A 3-month-old male infant with Type-IV pulmonary atresia with ventricular septal defect, complete atrioventricular canal, and Jeune syndrome (asphyxiating thoracic dystrophy) remained ventilator-dependent following Blalock-Taussig shunt and thoracic expansion surgery. Cardiac CT angiography demonstrated left pulmonary artery (LPA) origin stenosis with bilateral pulmonary inflammatory infiltrates (Figure 1A). Bronchoscopy confirmed severe type III laryngomalacia. Given the patient's critical condition and persistent ventilator dependence, bedside electrical impedance tomography (EIT) was conducted. In brief, a rapid bolus of 3 mL of 5% hypertonic saline was injected via the patient's existing central venous catheter within 2 s. The resulting transient decrease in thoracic electrical impedance, proportional to regional blood volume increase, was tracked by the EIT system to generate the perfusion image 1. Well-preserved bilateral ventilation-perfusion matching without significant regional shunt or deadspace were demonstrated (Figure 1B,C). It provided functional validation that pulmonary perfusion was not the limiting factor in weaning failure, despite anatomical LPA stenosis. The planned diagnostic pulmonary angiography was cancelled, avoiding associated anesthesia and vascular intervention risks. Subsequent therapeutic reorientation included cardiac function improvement (ventricular-volume-load reduction and myocardial function optimization), airway management (bronchoscopic holmium laser supraglottoplasty to improve upper airway patency), ventilatory support optimization with EIT. The patient successfully weaned from mechanical ventilation and discharged. This is the youngest reported case using saline-bolus perfusion to assist with clinical decision making (The case is approved by the ethic committee of Shandong Provincial Maternal and Child Health Care Hospital 2025-020) and followed the Declaration of Helsinki. Informed consent was obtained from the parents. The management of difficult weaning in postoperative complex congenital heart disease (CHD) presents significant clinical challenges, often involving complex cardiopulmonary interactions. EIT is a widely used bedside imaging modality to detect regional ventilation-perfusion distribution in adult patients. Studies using EIT for ventilation monitoring are published for pediatric subjects 2, 3. However, regional perfusion is rarely reported in infants. In our clinical center, it has been routinely used to assess the ventilation-perfusion matching in various pediatric patients. In patients with Jeune syndrome where restrictive mechanics and potential pulmonary vascular disease coexist, EIT's dual assessment can help differentiate the primary pathophysiology by revealing whether ventilation or perfusion is disproportionately impaired. Such information often helps in clarifying the underlying pathophysiology and guiding therapeutic decisions, whereas conventional imaging findings may not correlate with functional impairment. Continuous monitoring of heart rate, blood pressure, and oxygen saturation was maintained throughout the EIT procedure. No transient hemodynamic instability, alteration in oxygen saturation, or any other adverse event was observed during or immediately after the saline injection. The bedside, real-time ventilation-perfusion assessment provided by EIT is safe and effective technique in infants, enabled risk stratification by avoiding unnecessary invasive diagnostics. Chao Wang: conceptualization, data curation, writing – original draft. Zhiyu Feng: investigation, writing – review and editing. Shaochao Wang: investigation, writing – review and editing. Xinxin Feng: investigation, writing – review and editing. Zhanqi Zhao: conceptualization, writing – original draft, formal analysis, visualization. This work was partially supported by the Guangdong Basic and Applied Basic Research Foundation (Provincial-Enterprise Joint Fund for General Projects) Grant number 2024A1515220044. The authors declare no conflicts of interest. The images have not been previously published. The data that support the findings of this study are available from the corresponding author upon reasonable request. Data presented in the report are available upon reasonable request.
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