ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 515 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed680    
    Printed5    
    Emailed0    
    PDF Downloaded91    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents
LETTER TO EDITOR  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 533-534
Redo cardiac valve surgery and severe kyphoscoliosis: Anesthetic challenges


1 Department of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Click here for correspondence address and email

Date of Web Publication6-Jul-2016
 

How to cite this article:
Saravana Babu M S, Gadhinglajkar S, Sreedhar R, Agarwal N, Gregory DM, Pillai V. Redo cardiac valve surgery and severe kyphoscoliosis: Anesthetic challenges. Ann Card Anaesth 2016;19:533-4

How to cite this URL:
Saravana Babu M S, Gadhinglajkar S, Sreedhar R, Agarwal N, Gregory DM, Pillai V. Redo cardiac valve surgery and severe kyphoscoliosis: Anesthetic challenges. Ann Card Anaesth [serial online] 2016 [cited 2019 Sep 22];19:533-4. Available from: http://www.annals.in/text.asp?2016/19/3/533/185555


The Editor,

A 39-year-old lady, a known case of rheumatic heart disease and postopen mitral valvotomy, presented for double valve replacement (DVR). On examination, she had severe thoracic kyphoscoliosis and difficult airway marked by Grade IV Mallampati score. Features on chest X-ray were a severe kyphoscoliosis, hypoplasia of the left lung with Cobb's angle measuring 75° [Figure 1]. Pulmonary function test revealed severe restrictive pattern. Transthoracic echocardiogram reported severe aortic stenosis, moderate mitral stenosis, mild mitral regurgitation, and left ventricular ejection fraction of 65%.
Figure 1: Chest X-ray showing severe kyphoscoliosis with Cobb's angle of 75° and hypoplasia of the left lung. Cobb's angle is derived by drawing intersecting perpendicular lines from the superior surface of the superior end vertebra and from the inferior surface of the inferior end vertebra. The angle of deviation of these perpendicular lines from the straight line is the Cobb's angle

Click here to view


In operation room, a peripheral venous cannula and an invasive arterial cannula were secured and a standard American Society of Anesthesiologists monitoring was done. Lungs were preoxygenated and standard anesthetic induction was done. A 6.5 mm endotracheal tube was inserted using a gum elastic Bougie under video laryngoscopy guidance. A transesophageal echocardiography (TEE) probe was inserted and comprehensive study was done using an ultrasound system (iE33; Philips Medical Systems). Aortic valve (AV) area was 0.72 cm 2 with a peak velocity of 3.9 m/s and mean gradient (MG) of 56 mmHg. The mitral valve (MV) area was 2.16 cm² with MG of 3 mmHg. Surgeons changed the surgical plan to AV replacement (AVR) as the TEE showed adequate MV size and acceptable MG across MV. Seventeen # St. Jude heart valve prosthesis was implanted in aortic position. Post-cardio pulmonary bypass (CPB) TEE showed a normally functioning prosthesis with a peak velocity of 1.8 m/s, MG of 8 mmHg, and an indexed orifice area of 0.87 cm 2 /m 2 . The patient was weaned from CPB with infusion of dobutamine 5 mcg/kg/min. Trachea was extubated after 12 h of elective ventilation in the Intensive Care Unit. As postextubation blood gases showed retention of CO 2 , she needed noninvasive bilevel positive airway pressure for 24 h. She was discharged on the 8 th postoperative day with warfarin anticoagulation.

Redo cardiac surgeries have a multitude of technical challenges. [1] In our patient, we managed these expected difficulties by placing the arterial and venous lines under ultrasound guidance, attaching defibrillator paddles, inotropes loaded, keeping the CPB pump primed, and ready before induction of anesthesia. Problems with kyphoscoliosis [2] are (1) difficult airway, (2) restrictive pulmonary disease, and (3) decreased cardiac output. Cobb's angle should be used to assess the severity of scoliosis and its clinical manifestations. [3] We got Cobb's angle of 75°, showing she had decreased lung volume and needed surgical intervention (spinal fusion surgery) to correct scoliosis. [3] Since her cardiovascular status was not fit to tolerate the perioperative stress of scoliosis surgery, she presented for heart valve replacement first. Use of noninvasive ventilation after extubation, chest physiotherapy, incentive spirometry, and aggressive pulmonary toilet was needed to reduce the postoperative respiratory morbidity. [4]

Intraoperative TEE influences the surgical decision-making. [5] Pre-CPB TEE examination by our expert consultant changed the surgical plan from DVR to AVR, which reduced the CPB time and the systemic effects of CPB.

In summary, redo cardiac surgeries in kyphoscoliosis patients are rare coincidence. Prior planning to handle the intra- and post-operative challenges will help in the successful outcome of these cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Goodwin AT, Ooi A, Kitcat J, Nashef SA. Outcomes in emergency redo cardiac surgery: Cost, benefit and risk assessment. Interact Cardiovasc Thorac Surg 2003;2:227-30.  Back to cited text no. 1
    
2.
Gambrall MA. Anesthetic implications for surgical correction of scoliosis. AANA J 2007;75:277-85.  Back to cited text no. 2
    
3.
Koumbourlis AC. Review: Scoliosis and the respiratory system. Paediatr Respir Rev 2006;7:152-60.  Back to cited text no. 3
    
4.
Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther 1997;77:260-8.  Back to cited text no. 4
    
5.
Eltzschig HK, Rosenberger P, Löffler M, Fox JA, Aranki SF, Shernan SK. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery. Ann Thorac Surg 2008;85:845-52.  Back to cited text no. 5
    

Top
Correspondence Address:
M S Saravana Babu
Department of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.185555

Rights and Permissions


    Figures

  [Figure 1]



 

Top