Summary We present a case series of intra‐operative adverse events while using a specific type of bronchial blocker, designed to facilitate device positioning and minimise the risk of dislocation. The Rüsch® EZ‐blocker™ (Teleflex Life Sciences Ltd., Athlone, Ireland) is a Y‐shaped catheter equipped with two separately inflatable cuffs at the tip – one for each bronchial lumen. In this report, we describe four cases where the use of the EZ‐blocker was associated with the development of high airway pressures, hypoxaemia and expansion of the non‐dependent lung. Bronchoscopic evaluation showed spontaneous inflation of the cuff within the dependent (i.e. ventilated) bronchus, causing bronchial obstruction, and volume loss of the cuff within the non‐dependent (i.e. unventilated) bronchus, causing unintended expansion of the non‐dependent lung. After removal of the bronchial blocker, the catheter showed no visible defect, but a bench test revealed a functional connection inside the catheter which allowed air to pass slowly from one bronchial cuff to the other. This technical defect relates to the unique design of the EZ‐blocker as it is the only bronchial blocker equipped with two bronchial cuffs. Clinicians should be aware of this inherent risk since complications may develop insidiously and affect both lungs simultaneously. Early recognition and prompt intervention can prevent life‐threatening intra‐operative deterioration.

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BACKGROUND: Viscoelastic tests (VETs) are recommended during cardiac surgery to monitor coagulation status and guide transfusion. We compared the results of two VETs, the Sonoclot Analyzer and the ROTEM Sigma. Agreement between viscoelastic tests' subdiagnoses and overall diagnosis severity was assessed. Correlations with conventional coagulation tests (CCT) and the discriminatory potential of numerical VET outputs for transfusion thresholds was determined. METHODS: Single-centre, prospective observational study in a tertiary academic centre.In fifty adult patients undergoing elective cardiac surgery, parallel Sonoclot, ROTEM and CCT analysis was performed before heparin, or after protamine or coagulation product administration. All patients completed the study, resulting in 139 data points. RESULTS:Agreement on the severity of coagulation disorders was acceptable (83%), but poor (27%) on the differentiation of the underlying causes. Correlations between ROTEM parameters and CCT were good (post-protamine: FIBTEM A5 (r 2 = 0.90 vs fibrinogen) and EXTEM-FIBTEM A5 difference (r 2 = 0.81 vs platelet count) ). Sonoclot correlated less (Clot Rate (r 2 = 0.25 vs fibrinogen) and Platelet Function (r 2 = 0.43 vs platelet count)). This was reflected in the discriminatory potential of these parameters as found by linear mixed modelling. We suggest clinically useful grey zones for VET cutoff interpretation.CONCLUSIONS: ROTEM and Sonoclot accord well on the detection of severity of coagulation dysfunction, but not on the diagnosis of the underlying cause. ROTEM correlated more closely with CCT then Sonoclot. We propose a testing strategy that could lead to a cost-effective approach to the bleeding cardiac surgery patient.

Unfractionated heparin is used in multiple clinical settings. Its overdosing and underdosing and residual effect after suboptimal reversal must be adequately recognised. This mandates precise monitoring of low-range activity. Although applicable bedside and widely used, monitoring with activated clotting times (ACT) is imprecise. 1 Anti-Xa activity assays are recognised as laboratory standard but are not point-of-care tests (POCT). 2 Viscoelastic tests (VET) provide a broad bedside view of coagulation. 3 ROTEM offers a HEPTEM/INTEM clotting time (CT) ratio, and Sonoclot, another VET, proposes glass bead ACT (gbACT) for heparin detection. 4,5 In a previous observational study, we identified a novel potential Sonoclot parameter: the slope-45. 6 We compared the performance of these tests in identifying isolated lowrange heparin.

Our findings show that repeat ablation procedures following a second-generation cryoballoon ablation for persistent atrial fibrillation result in 75 % of freedom from any atrial tachycardia at 12 months follow-up. Of the recurrences, 63 % were due to new onset of atrial fibrillation and 37 % to organized tachycardias.