => "2016" "volumen" => "4" "paginaInicial" => "43" "paginaFinal" => "47" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implicaciones anestésicas del síndrome de cimitarra para cirugía no cardiaca" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Luna-Durán" 1 => "G. González-Serrano" 2 => "P. Echeverry" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Colomb Anestesiol" "fecha" => "2015" "volumen" => "43" "paginaInicial" => "245" "paginaFinal" => "249" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumonectomy in scimitar syndrome – is it correct?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.B. Karthekeyan" 1 => "V. Yachendra" 2 => "S.M. Kumar" 3 => "S. Rao" 4 => "M. Vakamudi" 5 => "B. Komarakshi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ind J Thorac Cardiovasc Surg" "fecha" => "2008" "volumen" => "24" "paginaInicial" => "176" "paginaFinal" => "179" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extrapleural pneumonectomy for scimitar syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.P. Mason" 1 => "T. Mihaljevic" 2 => "P.J. Mazzone" 3 => "S.C. Murthy" 4 => "T.W. Rice" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2006.05.010" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2006" "volumen" => "132" "paginaInicial" => "704" "paginaFinal" => "705" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16935140" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scimitar syndrome treated with pneumonectomy: a case associated with bronchospastic attack" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Kamiyama" 1 => "S. Kamata" 2 => "N. Usui" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00383-003-1085-3" "Revista" => array:6 [ "tituloSerie" => "Pediatr Surg Int" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "65" "paginaFinal" => "66" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14673615" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 55-year-old man with a small right lung and a right-sided heart" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Albores" 1 => "J. Bando" 2 => "M.I. Smith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.14-1054" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2015" "volumen" => "147" "paginaInicial" => "e95" "paginaFinal" => "e99" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25732479" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resonancia magnética en la valoración de las conexiones venosas pulmonares anómalas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. Bernal" 1 => "C. Méndez" 2 => "R. Soler" 3 => "E. Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rx.2015.07.006" "Revista" => array:6 [ "tituloSerie" => "Radiología" "fecha" => "2016" "volumen" => "58" "paginaInicial" => "111" "paginaFinal" => "119" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26433624" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006400000010/v1_201711240853/S2341192917301543/v1_201711240853/en/main.assets" "Apartado" => array:4 [ "identificador" => "71024" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cases Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006400000010/v1_201711240853/S2341192917301543/v1_201711240853/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301543?idApp=UINPBA00004N" ]
