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   Table of Contents - Current issue
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April-June 2017
Volume 20 | Issue 2
Page Nos. 125-283

Online since Thursday, April 6, 2017

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EDITORIALS  

Online virtual world of resources and the cardiac anaesthesiologist p. 125
Poonam Malhotra Kapoor
DOI:10.4103/0971-9784.203965  PMID:28393767
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Anger: An enemy of heart, raj yoga meditation is heart friendly p. 127
Usha Kiran, Suruchi Ladha
DOI:10.4103/aca.ACA_29_17  PMID:28393768
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ORIGINAL ARTICLES Top

Artificial intelligence in mitral valve analysis p. 129
Jelliffe Jeganathan, Ziyad Knio, Yannis Amador, Ting Hai, Arash Khamooshian, Robina Matyal, Kamal R Khabbaz, Feroze Mahmood
DOI:10.4103/aca.ACA_243_16  PMID:28393769
Background: Echocardiographic analysis of mitral valve (MV) has become essential for diagnosis and management of patients with MV disease. Currently, the various software used for MV analysis require manual input and are prone to interobserver variability in the measurements. Aim: The aim of this study is to determine the interobserver variability in an automated software that uses artificial intelligence for MV analysis. Settings and Design: Retrospective analysis of intraoperative three-dimensional transesophageal echocardiography data acquired from four patients with normal MV undergoing coronary artery bypass graft surgery in a tertiary hospital. Materials and Methods: Echocardiographic data were analyzed using the eSie Valve Software (Siemens Healthcare, Mountain View, CA, USA). Three examiners analyzed three end-systolic (ES) frames from each of the four patients. A total of 36 ES frames were analyzed and included in the study. Statistical Analysis: A multiple mixed-effects ANOVA model was constructed to determine if the examiner, the patient, and the loop had a significant effect on the average value of each parameter. A Bonferroni correction was used to correct for multiple comparisons, and P = 0.0083 was considered to be significant. Results: Examiners did not have an effect on any of the six parameters tested. Patient and loop had an effect on the average parameter value for each of the six parameters as expected (P < 0.0083 for both). Conclusion: We were able to conclude that using automated analysis, it is possible to obtain results with good reproducibility, which only requires minimal user intervention.
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Forbidden word entropy of cerebral oximetric values predicts postoperative neurocognitive decline in patients undergoing aortic arch surgery under deep hypothermic circulatory arrest p. 135
Anna Dubovoy, Peter Chang, Carol Persad, Wei Lau, Elizabeth Jewell, Daniel Cox, Milo Engoren
DOI:10.4103/aca.ACA_27_17  PMID:28393770
Purpose: Up to 53% of cardiac surgery patients experience postoperative neurocognitive decline. Cerebral oximetry is designed to detect changes in cerebral tissue saturation and therefore may be useful to predict which patients are at risk of developing neurocognitive decline. Methods: This is a retrospective analysis of a prospective study originally designed to determine if treatment of cerebral oximetry desaturation is associated with improvement in postoperative cognitive dysfunction in patients undergoing aortic reconstruction under deep hypothermic circulatory arrest. Cognitive function was measured, preoperatively and 3 months postoperatively, with 15 neuropsychologic tests administered by a psychologist; the individual test scores were summed and normalized. Bilateral cerebral oximetry data were stored and analyzed using measures of entropy. Cognitive decline was defined as any decrease in the summed normalized score from baseline to 3 months. Results: Seven of 17 (41%) patients suffered cognitive decline. There was no association between baseline cerebral oximetry and postoperative cognitive dysfunction. Nor were changes in oximetry values associated with cognitive decline. However, cognitive decline was associated with loss of forbidden word entropy (FwEn) (correlation: Rho ρ = 0.51, P = 0.037 for left cerebral oximetry FwEn and ρ = 0.54, P = 0.025 for right cerebral oximetry FwEn). Conclusion: Postoperative cognitive decline was associated with loss of complexity of the time series as shown by a decrease in FwEn from beginning to end of the case. This suggests that regulation of cerebral oximetry is different between those who do and those who do not develop cognitive decline.
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An analysis of the factors producing multiple ventricular arrhythmias during pulmonary artery catheterization p. 141
Hajime Satoh, Yuka Miyata, Tomohiko Hayasaka, Tsutomu Wada, Yukio Hayashi
DOI:10.4103/aca.ACA_18_17  PMID:28393771
Background: The development of arrhythmias during placement of a pulmonary artery catheter (PAC) is common. Aims: This study was designed to examine factors influencing development of ventricular arrhythmias in adult patients undergoing cardiovascular operations during the catheter placement. Settings and Designs: Prospective, observational, cohort study. Methods: We prospectively studied 174 patients undergoing cardiovascular operations. A PAC was inserted through the right internal jugular vein by staff anesthesiologists. Electrocardiography tracings were recorded as the catheter was advanced from the right atrium to the pulmonary artery. Arrhythmias were classified as absent, single, or multiple (two or more consecutive) ventricular arrhythmias. We examined risk factors to produce ventricular arrhythmias during the placement. Statistical Analysis: The data were analyzed using logistic regression analysis to assess factors for the occurrence of ventricular arrhythmias after univariate analyses. Results: Ventricular arrhythmias (single and multiple) occurred in 149 patients (85.6%) and multiple arrhythmias were observed in 78 patients (44.8%). There were no factors to facilitate the ventricular arrhythmias (single and multiple), whereas it showed that valvular diseases (P = 0.049) and the placement time (P < 0.001) are significant factors to produce multiple arrhythmias. Conclusion: Both valvular diseases and long placement time were significant risk factors to produce multiple ventricular arrhythmias during placement of a PAC.
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Carotid artery disease and periprocedural stroke risk after transcatheter aortic valve implantation p. 145
Parthasarathy D Thirumala, Sruthi Muluk, Reshmi Udesh, Amol Mehta, John Schindler, Suresh Mulukutla, Vinodh Jeevanantham, Lawrence Wechsler, Thomas Gleason
DOI:10.4103/aca.ACA_13_17  PMID:28393772
Objective/Background: To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke, following transcatheter aortic valve implantation (TAVI). Materials and Methods: Using data from the National Inpatient Sample database for analysis, patients who underwent TAVI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Various preoperative and perioperative risk factors and their association with perioperative strokes were studied. Results: Data on 7566 patients who underwent a TAVI procedure from 2012 to 2013 were extracted. The average age of the patient population was 81.2 ± 0.32 years. The overall perioperative stroke rate in our patient cohort was 2.79%. Majority (94.6%) of the strokes were ischemic. Multivariate analysis showed the following independent risk factors for perioperative strokes after TAVI: female gender odds ratio (OR) = 2.25 (95% confidence interval [CI], 1.42–3.57), higher van Walraven score OR = 6.6 (95% CI = 3.71–11.73), bilateral CS OR = 4.46 (95% CI = 2.03–9.82), and TAVI with a cardiac procedure done under cardiopulmonary bypass OR = 2.84 (95% CI = 1.57–5.14). Conclusion: Bilateral carotid disease is a significant risk factor for perioperative strokes following TAVI. Preoperative screening with carotid Doppler to identify high-risk patients appears to be warranted. In addition, patients of female gender were found to have an increased risk for carotid disease.
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Impact of dexmedetomidine on hemodynamic changes during and after coronary artery bypass grafting p. 152
Morteza Hashemian, Mehdi Ahmadinejad, Seyed Amir Mohajerani, Alireza Mirkheshti
DOI:10.4103/aca.ACA_76_16  PMID:28393773
Objective: To determine the effect of dexmedetomidine (Dex) on hemodynamic changes during cardiopulmonary pump and postoperative period in coronary artery bypass grafting (CABG). Methods and Design: This study is designed as a double-blinded, randomized clinical trial. Setting: University hospital and single center. Participants: patients candidate for elective CABG. Intervention: Dex 0.5 μg/kg/h or placebo was infused from the initiation of anesthesia up to extubation in Intensive Care Unit (ICU). Measurements: Heart rate (HR) and blood pressure (BP), pain score, and total morphine dose requirement were monitored and compared during cardiac pump up to 12 h postoperative in ICU. Results: Mean arterial pressure was significantly higher in Dex group in postoperation period at 1 (P = 0.010) and 2 h (P = 0.002) compared to control group. HR was significantly lower in Dex group in postcardiopulmonary bypass (CPB) time at 0 h (P = 0.001), 1 h (P = 0.0016), and 2 h (P = 0.001), and then in postoperative period in ICU at 1 h (P = 0.025), 2 h (P = 0.0012), and 4 h (P = 0.0025) compared to control group. Postoperative pain score was significantly lower during 12 h after surgery. Conclusion: Dex could effectively blunt hemodynamic response to surgical stress, particularly during CPB pump and afterward. Infusion of Dex maintains BP at higher range and HR at lower range compared to placebo.
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The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: A prospective randomized control study p. 158
Usha Kiran, Suruchi Ladha, Neeti Makhija, Poonam Malhotra Kapoor, Minati Choudhury, Sambhunath Das, Parag Gharde, Vishwas Malik, Balram Airan
DOI:10.4103/aca.ACA_32_17  PMID:28393774
Introduction: Rajyoga meditation is a form of mind body intervention that is promoted by the Brahma Kumaris World Spiritual University. This form of meditation can be easily performed without rituals or mantras and can be practiced anywhere at any time. The practice of Rajyoga meditation can have beneficial effects on modulating anxiety and cortisol level in patients undergoing major cardiac surgery. Materials and Methods: A prospective randomized control study was carried out in a single tertiary care center. One hundred and fifty patients undergoing elective coronary artery bypass surgery were enrolled in the study. The patients were randomized in two groups namely, Group 1 (Rajyoga group) and Group 2 (Control Group). Anxiety was measured on a visual analog scale 1–10 before the start of Rajyoga training or patient counseling (T1), on the morning of the day of surgery (T2), on the 2nd postoperative day (T3), and on the 5th postoperative day (T4). The serum cortisol level was measured in the morning of the day of surgery (T1), on the 2nd postoperative day (T2) and on the 5th postoperative day (T3), respectively. Results: In the study, it was seen that the anxiety level of the patients before the surgery (T1) and on the day of surgery (T2) were comparable between the two groups. However on the 2nd postoperative day (T3), the patients who underwent Rajyoga training had lower anxiety level in comparison to the control group (3.12 ± 1.45 vs. 6.12 ± 0.14, P < 0.05) and on the 5th postoperative day (T4) it was seen that Rajyoga practice had resulted in significant decline in anxiety level (0.69 ± 1.1 vs. 5.6 ± 1.38, P < 0.05). The serum cortisol level was also favorably modulated by the practice of Rajyoga meditation. Conclusion: Mindbody intervention is found to effective in reducing the anxiety of the patients and modulating the cortisol level in patients undergoing wellknown stressful surgery like coronary artery bypass surgery.
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Conscious sedation for balloon mitral valvotomy: A comparison of fentanyl versus sufentanil p. 163
Shailendra Deochandra Modak, Deepa G Kane
DOI:10.4103/0971-9784.203930  PMID:28393775
Context: Analgesia and sedation are required for the comfort of patient and the cardiologist during balloon mitral valvotomy. Aims: In this study, efficacy of analgesia, sedation, and patient satisfaction with sufentanil was compared with fentanyl. Settings and Design: Single-centered, prospective single-blind study of sixty patients. Materials and Methods: Patients between 15 and 45 years of rheumatic mitral stenosis with valve area of 0.8–1 cm2 undergoing elective balloon mitral valvotomy, randomly divided to receive bolus injection fentanyl 1 mcg/kg (Group 1, n = 30) followed by infusion at 1 mcg/kg/h or bolus of injection sufentanil 0.1 mcg/kg (Group 2, n = 30) followed by continuous infusion at 0.1 mcg/h. Both the groups received injection midazolam bolus 0.02 mg/kg followed by infusion at 15 mcg/kg/h. Pain intensity (by visual analog score [VAS]), level of sedation (by Ramsay sedation scale), overall patient and operator's satisfaction, effect on cardiorespiratory parameters, and discharge score (by modified Aldrete score) were assessed. Statistical Analysis Used: Statistical analysis used Student's unpaired t-test and Chi-square test. P < 0.05 was considered statistically significant. Results: Mean number of bolus doses in fentanyl group was 0.9 versus 0.13 in sufentanil group (P < 0.01). The mean value of mean blood pressure in fentanyl group was 83.52 mmHg versus 88 mmHg in sufentanil group (P < 0.05), but the value was within normal range in both the groups. The mean VAS – patient's opinion in fentanyl group was 8.97 versus 9.53 in sufentanil group (P < 0.05). Mean discharge score in fentanyl group was 17.87 versus 18.23 in sufentanil group (P < 0.05). No statistically significant difference was found with respect to heart rate, respiratory rate, oxygen saturation, PaCO2values, and anxiety scores. Conclusion: Sufentanil was found to be better with respect to analgesia, patient satisfaction, and recovery however not cost-effective for continuous infusion technique.
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Serial semi-invasive hemodynamic assessment following pericardiectomy for chronic constrictive pericarditis p. 169
Ujjwal Kumar Chowdhury, Poonam Malhotra Kapoor, Adil Rizvi, Vishwas Malik, Sandeep Seth, Rajiv Narang, Mani Kalaivani, Sarvesh Pal Singh, Sathiya Selvam
DOI:10.4103/aca.ACA_98_16  PMID:28393776
Objectives: This study was designed to prospectively investigate the effects of pericardiectomy via median sternotomy on intra- and postoperative hemodynamics by a new semi-invasive device (Flotrac/VigileoTM monitor) using arterial pressure waveform analysis. Patients and Methods: Thirty consecutive patients aged 15 to 55 years (mean+SD, 31.73 + 13.53 years), who had undergone total pericardiectomy via median sternotomy underwent serial hemodynamic evaluation. FlotracTM Sensor – derived stroke volume, stroke volume variation, systemic vascular resistance index (SVRI), cardiac index and right atrial pressure were measured just before and after pericardiectomy, at 12 hours, 24 hours, 48 hours, 72 hours and at discharge postoperatively. Results: Majority of patients (73.33%) exhibited statistically significant reduction of right atrial pressure and SVRI along with improvement in cardiac index and oxygen delivery in the immediate and late postoperative period. However, the stroke volume and stroke volume variation did not increase proportionately on completion of surgery. Patients with low cardiac output syndrome exhibited persistently high central venous pressure with reduced cardiac index and echocardiographically abnormal diastolic filling characteristics. Conclusions: We conclude that there is early normalization of hemodynamics following pericardiectomy via median sternotomy and the adequacy of pericardiectomy can be accurately assessed by the new semi-invasive arterial pressure waveform analysis device. Stroke volume variation is a non-predictor of fluid requirement during and after pericardiectomy.
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Methylene blue for postcardiopulmonary bypass vasoplegic syndrome: A cohort study p. 178
Michael Mazzeffi, Benjamin Hammer, Edward Chen, Mark Caridi-Scheible, James Ramsay, Christopher Paciullo
DOI:10.4103/aca.ACA_237_16  PMID:28393777
Background: Methylene blue (MB) has been used to treat refractory hypotension in a variety of settings. Aims: We sought to determine whether MB improved blood pressure in postcardiopulmonary bypass (CPB) vasoplegic syndrome (VS) in a complex cardiac surgery population. Furthermore, to determine variables that predicted response to MB. Setting and Design: This was conducted in a tertiary care medical center; this study was a retrospective cohort study. Materials and Methods: Adult cardiac surgery patients who received MB for post-CPB VS over a 2-year period were studied. Mean arterial blood pressure (MAP) and vasopressor doses were compared before and after MB, and logistic regression was used to model which variables predicted response. Results: Eighty-eight patients received MB for post-CPB VS during the study period. MB administration was associated with an 8 mmHg increase in MAP (P = 0.004), and peak response occurred at 2 h. Variables that were associated with a positive drug response were deep hypothermic circulatory arrest during surgery and higher MAP at the time of drug administration (P = 0.006 and 0.02). A positive response had no correlation with in-hospital mortality (P = 0.09). Conclusions: MB modestly increases MAP in cardiac surgery patients with VS. Higher MAP at the time of drug administration and surgery with deep hypothermic circulatory arrest predict a greater drug response.
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Safety and efficacy of ketamine-dexmedetomidine versus ketamine-propofol combinations for sedation in patients after coronary artery bypass graft surgery p. 182
Mona Mohamed Mogahd, Mohammed Shafik Mahran, Ghada Foad Elbaradi
DOI:10.4103/aca.ACA_254_16  PMID:28393778
Background and Aims: Prolonged mechanical ventilation after cardiac surgery is associated with serious complications that increase morbidity and mortality. The present study was designed to compare ketamine-propofol (KP) and ketamine-dexmedetomidine (KD) combinations for sedation and analgesia in patients after coronary artery bypass graft (CABG) surgery as regards hemodynamics, total fentanyl dose, time of weaning from mechanical ventilation, time of extubation, and any adverse outcome. Materials and Methods: Seventy post-CABG patients were sedated using ketamine 1 mg/kg IV then 0.25 mg/kg/h infusion combined with either dexmedetomidine or propofol to maintain Ramsay sedation score ≥4 during assisted ventilation. Group KP received ketamine + propofol 1 mg/kg bolus followed by 25–50 μg/kg/min. Group KD received ketamine + dexmedetomidine 1.0 μg/kg over 20 min and then 0.2–0.7 μg/kg/h. Total dose of fentanyl in the first 24 h, time of weaning, time of extubation, mean arterial blood pressure, heart rate, and Intensive Care Unit (ICU) stay time were recorded. Statistics: Sample size of 35 patients was calculated for 90% power, α = 0.05, β = 0.1, and anticipated effect size = 0.40 using sample size software (G*Power version 3.00.10, Germany). Analytic statistics was performed on IBM compatible computer using SPSS version 11.5 (IBM, New York, United States) software package under Windows XP operating system. All results presented in the form of mean ± standard deviation. Data compared using unpaired Student's t-test, P < 0.05 was considered as statistically significant. Results: Group KD showed a significant decrease in mean time of weaning and extubation in group KD in comparison with group KP (374.05 ± 20.25 min vs. 445.23 ± 21.7 min, respectively, P < 0.001) (432.4 ± 19.4 min and 504 ± 28.7 min, respectively, P < 0.0001). Fentanyl consumption showed a significant decrease in group KD in comparison with group KP (41.94 ± 20.43 μg and 152.8 ± 51.2 μg, respectively, with P < 0.0001). There were insignificant difference between both groups as regards hemodynamic stability and length of ICU stay. Conclusion: Using KD combination for sedation, post-CABG surgery provided short duration of mechanical ventilation with less fentanyl dose requirement in comparison with KP with insignificant difference in both groups as regards hemodynamic stability and length of the ICU stay.
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The utility of preoperative level of erythrocytosis in the prediction of postoperative blood loss and 30-day mortality in patients with tetralogy of fallot p. 188
Jhon Harold Guevara, Andres Zorrilla-Vaca, Gloria C Silva-Gordillo
DOI:10.4103/aca.ACA_25_17  PMID:28393779
Background: Postoperative major bleeding is a relatively common complication of patients undergoing corrective surgery of tetralogy of Fallot (TOF). Life-threatening blood losses can lead to aggressive transfusions or reoperation. Little is known about the risk factors associated with a bleeding tendency in TOF patients. This study aimed to establish predictive models for postoperative blood loss and mortality in TOF patients. Methods: We conducted a retrospective observational study involving patients with TOF who were posted for corrective cardiac surgery in a single hospital between 2010 and 2015. Hospital records including sociodemographic, pre- and intra-operative characteristics were extracted. Postoperative blood loss (within 24 and 48 h) and 30-day mortality were the primary and secondary outcomes, respectively. Multivariate linear and logistic regression models were used to identify determinants of outcomes. Results: A total of 60 patients were included in this study. The median age was 1 year (interquartile range = 0.62–5) and the male to female ratio of 1.7:1. Mean postoperative blood loss within 24 h was 283 ± 212 mL. In multivariate linear regression, preoperative hematocrit (β = 6.63, P = 0.042) and duration of intraoperative oxygenator with CPB (β = 5.16, P = 0.025) were significantly correlated with postoperative blood loss within 24 h. After adjusting for sociodemographic, intra- and post-operative characteristics, preoperative hematocrit (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 1.01–1.21), and postoperative red blood cell transfusions (OR = 3.88, 95% CI = 1.16–12.9) showed statistically significant association with 30-day mortality. The area under the receiver operating characteristic curve of the multivariable model was 0.863. Conclusions: Preoperative levels of erythrocytosis appear to predict postoperative blood loss and short-term mortality in TOF patients undergoing corrective surgery.
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Does sleep quality affects the immediate clinical outcome in patients undergoing coronary artery bypass grafting: A clinico-biochemical correlation p. 193
Minati Choudhury, Anushree Gupta, Milind P Hote, Poonam Malhotra Kapoor, Sandeep Khanna, MV Kalaivani, Usha Kiran
DOI:10.4103/aca.ACA_30_17  PMID:28393780
Objective: Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabolic disturbances. The vascular polypeptide endothelin 1 (ET-1) is involved in many of the health disorders. However, its potential involvement in patients having poor sleep quality along with cardiovascular problem is limited. The present study was formulated to conduct a prospective analysis of the relationship between ET-1 and in hospital outcome in sleep disorder patients undergoing routine coronary artery bypass grafting (CABG). Methods: A total of 156 patients were enrolled and divided into two groups based on the Pittsburg Sleep Quality Index (PSQI) of ≤5 (Group I, n = 101) or >5 (Group II, n = 55). Blood sample was collected before anesthesia induction (ET-1a) and at 48 h (ET-1b) to analyze the plasma ET-1 and blood sugar level. The patients were monitored for any intraoperative adverse events and postoperative complications during their hospital stay. Results: Both groups were comparable in relation to age, sex, incidence of smoking and alcohol consumption. The distribution of comorbid conditions was also similar in both groups. The ET-1 level was higher in Group II than Group I before anesthesia induction as well as 48 h postoperatively (4.5 ± 1.75 vs. 10.61 ± 9.3, P = 0.001; 2.08 ± 1.3 vs. 8.3 ± 9.86, P = 0.0001, respectively). The Group II patients had a longer duration of mechanical ventilation (14.6 ± 12.05 vs. 10.1 ± 8.19, P = 0.001), Intensive Care Unit stay (2.08 ± 0.95 vs. 2.7 ± 1.45, P = 0016) and hospital stay (5.98 ± 1.73 vs. 7.8 ± 3.66, P = 0.0001, respectively). The high number of patients from Group II required inotrope and intra-aortic balloon pump support while compared with Group I (P ≤ 0.05 in each). The overall postoperative complication rate was significantly higher among patients with PSQI of >5 (Group II) except the rate of infection and neurological complications which was similar among both group of patients. The postoperative in hospital mortality was nil in Group I and 3.6% in Group II (P = 0.05). There was a strong relationship between PSQI and ET-1 at both the time points. Conclusion: Poor sleep quality associated with a higher incidence of adverse perioperative events in patients undergoing elective CABG. There exists a potential link between poor sleep quality and ET-1 in these groups of patients.
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Comparison of Levosimendan versus Dobutamine in Patients with Moderate to Severe Left Ventricular Dysfunction Undergoing Off-pump Coronary Artery Bypass Grafting: A Randomized Prospective Study Highly accessed article p. 200
Ashok Kandasamy, Hariharan Antony Simon, P Murthy, Mahalakshmi Annadurai, Mushkath Mohamed Ali, Gayathri Ramanathan
DOI:10.4103/aca.ACA_195_16  PMID:28393781
Context: Recent upsurge in referral of patients with compromised left ventricular (LV) function for cardiac surgery has led to an increasing use inotropes to achieve improvement of tissue perfusion in the perioperative period. Aims and Objectives: To compare the hemodynamic effects and immediate postoperative outcomes with levosimendan and dobutamine in patients with moderate to severe LV dysfunction undergoing off-pump coronary artery bypass grafting (OPCAB). Settings and Design: University teaching hospital, randomized control study. Materials and Methods: Eighty patients were randomly divided into two groups of 40 each. Group I received levosimendan at 0.1 μg/kg/min and Group II received dobutamine at 5 μg/kg/min. Hemodynamic data were noted at 30 min, during obtuse marginal grafting, 1, 6, 12, and 24 h after surgery. Heart rate (HR), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI), left ventricular stroke work index (LVSWI) and right ventricular stroke work index (RVSWI), mixed venous oximetry (SvO2), and lactate were measured. Statistical Analysis Used: Chi-square and Student's t-test. Results: The HR, MAP, PCWP, SVRI, and PVRI were lower in Group I when compared to Group II. Group I patients showed a statistically significant increase in LVSWI, RVSWI, and CI, when compared to Group II. Comparatively, Group I patients maintained higher SvO2and lower lactate levels. Duration of ventilation, Intensive Care Unit (ICU), and hospital stay were lower in Group I. Conclusions: Levosimendan was associated with statistically significant increase in indices of contractility (CI, LVSWI, and RVSWI) and decrease in PCWP during and after OPCAB. Levosimendan group had lower incidence of atrial fibrillation, shorter length of ICU, and hospital stay.
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Thyromental height test for prediction of difficult laryngoscopy in patients undergoing coronary artery bypass graft surgical procedure p. 207
Nilesh Jain, Sucharita Das, Muralidhar Kanchi
DOI:10.4103/aca.ACA_229_16  PMID:28393782
Background: Patients undergoing coronary artery bypass graft (CABG) procedures have higher incidence of difficult laryngoscopy and intubation than general surgery population. Accurate prediction of difficult laryngoscopy in CABG patients is desirable to reduce the hemodynamic response and myocardial oxygen requirements. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway. We, in our prospective observational study, evaluated the accuracy of the TMHT in predicting difficult laryngoscopy. Methodology: A total of 345 patients undergoing CABG of either sex, in the age group of 35–80 years, American Society of Anesthesiologists 111, undergoing CABG, were studied. Airway assessment was performed with modified Mallampati test with the addition of thyromental distance, sternomental distance, and TMHT. Intraoperatively, direct laryngoscopy was done in accordance with Cormack and Lehane grade of laryngoscopy. The preoperative data and laryngoscopic findings were used together to evaluate the accuracy of TMHT. The sensitivity, specificity, positive and negative predictive values of other three tests were calculated according to standard formula. Results: A total of 345 patients were in the group with mean age of study population at 56.7 (standard deviation 9.1) years (35–80 years). This study showed that almost all tests had good specificity, but sensitivity was poor. However, sensitivity of TMHT was 75% with accuracy of 95%. Receiver operating characteristic curve analysis of TMHT-derived cutoff was 52.17 which increased sensitivity to 81.25% and specificity to 92.3%. Conclusion: TMHT had a higher sensitivity compared to other tests along with good positive and negative predictive value and a very high specificity.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD Top

Coagulopathies in cyanotic cardiac patients: An analysis with three point - of - care testing devices (Thromboelastography, rotational thromboelastometry, and sonoclot analyzer) p. 212
Vandana Bhardwaj, Poonam Malhotra, Suruchi Hasija, Ujjwal Kumar Chowdury, Neha Pangasa
DOI:10.4103/aca.ACA_4_17  PMID:28393783
Introduction: In the last few years, viscoelastic point-of-care (POC) coagulation devices such as thromboelastography (TEG), rotational thromboelastometry (ROTEM), and Sonoclot (SON) analyzer have been increasingly used in major surgeries for timely assessment and management of coagulopathies. The aim of the present study was to evaluate coagulation profile of cyanotic cardiac patients with TEG, ROTEM, and SON analyzer. In addition, we assessed the correlation of standard laboratory coagulation tests and postoperative chest drain output (CDO) with the parameters of POC testing devices. Materials and Methods: Thirty-five patients of either gender, belonging to the American Society of Anesthesiologists Grade I–III, and undergoing elective cardiac surgery on cardiopulmonary bypass for cyanotic congenital heart disease were included in this study. To identify possible coagulation abnormalities, blood samples for TEG, ROTEM, SON, and standard laboratory coagulation were collected after induction of anesthesia. The correlations between variables were assessed using Pearson's correlation coefficient. P < 0.05 was considered statistically significant. Results and Discussion: EXTEM clot time (CT) and clot formation time (CFT) were prolonged in 87% and 45% patients whereas INTEM CT and CFT were prolonged in 36% and 73% patients, respectively. FIBTEM maximum clot firmness (MCF) was decreased in 30% patients. We observed significant correlation between fibrinogen concentration and ROTEM FIBTEM MCF (r = 0.94, P < 0.001). The SON platelet function (SON PF) showed good correlation with platelet count (r = 0.85, P < 0.001). We also found significant correlation between preoperative FIBTEM MCF and CDO in first 4 postoperative hours (r = 0.49, P = 0.004) and 24 postoperative hours (r = 0.52, P = 0.005). Receiver operating characteristic analysis demonstrated that SON PF and TEG maximum amplitude are highly predictive of thrombocytopenia below 100 × 109/L (area under the curve [AUC] - 0.97 and 0.92, respectively), while FIBTEM-MCF is highly predictive of hypofibrinogenemia (fibrinogen <150 mg/dL (AUC, 0.99). Conclusion: Cyanotic cardiac patients have preoperative coagulation abnormalities in ROTEM, TEG, and SON parameters. ROTEM FIBTEM is highly predictive of hypofibrinogenemia while SON PF is highly predictive of thrombocytopenia. ROTEM FIBTEM can be studied as a marker of increased postoperative CDO.
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REVIEW ARTICLES Top

Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet? p. 219
Efstratios Apostolakis, Nikolaos A Papakonstantinou, Ioanna Koniari
DOI:10.4103/aca.ACA_39_16  PMID:28393784
Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.
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Modifying risks to improve outcome in cardiac surgery: An anesthesiologist's perspective p. 226
Murali Chakravarthy
DOI:10.4103/aca.ACA_20_17  PMID:28393785
Challenging times are here for cardiac surgical and anesthesia team. The interventional cardiologist seem to have closed the flow of 'good cases' coming up for any of the surgery,; successful percutaneous interventions seem to be offering reasonable results in these patients, who therefore do not knock on the doors of the surgeons any more . It is a common experience among the cardiac anesthesiologists and surgeons that the type of the cases that come by now are high risk. That may be presence of comorbidities, ongoing medical therapies, unstable angina, uncontrolled heart failure and rhythm disturbances; and in patients with ischemic heart disease, the target coronaries are far from ideal. Several activities such as institution of preoperative supportive circulatory, ventilatory, and systemic disease control maneuvers seem to have helped improving the outcome of these 'high risk ' patients. This review attempts to look at various interventions and the resulting improvement in outcomes. Several changes have happened in the realm of cardiac surgery and several more are en route. At times, for want of evidence, maximal optimization may not take place and the patient may encounter unfavorable outcomes.. This review is an attempt to bring the focus of the members of the cardiac surgical team on the value of preoperative optimization of risks to improve the outcome. The cardiac surgical patients may broadly be divided into adults undergoing coronary artery bypass graft surgery, valve surgery and pediatric patients undergoing repair/ palliation of congenital heart ailments. Optimization of risks appear to be different in each genre of patients. This review also brings less often discussed issues such as anemia, nutritional issues and endocrine problems. The review is an attempt to data on ameliorating modifiable risk factors and altering non modifiable ones.
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Prosthesis-patient mismatch - what cardiac anesthesiologists need to know? p. 234
Kathirvel Subramaniam, Soheyla Nazarnia
DOI:10.4103/aca.ACA_9_17  PMID:28393786
Prosthesis-patient Mismatch (PPM) is not uncommon with an incidence reported up to 70% after aortic valve (AV) replacement. Severe forms of PPM are less common (up to 20%); PPM can lead to increased short- and long-term morbidity and mortality. It is important to discriminate PPM from other forms of prosthetic valve dysfunction. Sometimes, prosthetic valve degenerative disease may coexist with PPM. Echocardiography plays an important role in the prevention and diagnosis of PPM. Preemptive strategies to prevent PPM include insertion of newer generation prosthetic valves with better hemodynamic characteristics, stentless prosthesis, aortic root enlargement to insert a larger prosthesis, aortic homograft, and transcutaneous AV implantation. We present an illustrative case and review the literature on PPM pertinent to anesthesiologists.
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INTERESTING IMAGES Top

Right-to-left shunting through the unidirectional valved patch after closure of ventricular septal defect p. 243
Sachin Talwar, Poonam Malhotra Kapoor, Jitin Narula, Vikas Kumar Keshri, Shiv Kumar Choudhary, Balram AIran
DOI:10.4103/aca.ACA_43_17  PMID:28393787
Postoperative transesophageal echocardiography images of a patient undergoing unidirectional valved patch closure of ventricular septal defect in the setting of severe pulmonary hypertension are presented. The images and videos elegantly demonstrate a functioning valve without any obstruction to the left ventricular outflow.
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Transthoracic echocardiography versus transesophageal echocardiography for rupture sinus of Valsalva aneurysm p. 245
Ira Dhawan, Vishwas Malik, Kamal Prakash Sharma, Neeti Makhija, Neha Pangasa
DOI:10.4103/aca.ACA_41_17  PMID:28393788
We report a rare case of sinus of Valsalva aneurysm of both right and left coronary sinus (LCS), with perforation of the LCS opening into the left ventricle. The LCS aneurysm with its perforation was undiagnosed on transthoracic echocardiography emphasizing the role of transesophageal echocardiography in delineating the anatomy.
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Knife in the superior mediastinum: Amazing escape p. 247
Kareem Salhiyyah, Ahmed Ashoub, Paul Diprose, Clifford Barlow
DOI:10.4103/aca.ACA_251_16  PMID:28393789
This text describe through images, how a knife is retrieved from the superior mediastinum.
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Inverted left atrial appendage masquerading as a left atrial mass p. 248
Suresh Kumaran, Gladdy George, AV Varsha, Raj Sahajanandan
DOI:10.4103/aca.ACA_192_16  PMID:28393790
An inverted left atrial appendage after cardiac surgery is a rare finding and can be misinterpreted as a thrombus, mass, or vegetation. We report a case where intraoperative transesophageal echocardiography assisted in making an accurate diagnosis.
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Serpentinous structure in the right atrium p. 250
Monish S Raut, Arun Maheshwari, Ganesh Shivnani
DOI:10.4103/0971-9784.203943  PMID:28393791
Thin, slender, filament like structure is common finding in right atrium echocardiographically. These structures generally represent embryological remnants like thebasian valve, eustachian valve and chiari network. Apart from these variants, they can also be initial finding of thrombotic process specially in the presence of central venous catheter. Early detection and removing the catheter can prevent further thromboembolism in such cases.
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CASE REPORTS Top

Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management p. 252
Madan Mohan Maddali, Pranav Subbaraya Kandachar, Said Al-Hanshi, Mohammed Al Ghafri, John Valliattu
DOI:10.4103/aca.ACA_197_16  PMID:28393792
Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.
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Transient cortical blindness following intracardiac repair of congenital heart disease in an 11-year-old boy p. 256
Saswata Bharati, Manish Kumar Sharma, Amitabha Chattopadhay, Debasis Das
DOI:10.4103/aca.ACA_159_16  PMID:28393793
Postoperative blindness (PB) primarily involves reception and conductance parts of the visual pathway due to ischemia following cessation of blood supply, for example, retinal vascular occlusion. Although a rare cause of PB, cortical blindness (CB), which results from ischemia/infarction of visual cortex, has a poor outcome due to its mostly nonreversible nature. Ischemic optic neuropathy is the most common cause of PB following cardiac surgeries. CB following cardiac surgeries involving cardiopulmonary bypass has been rarely reported. Only a few of those articles reported partial or complete reversal of CB. We report an incidence of transient CB in an 11-year-old child who was operated for double chambered right ventricle with ventricular septal defect.
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Partial anomalous pulmonary venous return: Scimitar vein p. 259
Timothy Heinke, Scott R Stewart, Toby Steinberg, William R Hand, James H Abernathy
DOI:10.4103/aca.ACA_82_16  PMID:28393794
Scimitar syndrome is a rare association of congenital cardiopulmonary anomalies characterized by partial anomalous pulmonary venous return, in which an abnormal right pulmonary vein drains into the inferior vena cava. This case exemplifies the role of transesophageal echocardiography in perioperative management and surgical decision-making.
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Diagnostic dilemma: Low oxygen saturation during cardiac surgery p. 262
Suruchi Ladha, Shivani Aggarwal, Usha Kiran, Arindam Choudhary, Poonam Malhotra Kapoor, Ujjwal Kumar Choudhary
DOI:10.4103/aca.ACA_34_17  PMID:28393795
We report a case of rheumatic heart disease with severe mitral stenosis having cyanosis and low oxygen saturation on pulse oximetry. The findings of clinical examination and low values on pulse oximetry were inconsistent with the findings of normal partial pressure of oxygen and oxygen saturation on arterial blood gas analysis, leading to diagnostic dilemma. In such clinical scenario, the anesthesiologist should be aware and vigilant about the differential diagnosis of low oxygen saturation on pulse oximetry.
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Modified blalock-taussig shunt and levosimendan for left ventricular preparation in a child with transposition of great arteries and regressed ventricle undergoing rapid 2 stage arterial switch operation p. 265
Manoj Kumar Sahu, Anish Gupta, Intekhab Alam, Sarvesh Pal Singh, Ramesh Menon, V Devagouru
DOI:10.4103/0971-9784.203929  PMID:28393796
Rapid two-stage arterial switch operation (ASO) is very relevant as many patients of transposition of great arteries (TGA) present late to the hospital when primary switch either is not possible or carries a high risk of morbidity and mortality. Hence, other means apart from the traditional methods of left ventricle preparedness should be tried to help this category of patients, who are to undergo rapid two-stage ASO. We successfully used levosimendan and continuous positive airway pressure after 1st stage operation in a patient with dTGA and regressed ventricle, which helped in left ventricular preparedness, and the child underwent rapid two-stage ASO uneventfully.
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LETTERS TO EDITOR Top

Successful intravenous streptokinase therapy in refractory extensive deep vein thrombosis associated with inferior vena cava agenesis: A novel treatment for a rare case p. 268
Nahid Azdaki, Mahyar Mohammadifard, Mohammad-Reza Ghasemian, Amin Saburi
DOI:10.4103/aca.ACA_211_16  PMID:28393797
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High blood tacrolimus and hyperkalemia in a heart transplant patient p. 270
Manoj Kumar Sahu, Sarvesh Pal Singh, Anupam Das, Atul Abraham, Balram Airan, Intekhab Alam, Ramesh Menon, V Devagourou, Anish Gupta
DOI:10.4103/0971-9784.203933  PMID:28393798
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Three-dimensional parametric imaging for intraoperative quantification of regional left ventricular function in ischemic cardiomyopathy p. 272
Neelam Aggarwal, MS Saravana Babu
DOI:10.4103/aca.ACA_28_17  PMID:28393799
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Role of MicroRNA in cardiac anesthesia: An innovative consequences and new possibility p. 274
Mayadhar Barik, Abhay Kumar, Pravash Ranjan Mishra, Poonam Malhotra Kapoor
DOI:10.4103/aca.ACA_37_16  PMID:28393800
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Hyperhomocysteinemia and left ventricular thrombus p. 276
Monish S Raut, Arun Maheshwari
DOI:10.4103/aca.ACA_203_16  PMID:28393801
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VIDEO COMMENTARIES Top

Importance of 3D real time perioperative tee in ASD device embolisation p. 278
MS Sarvana Babu, Neelam Aggarwal, A Asha, Digraje Sunita Ashok, Thomas Koshy
DOI:10.4103/0971-9784.203960  PMID:28393802
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Echocardiography for hypertrophic obstructive cardiomyopathy p. 279
Kalpna Irpachi, K Ashok Kumar, Poonam Malhotra Kapoor
DOI:10.4103/0971-9784.203959  PMID:28393803
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ERRATUM Top

Erratum: Annals of Cardiac Anesthesia: Beacon journey toward excellence: 2015–2017 p. 280

DOI:10.4103/0971-9784.201630  PMID:28393804
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Erratum: Delirium after cardiac surgery: A pilot study from a single tertiary referral center p. 281

DOI:10.4103/0971-9784.201631  PMID:28393805
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Erratum: Percutaneous tracheostomy in patients on anticoagulants p. 282

DOI:10.4103/0971-9784.203968  PMID:28393806
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Erratum: Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography p. 283

DOI:10.4103/0971-9784.203969  PMID:28393807
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