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   Table of Contents - Current issue
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January-March 2019
Volume 22 | Issue 1
Page Nos. 1-110

Online since Monday, January 14, 2019

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REVIEW ARTICLES  

Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management Highly accessed article p. 1
Neeti Makhija, Rohan Magoon, Ira Balakrishnan, Sambhunath Das, Vishwas Malik, Parag Gharde
DOI:10.4103/aca.ACA_226_17  PMID:30648672
The presence of dynamic left ventricular outflow tract obstruction (LVOTO) can complicate the postoperative course of patients undergoing surgical aortic valve replacement (AVR). The phenomenon of LVOTO is a consequence of an interplay of various pathoanatomic mechanisms. The prevailing cardiovascular milieu dictates the hemodynamic significance of the resultant LVOTO in addition to the anatomical risk factors. A thorough understanding of the predisposing factors, mechanism, and hemodynamic sequel of the obstruction is pivotal in managing these cases. A comprehensive echocardiographic examination aids in risk prediction, diagnosis, severity characterization, and follow-up of management efficacy in the setting of postoperative LVOTO. The armamentarium of management modalities includes conservative (medical) and surgical options. A stepwise approach should be formulated based on the physiological and anatomical substrates predisposing to LVOTO. The index phenomenon occurs more frequently than appreciated and should be considered when the post-AVR patients exhibit hemodynamic instability unresponsive to conventional supportive measures. The present article provides an overview of various peculiarities of this under-recognized phenomenon in the context of the perioperative management of patients undergoing AVR.
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Cardiac output monitoring: Technology and choice Highly accessed article p. 6
Jeff Kobe, Nitasha Mishra, Virendra K Arya, Waiel Al-Moustadi, Wayne Nates, Bhupesh Kumar
DOI:10.4103/aca.ACA_41_18  PMID:30648673
The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.
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ORIGINAL ARTICLES Top

Conversion during off-pump coronary artery bypass graft surgery: A case–control study p. 18
Murali Chakravarthy, Dattatreya Prabhakumar, TA Patil, Antony George, Vivek Jawali
DOI:10.4103/aca.ACA_227_17  PMID:30648674
Objectives: Off pump coronary artery bypass (OPCAB) surgery is carried out as an alternative to conventional coronary artery bypass grafting using cardiopulmonary bypass (CPB). At times 'conversion' to CPB may be required to bail out a situation resulting from acute decompensation of the heart. It is reported that such conversion carries significant mortality risk. Since we conduct coronary revascularization by OPCAB technique as the preferred technique, we conducted this study with an aim to identify the markers of adverse outcome during conversion in Indian patients. Design: Case control retrospective study. Setting: Tertiary referral center. Participants: We conducted three thousand two hundred OPAB surgeries in the period between 2013 to16. Ninety patients (3.1%) required conversion to complete the revascularization (Con version group). Twice the number of patients who underwent OPCAB surgery without conver sion were chosen as controls (Control group). Intervention: OPCAB surgery Results: Mortality in the conversion group was 5.56% in contrast to 0.06% in the controls (P = 0.01). The conversion group had higher left ventricular end diastolic pressure, incidence of endarterectomy, and intra-aortic balloon counter pulsation requirement. Female gender was also predictive of conversion. The total chest drain, duration of ventilation, ICU stay and hospital stay were also higher in the conversion group. Conversion was associated with 9.47 times the odds for mortality. Conclusion: Conversion during OPCAB is associated with significantly increased mortality. Female gender, increased left ventricular end diastolic pressure and preoperative requirement of Intra-aortic balloon are markers of increased risk of mortality when converted.
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Rupture of sinus of valsalva – A 15 years single institutional retrospective review: Preoperative heart failure has an impact on post operative outcome? p. 24
Anitha Diwakar, Sathya Swaroop Patnaik, Channabasavaraj S Hiremath, Kolli S Chalam, Parvatkumar Dash
DOI:10.4103/aca.ACA_243_17  PMID:30648675
Background: We reviewed our experience with ruptured sinus of Valsalva aneurysms (RSOV) to determine a correlation with preexisting heart failure (HF) and coexisting cardiac lesions (aortic regurgitation [AR] and ventricular septal defect [VSD]) to postoperative left ventricular (LV) dysfunction and postoperative outcomes. Materials and Methods: Retrospective review of RSOV cases over 15 years showed that RSOV repair was done in 87 patients. We looked for patients who presented with HF and patients having AR and/or VSDs. Statistical analysis was done to see if the coexisting lesions and preoperative HF were associated with postoperative LV dysfunction. Chi-square test was used on contingency table for statistical analysis. Complications in the postoperative period and prolonged Intensive Care Unit stay were noted. Results: 17% (15/87) presented with HF. Fifty-two patients had moderate to severe AR and 50 patients had VSD. Seventeen patients had postoperative LV dysfunction. The correlation of preoperative HF and coexisting lesions with postoperative LV dysfunction was not statistically significant. Two patients underwent redo surgery for residual RSOV and AR. Two patients had arrhythmias. One patient had cerebrovascular accident. No mortality was seen in the study. Conclusion: Preoperative HF and the presence of VSD and/or AR have no statistical significant correlation with postoperative LV dysfunction. As the outcome of RSOV repair is good, all patients need to undergo early repair to avoid complications.
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Management issues during postinfarction ventricular septal defect and role of perioperative optimization: A case series p. 30
Fayaz Mohammed Khazi, Faozi Al-Safadi, Yehia Karaly, Nayyer R Siddiqui, Bassil Al-Zamkan, Obaid Aljassim
DOI:10.4103/aca.ACA_189_17  PMID:30648676
The development of a myocardial infarction ventricular septal rupture is a rare fatal complication, and the surgical repair is the treatment of choice. In most of the scenarios, the operation will be done as an emergency procedure that carries high mortality. Prognosis of these patients depends on prompt echocardiographic diagnosis and the proactive medical and surgical therapy. More recently, various options have been put forward including the timing for surgery, percutaneous closure devices, and the improved outcome with initial stabilization with medical treatment including mechanical support. In this retrospective case series, we are presenting the management of these patients who presented us in different clinical scenarios and trying to identify the risks for the poor outcome and to formulate a strategy to improve the outcome.
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Comparison of hemodynamic response and postoperative pain score between general anaesthesia with intravenous analgesia versus general anesthesia with caudal analgesia in pediatric patients undergoing open-heart surgery p. 35
Dharma Jivan Samantaray, Meena Trehan, Vivek Chowdhry, Satish Reedy
DOI:10.4103/aca.ACA_215_17  PMID:30648677
Context: Regional anesthesia may attenuate adverse physiological stress responses associated with cardiothoracic surgery. In this study, hemodynamic stress response at the different time of surgical stimuli was compared between patients receiving general anesthesia (GA) along with caudal epidural analgesia with GA with intravenous analgesia in pediatric population undergoing open-heart surgery. Aims: This study aims to compare the hemodynamic response at the different time of surgical stimuli and postoperative pain score, in pediatric patients undergoing open-heart procedures. Settings and Design: We designed a prospective randomized controlled trial to study hemodynamic effects between Group I and Group II. Fifty patients were randomly allocated equally into Group I (GA + caudal epidural) and Group II (GA + intravenous analgesia) by sealed envelope technique. Subjects and Methods: After obtaining approval from Institutional Ethical Committee, this prospective study was conducted in 50 American Society of Anesthesiologist Classes II and III pediatric patients aged between 1 and 12 years posted for cardiac surgery in our institution. Statistical Analysis: ANOVA, two-way ANOVA, and Student's test. Results: The heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure variations were compared between Groups I and II at different time intervals. The variations were found to be significantly higher at the time of skin incision and 2 min after skin incision in Group II as compared to Group I. Pain score was compared between the groups and was found to be significantly lower with Group I (2.5 ± 1.2) as compared to Group II (4.6 ± 1.7), P = (0.004). Conclusions: Caudal analgesia with GA (Group I) was found to have better hemodynamic control and significantly better postoperative pain relief in the first 24 h after awakening.
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Assessment of ventricular function in patients of atrial septal defect by strain imaging before and after correction p. 41
Prashant Kumar, Achyut Sarkar, Sandeep Kumar Kar
DOI:10.4103/aca.ACA_153_17  PMID:30648678
Background: Atrial septal defect (ASD) is a common congenital heart disease associated with volume overload of Right ventricle (RV) with variable effect on Left ventricle (LV). Two-dimensional (2D) Strain analysis is a new tool for objective analysis of myocardial function. This prospective study evaluated the systolic function of right and left ventricle by conventional 2D echo and strain echo and measured changes in cardiac hemodynamics that occurred in patients of ASD before and after correction. Patients and Methods: 2D echo and strain analysis of each patient before and at 48 hrs, 3 months and 6 months after correction was performed. Routine 2D echo parameters and global longitudinal strain of both ventricles were measured. Result: Improvement in LV ejection fraction (P = 0.0001) and myocardial performance index (MPI) (P < 0.0001) occurred at the end of 6 months, whereas decrease in RV MPI (P < 0.0001) and tricuspid annular plane systolic excursion (P < 0.0001) became statistically significant after 3 months of ASD correction. In comparison to conventional 2D echo, global longitudinal strain of RV decreased significantly only after 48 hours of ASD correction while there was no improvement in left ventricular global longitudinal strain after 6 month of correction. Conclusion: There was improvement in RV function with subtle change in LV function by strain imaging and most of these changes were completed within 6 months of ASD correction and nearly correlated with conventional 2DEchocardiography.
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“Vitamin D” as a profile marker for cardiovascular diseases p. 47
Deepak Oberoi, Vinit Mehrotra, Anurag Rawat
DOI:10.4103/aca.ACA_66_18  PMID:30648679
Objective: A growing body of research indicates that there exists a correlation between Vit D deficiency and cardiovascular diseases (CVD). In addition to being genetically determined, it is strongly influenced by lifestyle factors. In this study, Vit D and its interrelated factors have been studied as profile marker for identifying the risk of CVD in patients. Methods: The present study includes comparison of a total 200 adults CVD patients with the healthy patients as control, by measuring their serum lipid levels and Vit D concentrations with other CVD risk factors. Results: The average serum Vit D in CVD patients and controls are found to be 22.55±6.2 ng/ml and 37.62±3.2 ng/ml respectively, showing that 63% of CVD patients and 35% of controls are Vit D deficient. Serum lipids levels were considered as marker for patients having CVD which include high levels of total cholesterol, triglycerides, and low-density lipoprotein-cholesterol while low levels of high-density lipoproteins-cholesterol levels. Other risk factors like hypertension, lifestyle, smoking, dietary factors and nutritional status shows significantly correlation for CVD patients compared to controls. Conclusion: Literature supports the relationship between lipid profile and Vit D level by using this as a profile marker for CVD patients. Our study also suggests the same that vitamin D can be used as profile marker for cardiovascular diseases.
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Practice patterns of left-sided double-lumen tube: Does it match recommendation from literature – A single-centre observational pilot study p. 51
Prachi Kar, Archana Pathy, Ayya Syama Sundar, Ramachandran Gopinath, Srilata Moningi
DOI:10.4103/aca.ACA_11_18  PMID:30648680
Context: Choosing appropriate-size double-lumen tube (DLT) has always been a challenge as it depends on existing guidelines based on gender, height, tracheal diameter (TD), or personal experience. However, there are no Indian data to match these recommendations. Aim: To find out whether the size of DLT used correlates with height, weight, TD, or left main stem bronchus diameter (LMBD). We also documented clinical consequences of any of our current practice. Setting and Design: Single-center observational pilot study. Subjects and Methods: Prospective, observational study of 41 patients requiring one-lung ventilation with left-side DLT. The choice of DLT was entirely on the discretion of anesthesiologist in charge of the case. Data were collected for TD, LMBD, height, weight, age, sex, and amount of air used in the tracheal and bronchial cuff. Any intraoperative complications and difficulty in isolation were also noted. Statistical Analysis: The statistical analysis was done with the National Council of Statistical Software version 11. Results: Average TD and LMBD were 16.5 ± 0.9 and 10.7 ± 0.8 mm for males and 14.2 ± 1.1 and 9.4 ± 1.1 mm for females, respectively. There was a weak correlation between DLT size and height (R2 = 0.0694), TD (R2 = 0.3396), and LMBD (R2 = 0.2382) in the case of males. For females, the correlation between DLT size and height (R2 = 0.2656), TD (R2 = 0.5302), and LMBD (R2 = 0.5003) was slightly better. Conclusion: Although there was a weak correlation between DLT size and height, TD, and LMBD, the overall intraoperative outcome and lung isolation were good.
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A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor p. 56
Deepak Prakash Borde, Shreedhar S Joshi, Murali Chakravarthy, Vishwas Malik, Ranjith B Karthekeyan, Antony George, Thomas Koshy, Uday Gandhe, Suresh G Nair
DOI:10.4103/aca.ACA_67_18  PMID:30648681
Context: Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India. Aims: The aim of this survey is to gather information on variations during the conduct of CPB in India. Settings and Design: This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists. Subjects and Methods: Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices. Results: The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes. Conclusions: There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.
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Descriptive statistics and normality tests for statistical data p. 67
Prabhaker Mishra, Chandra M Pandey, Uttam Singh, Anshul Gupta, Chinmoy Sahu, Amit Keshri
DOI:10.4103/aca.ACA_157_18  PMID:30648682
Descriptive statistics are an important part of biomedical research which is used to describe the basic features of the data in the study. They provide simple summaries about the sample and the measures. Measures of the central tendency and dispersion are used to describe the quantitative data. For the continuous data, test of the normality is an important step for deciding the measures of central tendency and statistical methods for data analysis. When our data follow normal distribution, parametric tests otherwise nonparametric methods are used to compare the groups. There are different methods used to test the normality of data, including numerical and visual methods, and each method has its own advantages and disadvantages. In the present study, we have discussed the summary measures and methods used to test the normality of the data.
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Evaluation of risk scores in predicting perioperative blood transfusions in adult cardiac surgery p. 73
NR Madhu Krishna, PS Nagaraja, Naveen G Singh, SN Nanjappa, Karthik Narendra Kumar, V Prabhakar, N Manjunatha
DOI:10.4103/aca.ACA_18_18  PMID:30648683
Objective: Allogeneic blood product transfusions are associated with an increased morbidity and mortality risk in cardiac surgery. At present, a few transfusion risk scores have been proposed for cardiac surgery patients. The present study is aimed to develop a new score and to compare with preexisting scores – Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) score. Methodology: A total of 1014 adult patients undergoing cardiac surgery were enrolled in the retrospective study. Independent predictors of allogeneic blood transfusions were selected from TRACK and TRUST scores. A predictive score was developed from six variables using logistic regression analysis, and new score was compared to the other existing scores – TRACK and TRUST. Results: The new score had following predictors: age >58 years, weight <63 kg for males and <49 kg for females, gender (female), complex surgery, hemoglobin <13.5 g/dl, and creatinine >1.36 mg/dl. Validation of new score demonstrated an acceptable predictive power (area under the curve [AUC] 0.749) and a good calibration at the Hosmer–Lemeshow test. New score was comparable with TRACK score with P = 0.578 (AUC of TRACK 0.756 and AUC of new score 0.749). There was a significant difference between new score and TRUST score, P = 0.01 (AUC of TRUST 0.72 and AUC of new score 0.749). Conclusion: New score is a simple risk model based on six predictors having a similar accuracy and calibration in predicting the transfusion rate in cardiac surgery as compared to TRACK score.
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CASE REPORTS Top

Bioprosthetic valve thrombosis in carcinoid heart disease p. 79
Kimberly Naden Hollander, Brijen L Joshi
DOI:10.4103/aca.ACA_2_18  PMID:30648684
Tricuspid regurgitation in carcinoid syndrome leads to significant morbidity and mortality that may warrant a tricuspid valve replacement. However, for patients with high serotonin levels and known hypercoagulable risks, the optimum timing for surgery and postoperative anticoagulation approaches remain unclear. High serotonin-triggered hypercoagulability makes prosthetic valves susceptible to thrombosis. Despite appropriate management with a somatostatin analog, some patients continue to have high markers of serotonin that causes platelet aggregation and rapid clot formation. In severely symptomatic patients who require valve surgery, it may not be feasible to postpone surgery until these metabolites are normalized, which may add a substantial risk for postoperative valve thrombosis to an otherwise uneventful procedure. In some, there is a significant need to predict and prevent bioprosthetic valve thrombosis in carcinoid heart disease and to identify best anticoagulation practices across a spectrum of its complex coagulation dynamics and clinical presentation.
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Unrecognized double aortic arch in a preterm infant: Diagnostic challenges and perioperative management p. 83
Balaji Srimurugan, Jessin Jayashankar, Rakhi Balachandran, Sunil S Gopalraj
DOI:10.4103/aca.ACA_3_18  PMID:30648685
Vascular rings are relatively rare, and are frequently overlooked as a potential cause of neonatal respiratory distress in non specialized centres. This might lead to delay in diagnosis during which the child is subjected to repeated respiratory insults. Procrastination in prompt diagnosis and management can lead to significant comorbidities or even death. We highlight the case report of a preterm infant with an unrecognized double aortic arch who presented with severe respiratory morbidity and the subsequent management.
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Off-pump coronary bypass grafting in a post-pneumonectomy patient: Challenges and management p. 86
Anand Kumar, Udgeath Dhir, Vishal Jain, Surendra Yadav, Ankit Purohit
DOI:10.4103/aca.ACA_37_18  PMID:30648686
Pulmonary complications are common in cardiac surgical patients. Limited respiratory reserves along with the pain associated with sternotomy add to the morbidity. Patients undergoing cardiac surgery who have had a pneumonectomy done before can be even more challenging to manage perioperatively due to a single-functioning lung. We present a case of a postpneumonectomy patient who underwent off-pump coronary artery bypass grafting. Perioperative optimization of lung function tests was stressed upon including the chest physiotherapy and early mobilization. Preoperative thoracic epidural catheter was inserted for postoperative pain and other proven benefits of thoracic epidural in coronary artery disease patients. We could conclude from our experience that proper optimization of lung function tests and meticulous pain management along with fast-tracking are keys to the management of such patients.
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The dilemma of the “ischemic-looking” electrocardiogram: Pulmonary embolism or acute coronary syndrome? p. 89
Paurush Ambesh, Aditya Kapoor, Sudeep Kumar, Sunil K Jain
DOI:10.4103/aca.ACA_40_18  PMID:30648687
Pulmonary embolism (PE) may be potentially fatal if not diagnosed and treated in time. Although specific electrocardiogram (ECG) findings often suggest the diagnosis of PE, occasionally, the ECG may mimic that of an acute coronary syndrome (ACS). We report an interesting case of a 45-year-old female presenting with sudden onset chest pain and shortness of breath with widespread ST depression in anterior precordial leads. Although initially treated and referred as a case of ACS, careful analysis of the ECG and subsequent echocardiography and computed tomography imaging confirmed the diagnosis of PE. Intensivists and cardiologists need to be aware that diagnostic dilemma between PE and ACS is not uncommon due to such “ischemic-looking” ECG as well as elevated troponin levels in both conditions. The use of multimodality imaging techniques is helpful in arriving at the correct diagnosis.
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Perioperative management of intramyocardial hydatid cyst with off-pump technique p. 92
Yamini Gupta, Madhuri Priyadarshi
DOI:10.4103/aca.ACA_46_18  PMID:30648688
Cardiac echinococcosis is a rare disease. Depending on the location of hydatid cyst in the heart, clinical presentation can be an asymptomatic case or lethal stroke, arrhythmias, valvular dysfunction, cardiac tamponade, cardiac failure, shock, and even death. Treatment of choice for cardiac hydatid cysts is surgical excision, even in an asymptomatic patient. We present a case report of an asymptomatic case of off-pump removal of intramyocardial hydatid cyst. A 21-year-old male presented asymptomatically and was diagnosed with a hydatid cyst incidentally during a regular checkup. Echocardiography and cardiac computed tomography angiography images demonstrated an intramyocardial hydatid cyst on the lateral aspect of the left ventricle with slight extension over the anterior and posterior regions. Important aspects of diagnosis and management specific to cardiac hydatid cyst along with the review of literature have been discussed.
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INTERESTING IMAGES Top

Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery p. 96
Fotini Ampatzidou, Charilaos-Panagiotis Koutsogiannidis, Aggelos Megalopoulos, George Trelopoulos, George Drossos
DOI:10.4103/aca.ACA_60_18  PMID:30648689
Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.
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Massive subcutaneous emphysema after off-pump coronary bypass surgery p. 97
Monish S Raut, Sumir Dubey, Ganesh Shivnani, Arun Maheshwari, Sibashankar Kar
DOI:10.4103/aca.ACA_135_18  PMID:30648690
Subcutaneous emphysema is a condition when air gets accumulated into the tissues under the skin and in the soft tissues of the chest wall or neck but can also spread to other parts of the body. It generally causes minimal symptoms and nonlethal; sometimes, it may be severe and life-threatening if deeper tissues of the thoracic outlet and chest are involved. It is essential to know the mechanisms of subcutaneous emphysema after cardiac surgery.
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Quadricuspid aortic valve associated with aortic insufficiency contributors p. 99
Nicholas Paul Suraci, Bryan Kerner, Salomon Poliwoda, Orlando Santana, Gerald Rosen
DOI:10.4103/aca.ACA_151_18  PMID:30648691
A 51-year-old male presented with a wound in his right hand that was suspicious for possible septic emboli of cardiac origin. With transesophageal echocardiography, the patient was found to have a rare quadricuspid aortic valve. This quadricuspid valve can present with variable symptoms and physical exam findings. Due to embryological defects, this pathology is associated with several other anatomical defects that are important to recognize prior to surgical intervention. Transesophaegeal echocardiography remains the gold standard in detection of quadricuspid aortic valve and identification of other possible cardiac lesions.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD Top

ANSiscope™: Can it be the crystal ball of cardiac anesthesia? p. 101
Rohini Mayur Balaji, PS Nagaraja, Naveen G Singh, V Prabhakar, N Manjunatha
DOI:10.4103/aca.ACA_9_18  PMID:30648692
Background: Autonomic dysfunction (AD) is infrequently evaluated preoperatively despite having profound perioperative implications. The ANSiscope™ is a monitoring device that quantifies AD. This study aims to determine the potential of the device to predict hypotension following anesthetic induction, occurrence of arrhythmias, and inotrope requirement for patients undergoing off-pump coronary artery bypass surgery (OPCAB). Study Design: Prospective observational double-blinded study. Materials and Methodology: Seventy-five patients undergoing OPCAB had their autonomic function assessed by ANSiscope™. They were classified into four groups based on their AD and compared to perioperative adverse events. Results: Patients with diabetes had a higher ANSindex (P = 0.0263). They had a greater decrease in systolic blood pressure (P = 0.001) and mean arterial pressure (P = 0.004) postinduction, had an increased incidence of arrhythmias (P = 0.009), required higher inotropic support immediately (P = 0.010) and at 24 h after surgery (P = 0.018), and longer duration of postoperative ventilation (P < 0.001). They also had a higher incidence of emergency conversion of OPCAB to on-pump surgery (P = 0.009). Conclusions: An increased association between AD as quantified by the ANSiscope™ and perioperative adverse outcomes was observed. An increased rate of emergency conversion of OPCAB to on-pump surgery with higher dysfunction was noted. The authors opine that the threshold for conversion must be lower in patients deemed to be at a higher risk. Proper evaluation of the autonomic nervous system empowers the anesthesiologist to anticipate and adequately prepare for complications.
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LETTERS TO EDITOR Top

Clinical usage of high-flow oxygenation in postcardiac surgery patients p. 107
Ali Jabbari, Ebrahim Alijanpour, Shabnam Tabasi
DOI:10.4103/aca.ACA_7_18  PMID:30648693
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Watchful waiting in an unusual cause of hypoxemia after implantable cardioverter-defibrillator lead extraction p. 109
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DOI:10.4103/aca.ACA_95_18  PMID:30648694
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