In neonates and children the blood vessels are small in calibre and the correct choice of arterial and venous cannulas together with accurate placement are crucial to avoid obstructing vascular branches,and misdirecting flow or impairing venous drainage.Normally in children, to establish the cardiopulmonary bypass (CPB)one arterial cannula is inserted inthe ascending aorta,and single stagevenous cannulae, where two cannulae inserted into the superior and inferior vena cava and joined by the Y-pieceare used in the most open-heartsurgeries to facilitate the circulatory, respiratory support along with the temperature management. Rarely aortic cannulation can lead to aortic dissection, aortic posterior wall rupture leading to trauma to the esophagus, dislodgement of the aortic atheroma, fatal bleeding leading even to cardiac arrest. In addition, SVC and IVC syndrome can also occur due displacement or obstruction by the venous cannulae. However, repeated cardiac arrestsin childrenafter successful weaning from CPB,even with the use of an appropriate size aortic cannula has not been reported in the literature to date. We wish to discuss this fatal complicationafter weaning from CPB, due to aortic flow obstruction due to aortic cannula in a one-year-old, 5.5 kg child following successfulventricular septal defect(VSD) repair. The international review board approval or waiver and clinical trial registrations are not applicable for this case report publication

Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index (CI). It occurs in 9- 44% of cardiac surgery patients after cardiopulmonary bypass (CPB) and is associated with significant morbidity and mortality. The pathogenesis of VPS is multifactorial involving the activation of contact, coagulation, and complement systems and the activation of leukocytes. platelets and endothelial cells resulting in an imbalance in the regulation of the vascular tone; inducible nitric oxide synthase [iNOS] triggered by inflammatory cytokines during CPB produces nitric oxide (NO), which increases vascular levels of cyclic guanosine monophosphate (cGMP), resulting in vasodilation. leading to postcardiac surgery VPS. Standard treatment options for severe refractory VPS are extremely limited and include vasopressor support. latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hypo- responsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine (NE) and early prescription of vasopressin. This review will address the various definitions, risk factors, pathophysiology, potential cardiac candidates, and potential therapeutic interventions for VPS following cardiac surgery focussed on the outcome. This review did not require any ethical approval or consent from the patients.

The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 Kg). The overall safety profile of TEE probe is quite favourable with a reported incidence of complications is about 1-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, non-sustained ventricular and supraventricular tachyarrhythmias or bradyarrhythmias [3rd degree heart block], and even angina and myocardial infarction. We hereby document a repeated and fatal intraoperative VF precipitated by TEE probe in a 2-year-old, 10 kg paediatric patient diagnosed with ostium secundum atrial septal defect (OS-ASD), supravalvular pulmonary stenosis (PS) and severe right ventricular (RV) dysfunction.