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January-March 2020
Volume 23 | Issue 1
Page Nos. 1-111

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REVIEW ARTICLES  

Anaphylaxis-induced atrial fibrillation and anesthesia: Pathophysiologic and therapeutic considerations Highly accessed article p. 1
Nicholas G Kounis, Ioanna Koniari, George Tzanis, George D Soufras, Dimitrios Velissaris, George Hahalis
DOI:10.4103/aca.ACA_100_19  
Atrial fibrillation is the most common cardiac arrhythmia in western society affecting more than 35 million individuals worldwide annually. It is a common postoperative complication and may also occur spontaneously during general and local anesthesia administration. Aging, diabetes mellitus, hypertension, and cardiovascular diseases including cardiomyopathies, congenital cardiac anomalies, heart failure, myocardial ischemia, pericarditis, previous cardiac surgery, vascular disease, and valvular heart disease are some correlated factors. Beyond age, increased incidence of atrial fibrillation has been correlated to autoimmune system activation as it is the underlying mechanism of persistent atrial fibrillation development. Current research supports an association between the complement system activation and lymphocyte-pro-inflammatory cytokines release with the cardiac conduction system and atrial fibrosis. The loss of CD28 antigen from CD4+CD28+T lymphocytes seems to play a major role in atrial fibrillation development and prognosis. Except atrial fibrillation, a variety of additional electrocardiographic changes, resembling those with digitalis intoxication may accompany anaphylaxis and particularly Kounis syndrome. Histamine is one well-known mediator in allergic and inflammatory conditions as physiologically regulates several cardiovascular and endothelial functions with arrhythmogenic potential. The increased oxidative stress, measured by the redox potentials of glutathione, has been correlated with atrial fibrillation incidence and prevalence. The use of antazoline, a first-generation antihistamine agent used for rapid conversion of recent-onset atrial fibrillation in patients with preserved left ventricular function and for rapid atrial fibrillation termination during accessory pathway ablation denotes that anaphylaxis-induced histamine production could be the cause of atrial fibrillation at least in some instances. The anaphylaxis diagnosis in anesthesia can be challenging owing to the absence of cutaneous manifestetions such as flushing, urticaria, or angioedema. Anticoagulation for stroke prevention, rate and rhythm control medications, invasive methods such as radiofrequency ablation or cryoablation of pulmonary veins as well surgical ablation constitute the treatment basis of atrial fibrillation. Understanding the underlying mechanisms of atrial fibrillation by cardiologists, anesthesiologists and surgeons, as well as potential treatments, to optimize care is of paramount importance.
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Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation? Highly accessed article p. 7
Maria Maimari, Nikolaos G Baikoussis, Stelios Gaitanakis, Anna Dalipi-Triantafillou, Andreas Katsaros, Charilaos Kantsos, Vasileios Lozos, Konstantinos Triantafillou
DOI:10.4103/aca.ACA_158_18  
Atrial fibrillation(AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restrictingand susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation(POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more “malignant” than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy(MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy(FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association(AHA), the term “minimally invasive” refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.
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ORIGINAL ARTICLES Top

Airway anomalies in cases of anomalous pulmonary venous connection–A single-center experience Highly accessed article p. 14
Anuradha Kamath, Pankaj Punetha, Aditya N Doddamane, Kolli S Chalam, CS Hiremath
DOI:10.4103/aca.ACA_43_19  
Background: Patients with congenital heart defects may present with concomitant defects involving other organ systems. Roughly 4 percent of this nature are airway anomalies. Presence of anomalous airways summon major challenge before the anesthesiologist, surgeon, and intensivist in the perioperative management of such patients. There is paucity of literature in the study of airway anomalies in the subset of congenital anomalous pulmonary venous connections. We present the analysis of three cases of airway anomalies in patients operated for anomalous venous drainage at our center. We hope to explicate the clinical implications and management of such rare presentations. Methods: The records of all patients who underwent surgical correction for anomalous venous return between January 2016 and January 2018 were reviewed retrospectively. The records were examined for presence of any airway issues, abnormal radiological findings, perioperative intubation or extubation issues and perioperative surgical findings. Results: Amidst the 410 cases operated for congenital heart defects in this period, 92 were operated cases for anomalous pulmonary venous return, of which 3 patients presented with airway issues. One patient had an aberrant right tracheal bronchus with normal carina and bilateral main bronchial stenosis, the second patient had a hypoplastic left lung and the third patient had congenital lobar emphysema of the left lung. Conclusion: Prudent perioperative management necessitates prior evaluation and preemptive planning for airway anomalies in patients with anomalous venous return, since they can belong to the “Malinosculation Syndrome” group, which involves anomalous communication by means of small openings between the different components of lung tissue, namely, the lung parenchyma, tracheobronchial tree, arteries, and veins.
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Role of central venous-Arterial pCO2 difference in determining microcirculatory hypoperfusion in off-pump coronary artery bypass grafting surgery Highly accessed article p. 20
Hitendra Kanzariya, Jigisha Pujara, Sunny Keswani, Karan Kaushik, Vivek Kaul, R Ronakh, Himani Pandya
DOI:10.4103/aca.ACA_48_19  
Background: Cardiac surgery is frequently associated with macro and microcirculatory hypoperfusion. Patients with normal central venous oxygen saturation(Scvo2) also suffer from hypoperfusion. We hypothesized that monitoring central venous-arterial pco2 difference(dCO2) could also serve as additional marker in detecting hypoperfusion in cardiac surgery patient. Methods: This is a prospective observational study. Patients undergoing off-pump coronary artery bypass grafting included in this study. The dCO2 was measured postoperatively. The patients with a ScvO2≥70% were divided in to 2 groups, the high-dCO2 group(≥8mmHg) and the low-dCO2 group(<8mmHg). Results: The 65patient had scvO2≥70%. Out of these, 20patients were assigned to the high dCO2 group and 45patients to the low dCO2 group. Patients with high dco2 had higher lactate levels after ICU admission. They also had significantly prolonged need for mechanical ventilation(14.90±10.33 vs 10±9.65, P =0.0402), ICU stay(5.05±2.52 d vs 3.75±2.36 d, P =0.049) and hospital stay (12.25±5.90 d vs 8.57±5.55 d P =0.018). The overall rate of post-operative complications was similar in both the group. Conclusion: The present study demonstrates dCO2 as an easy to assess and routinely available tool to detect global and microcirculatory hypoperfusion in off-pump CABG patients, with assumed adequate fluid status and ScvO2 as a hemodynamic goal. We observed that high dCO2(>8 mmHg) was associated with decreased DO2I, increased oxygen extraction ratio, the longer need for mechanical ventilation and longer ICU stay.
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Statin reload before off-pump coronary artery bypass graft: Effect on biomarker release kinetics Highly accessed article p. 27
Atul Kaushik, Aditya Kapoor, Surendra K Agarwal, Shantanu Pande, Prabhat Tewari, Gauranga Majumdar, Archana Sinha, Shiridhar Kashyap, Roopali Khanna, Sudeep Kumar, Naveen Garg, Satyendra Tewari, Pravin Goel
DOI:10.4103/aca.ACA_133_18  
Objectives: Statins confer protection from ischemia/reperfusion through various pathways including pleiotropic mechanisms. Following chronic administration, activation of intrinsic cellular mechanisms causes attenuation of these pleiotropic effects. Methods: Since coronary artery bypass surgery(CABG) represents a reversible ischemia-reperfusion sequence, we assessed if statin reload is effective in patients undergoing off-pump CABG(n=100) in limiting myocardial injury. Patients received loading dose of rosuvastatin(40mg initiated 7days before surgery) while nonloaded patients continued whatever statin dose they were receiving and served as controls. Cardiac biomarkers(Troponin-I, creatine kinase muscle/brain[CK-MB], and B-type natriuretic peptide[BNP]) were measured at 8, 24, and 48h postoperatively. The primary end-point was the extent of perioperative myocardial injury(area under the curve[AUC]: AUC of each biomarker). Results: Despite similar baseline levels, all biomarkers at 8, 24, and 48h were significantly lower in the loaded group. The AUC for each biomarker was also significantly lower in the loaded group (cTnI 37.96vs. 70.12ng. hr/ml, CK-MB 229.64vs. 347.04ng. hr/ml, and BNP 5257.56 vs. 15606.68pg. hr/ml, all P <0.001). Delta cTnI(change from baseline to peak level) (1.00±1.34 vs. 2.25±2.59), delta CK-MB(4.54±5.89vs. 10.68±9.95), and delta BNP(120.41±172.48vs. 449.23±790.95) all P <0.001 were also significantly lower in the loaded group. Those loaded with rosuvastatin had lower inotrope duration(22.9±23.33vs. 31.26±25.39h, P =0.04) and ventilator support time(16.94±6.78vs. 23.8±20.53h, P =0.03). Conclusion: In patients undergoing off-pump CABG, statin reload can “recapture” cardioprotection in patients already on statins with favorable effect on release kinetics of biomarkers and postoperative outcomes.
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Transesophageal echocardiographic evaluation of pulmonary vein diastolic wave deceleration time–As a predictor of left atrial pressure p. 34
Bhavya G Reddy, Naveen G Singh, PS Nagaraja, S Subhash, CG Prabhushankar, N Manjunatha, Vineela Chintha
DOI:10.4103/aca.ACA_253_18  
Background: The deceleration time of the pulmonary venous diastolic flow has been well-correlated with invasive pulmonary capillary wedge pressure in several studies regardless of left ventricular systolic function. This study was conducted to correlate deceleration time of pulmonary venous diastolic wave, DT(D), and left atrial pressure(LAP), obtained noninvasively from mitral early diastolic inflow velocity-to-early diastolic mitral annulus velocity ratio(E/e′), and to assess the ease of each method in patients with coronary artery disease undergoing off-pump coronary artery bypass grafting(OPCAB) by transesophageal echocardiography. Methods: Forty-five adult patients with coronary artery disease, with left ventricular ejection fraction of≥50% posted for elective OPCAB were enrolled in the study. Results: Forty values of LAP and DT(D) were analyzed. Asignificant linear correlation (r = −0.64) was found between DT(D) and LAP. Area under the curve of DT(D) of≤183 ms for predicting elevated LAP(>15) was 0.903(95% confidence interval: 0.767 to 0.974, P <0.0001). Conclusion: Deceleration time of pulmonary venous flow diastolic waveform, DT(D), feasible promising echocardiographic measure in determining elevated LAP and DT(D)≤183 ms predicts elevated LAP.
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Portal venous pulsatility fraction, a novel transesophageal echocardiographic marker for right ventricular dysfunction in cardiac surgical patients p. 39
Naveen G Singh, Karthik N Kumar, PS Nagaraja, N Manjunatha
DOI:10.4103/aca.ACA_250_18  
Background: Right ventricular(RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function. Aims: To investigate if portal venous pulsatility fraction(PF) could serve as effective and complementary tool in identifying RV dysfunction. Materials and Methods: Thirty adult patients aged 18-65years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion(TAPSE), RV fractional area change(FAC), RV ejection fraction(EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility. Results: Portal vein was demonstrated in 27patients(90%). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = −0.55, P =0.003), RV FAC(r = −0.44, P =0.02), and RV EF(r = −0.53, P =0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of≥45% indicated RV dysfunction with sensitivity of 92.3%, specificity of 71.4%, positive predictive value of 75%, and negative predictive value of 90.9%. Area under ROC curve was 0.819(95% confidence interval=0.624–0.939, P =0.0006). Conclusion: Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.
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Role of urinary PO2 analysis during conventional versus conventional and modified ultrafiltration techniques in adult cardiac surgery p. 43
Vijitha Burra, PK Sunil, NB Praveen, PS Nagaraja, Naveen G Singh, N Manjunatha, Vikram Somashekhar Basappanavar
DOI:10.4103/aca.ACA_2_19  
Background: Medullary hypoxia is the initial critical event for kidney injury during cardiopulmonary bypass, and therefore urinary PO2 with its potential of detecting medullary oxygenation for its management. Therefore, we tested the role of urinary PO2 in predicting kidney injury in those undergoing conventional versus combined(conventional and modified) ultrafiltration during cardiac surgery in adults. Methodology: We prospectively evaluated 32 adults between 18 and 65years of age undergoing elective on-pump cardiac surgery with ejection fraction>35% by conventional(groupC) versus combined ultrafiltration(groupCM). Urine samples were analyzed for PO2 after induction, 30min, 3h, and 6h post filtration along with blood urea and serum creatinine after induction, at 6h, 24h, and 48h post filtration. Demographic variables, cardiopulmonary bypass duration, flow rates, inotropic score, ventilation duration, diuretic use, and intensive care unit(ICU) stay were assessed between two groups. Results: Both the groups(16 in each group) had comparable urinary PO2 after induction(P=0.387) with significant decrease in groupC at 30min, 3h, and 6h post filtration(P <0.05). There was a statistically significant increase in serum creatinine(mg/dL) at 48 h in groupC compared with groupCM(1.57vs. 1.25, respectively; P ≤0.05). There was an increased diuretic usage and length of ICU stay in groupC. Conclusion: Combined ultrafiltration technique had renoprotective effect in cardiac surgery analyzed by urinary PO2 levels.
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A comparison of immediate postoperative complications in using left internal mammary artery+vein versus only vein as conduit in patients undergoing off-pump coronary artery bypass grafting p. 48
Tarun Chaudhary, Deepak Oberoi, Vinit Mehrotra
DOI:10.4103/aca.ACA_146_18  
Objective: The objective of the study is to compare the immediate postoperative cardiac complications in patients undergoing off-pump coronary artery bypass grafting(OPCABG) using mixed(arterial and venous grafts) versus only venous grafts and to compare the requirement of packed red cell units and intra-aortic balloon pump(IABP) in both the groups. Materials and Methods: This was an observational, analytical, prospective study. Sample Size: Fifty new patients were included in the study. Inclusion/Exclusion Criteria: Patients diagnosed with triple-vessel coronary artery disease(CAD) undergoing OPCABG with an ejection fraction(EF) of more than 30%. Patients who have undergone prior CABG, EF<30%, preexisting valvular heart disease, any evidence pulmonary hypertension, preoperative IABP, any history of neurological dysfunction, left atrium size more than 5.5cm, and history of coagulation disorder was excluded from the study. Results: The most common immediate postoperative cardiac complication observed was atrial fibrillation followed by ventricular arrhythmias in both the groups. There was no statistically significant difference in complication rate between the two groups. Postoperative requirement of IABP and requirements of blood products were also similar in both the groups. Conclusion: Patients undergoing off-pump CABG have similar immediate postoperative complications irrespective of the type of conduit used.
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A retrospective comparison of preoperative estimated glomerular filtration rate as a predictor of postoperative cardiac surgery associated acute kidney injury p. 53
Habib Md Reazaul Karim, Md Yunus, Samarjit Dey
DOI:10.4103/aca.ACA_156_18  
Background: Cardiac surgery-associated acute kidney injury(CSA-AKI) remains common with distressingly high mortality. Over time, risk scorings systems have been developed to predict it and preoperative low estimated glomerular filtration rate(eGFR) has been regarded as one of the predicting risk factors. Objectives: The present study is aimed at assessing the relation of different ranges of preoperative eGFR with an incidence of CSA-AKI defined by the AKI network(AKIN) criteria. Materials and Methods: Files of 134patients with eGFR of>40cc/min/1.73 m2 body surface area(BSA) who underwent cardiac surgeries on cardiopulmonary bypass were screened for data collection. Occurrences of CSA-AKI were evaluated as per the AKIN criteria over the course of 3 postoperative days. The relationships of different ranges of preoperative eGFR with CSA-AKI were analyzed by appropriate statistical tests using Instat software and P <0.05 was considered statistically significant. Results: Atotal of 60males and 74females with a mean+standard deviation(SD) age of 37.98±12.50years and mean+SD preoperative eGFR of 70.20±20.89cc/min/1.73 m2 were analyzed in this study. About 49.25% of patients suffered from CSA-AKI by the 3rdpostoperative day. The crude risk of CSA-AKI in patients with eGFR 40–60cc/min/1.73 m2 was not higher (odds ratio 0.29) as compared to patients in patients with eGFR>100cc/min/1.73 m2. The CSA-AKI trend with different eGFR was also statistically insignificant(P>0.05). Conclusion: In patients with preoperative eGFR>40cc/min/1.73 m2 BSA, a lower preoperative eGFR(40–60cc/min/1.73 m2) does not predict higher incidence of CSA-AKI as defined by AKIN criteria as compared to higher preoperative eGFR(>100cc/min/1.73 m2). Lower height is independently associated with higher incidence of CSA-AKI in such patients.
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Immediate changes in hemodynamics and gas exchange after initiation of noninvasive ventilation in cardiac surgical patients p. 59
Mohammad Hamid, Mohammad I Akhtar, Saba Ahmed
DOI:10.4103/aca.ACA_69_18  
Introduction: Cardiac surgery is associated with pulmonary dysfunction and complications such as prolonged intubation and reintubation. Bilevel positive airway pressure(BiPAP) machine has been used in the clinical settings to improve oxygenation, reduce work of breathing, and avoid reintubation. The effect of BiPAP on cardiovascular parameters is not well established, and very few studies have targeted hemodynamic changes. The aim of the study was to assess the immediate effect of BiPAP on respiratory and hemodynamic parameters in post-cardiac surgery patients. Materials andMethods: This quasi-experimental study was done on 33 adult cardiac surgery patients. Ethical review committee approval was sought and consent was taken. All patients who were in respiratory distress with respiratory rate of>30/min and/or PaO2:FiO2 ratio of<200 were included. Hemodynamic and respiratory parameters were recorded just before and 15min after BiPAP application. Sample size was determined on the basis of BiPAP effect on one of the variables, PaO2:FiO2 ratio. Results: Atotal of 33patients were included in the study. The average age of the patients was 60.97±10.8, of which 23(69.7%) were males and 10(30.7%) females. BiPAP application leads to statistically significant improvement in ventilator parameters including SaO229(87.7%), PaO229(87.8%), PaCO221(63.6%), and PaO2:FiO2 ratio in 27(81.8%). Conclusion: Ventilatory parameters were significantly improved after BiPAP application in this study, but hemodynamic parameters showed no statistically significant change. BiPAP application was also able to decrease the need for reintubation in post-cardiac surgery patients.
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Comparison of effectiveness of tranexamic acid and epsilon-amino-caproic-acid in decreasing postoperative bleeding in off-pump CABG surgeries: Aprospective, randomized, double-blind study p. 65
Swapnil Verma, Upadhyayula Srinivas, Anand Kumar Sathpathy, Priyanka Mittal
DOI:10.4103/aca.ACA_142_18  
Context: Off-pump coronary artery bypass graft(CABG) surgeries have been shown to have increased fibrinolysis due to tissue plasminogen activator release. There are no trials comparing the two available antifibrinolytics(tranexemic acid and epsilon-amino-caproic acid) in off-pump CABG surgeries. Aims: The aim of the present study was to compare the effectiveness of tranexamic acid and epsilon-amino-caproic acid with respect to postoperative bleeding at 4 and 24 hours as the primary outcome, and rate of postoperative transfusion, re-operations, complication rate, serum fibrinogen, and D-dimer levels as secondary outcomes. Settings and Design: The study was carried out at a tertiary-level hospital between June 2017 and June 2018. It was a prospective, randomized, double-blind study. Materials and Methods: Eighty patients undergoing off-pump CABG, were randomly allocated to receive tranexamic acid or epsilon-amino-caproic acid. The patients were followed up in the postoperative period and were assessed for primary and secondary outcomes. Statistical Analysis Used: Statistical analysis was performed using SPSS software, version19.0(SPSS Inc., Chicago, IL). Nonparametric data were expressed as median with interquartile range and compared using Mann–Whitney U-test, parametric data was represented as mean with standard deviation and analyzed using Student's t-test. Nominal data were analyzed using Chi-square test. Results: Bleeding at 4 hours did not show significant difference between groups, 180ml(80–250) vs 200ml(100–310). Bleeding at 24 hours was significantly lesser in tranexamic acid group as compared to epsilon-amino-caproic acid group, 350ml(130–520) vs 430ml(160–730)(P=0.0022) The rate of transfusion, re-operations, seizures, renal dysfunction, fibrinogen levels, and D-dimer levels did not show significant difference between the groups. Conclusions: Tranexamic acid significantly reduced postoperative bleeding in off-pump CABG at 24 hours as compared to epsilon-amino-caproic-acid.
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Enhanced recovery and early extubation after pediatric cardiac surgery using single-dose intravenous methadone p. 70
John P Iguidbashian, Peter H Chang, John Iguidbashian, Jason Lines, Bryan G Maxwell
DOI:10.4103/aca.ACA_113_18  
Background/Aims: Methadone may offer advantages in facilitating early extubation after cardiac surgery, but very few data are available in the pediatric population. Setting/Design: Community tertiary children's hospital, retrospective case series. Materials and Methods: We performed a retrospective analysis of all pediatric cardiac surgical patients for whom early extubation was intended. Amultimodal analgesic regimen was used for all patients, consisting of methadone (0.2–0.3mg/kg), ketamine(0.5mg/kg plus 0.25mg/kg/h), lidocaine(1mg/kg plus 1.5mg/kg/h), acetaminophen(15mg/kg), and parasternal ropivacaine(0.5 mL/kg of 0.2%). Outcome variables were collected with descriptive statistics. Results: A total of 24 children[median=7(interquartile range=3.75–13.75) years old, 23.7(14.8–53.4) kg] were included in the study; 22(92%) had procedures performed on bypass and 11(46%) involved a reentry sternotomy. Methadone dosing was 0.26(0.23–0.29) mg/kg. None of the children required intraoperative supplemental opioids; 23(96%) were extubated in the operating room. The first paCO2 on pediatric intensive care unit admission was 51(45–58) mmHg. Time to first supplemental opioid administration was 5.1 (3.5–9.5) h. Cumulative total supplemental opioids(in intravenous morphine equivalents) at 24 and 72 h were 0.2(0.09–0.32) and 0.42(0.27–0.68) mg/kg. One child required postoperative bilevel positive airway pressure support, but none required reintubation. None had pruritus; three(13%) experienced nausea. Conclusion: A methadone-based multimodal regimen facilitated early extubation without appreciable adverse events. Further investigations are needed to confirm efficacy of this regimen and to assess whether the excellent safety profile seen here holds in the hands of multiple providers caring for a larger, more heterogeneous population.
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An original backup technique to assess the correct positioning of right-sided double-lumen tubes without fiberoptic bronchoscopy: Apilot feasibility study p. 75
Céline Khalifa, Sophie Fossoul, Mona Momeni, Valérie Lacroix, Christine Watremez
DOI:10.4103/aca.ACA_127_18  
Background: Accurate positioning of a right-sided double-lumen tube is essential but challenging due to the location and the potential obstruction of the right upper lobe bronchus. Fiberoptic bronchoscopy is, therefore, necessary but requires a specific training period for the anesthesiologist and might not always be available. Objective: We describe an original backup technique to assess the correct placement of these tubes in cases a fiberopetic bronchoscopy is lacking. Design: Prospective pilot feasibility study with 10 adult patients scheduled for a left thoracic surgery. Setting: Operating theater in a universitary hospital. Materials and Methods: The new technique uses a fluoroscopy and an adult central venous catheter wire. The time needed to perform the new technique, its success rate and its efficacy in properly exclude the left lung were evaluated. Any oxygen desaturation episode(SpO2<90%) was considered. The technique was performed by two anesthesiologists with different experience in thoracic anesthesia. Results: The success rate of our technique was 90%, which did not depend on the anesthesiologist's experience. The range of time to successfully place the tube in the dorsal decubitus position and subsequently in the right lateral decubitus position was respectively 1min–6min and 1min–15min. None of the patients presented any desaturation episodes. Conclusions: We describe an original, safe, and acceptable backup technique to properly insert right-sided double-lumen endobronchial tubes, whenever a fiberoptic bronchoscopy is not available. Moreover, this technique is easy enough to be performed by anesthesiologists with limited experience in thoracic anesthesia.
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INTERESTING IMAGE Top

Wandering paravertebral catheter detected during thoracoscopy p. 80
Nambiath Sujata, Raj Tobin, Alok Gupta, Gautam Girotra
DOI:10.4103/aca.ACA_235_18  
We report a case of intrapleural migration of paravertebral catheter inserted under ultrasound guidance, detected during video assisted thoracoscopic surgery.
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CASE REPORTS Top

Management of ruptured sinus of valsalva for device closure in a patient with haemophilia p. 82
Ira Dhawan, Arindam Choudhury, Shivani Aggarwal, Sandeep Chauhan
DOI:10.4103/aca.ACA_112_17  
The association of Hemophilia A and ruptured aneurysm of sinus of valsalva (RSOV) has never been reported to the best of our knowledge. We report the case of a 29-year-old male patient with Hemophilia type A who presented with a RSOV into right atrium (RA). The patient underwent device closure off the RSOV and received Factor VIII infusions to decrease blood loss. The peri-procedural management is being presented in this case report.
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Incidental finding of a left atrial thrombus during surgical management of a massive pulmonary embolism p. 87
Sarah Dunn, Nisha Dave, Yiliam F Rodriguez-Blanco, Oscar Aljure
DOI:10.4103/aca.ACA_119_18  
A 58-year-old male presented with a hemodynamically significant pulmonary embolism. Computed tomography angiogram revealed a saddle embolus in the main pulmonary artery with extensive clot burden affecting all lobes and right heart strain. Transthoracic echocardiogram displayed a dilated right ventricle with reduced systolic function. The patient was scheduled for pulmonary embolectomy. The intraoperative transesophageal echocardiogram(TEE) demonstrated a mobile left atrial thrombus that was missed on previous imaging. After removal of the thrombi, TEE showed a patent foramen ovale(PFO). The left atrial thrombus passed across the PFO secondary to increased right heart and pulmonary pressures.
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Unusual left ventricle to left atrial fistula p. 90
Monish S Raut, Sumir Dubey, Akshay Gupta, Arun Maheshwari
DOI:10.4103/aca.ACA_130_18  
Left ventricular to left atrial fi stula is a very uncommon finding. Most of the cases are secondary to surgical procedures or paravalvular infectious process. The present case depicted an unusual regurgitation (apart from transmitral MR) through LV-LA fistula causing deterioration of the patient's symptoms.
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Near-infrared spectroscopy: An important tool during the blalock-taussig shunt p. 92
Aditya Lamba, Reena Khantwal Joshi, Raja Joshi, Neeraj Agarwal
DOI:10.4103/aca.ACA_138_18  
Near infra red spectroscopy (NIRS) is a noninvasive diagnostic tool for measuring regional oxygen saturation (rSO2). Cerebral oxygenation measured with NIRS is used to corroborate mixed venous oxygenation and hence considered an indicator of tissue perfusion. We describe NIRS guiding an anatomical variation leading to inadequate cerebral circulation or any impairment in cerebral oxygen delivery during Blalock Taussig shunt.
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Emergencycaesarean section of a patient with eisenmenger's syndrome: Atight-rope walk p. 95
Gauri R Gangakhedkar, Rachana D Chhabria, Surabhee D Gour, Yogalakshmi Palani
DOI:10.4103/aca.ACA_175_18  
Successful management of a pregnant patient with complex congenital heart disease is a challenge for anesthesiologists, requiring thorough knowledge of the impact of pregnancy on the cardiac lesion. Hearing and speech impaired patients pose a barrier to effective communication between the patient and the doctors, thus increasing the anxiety and risk of complications. Here, we present a case of a hearing and speech impaired woman with the rare and dangerous Eisenmenger's syndrome, presenting for an emergency cesarean section(CS).
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Aorto-left ventricular tunnel – A case report p. 98
Anitha Diwakar, Kolli S Chalam, Channabasavaraj S Hiremath, Krishna Manohar, PK Dash
DOI:10.4103/aca.ACA_14_19  
Aorto-left ventricular tunnel(ALVT) is a rare congenital anomaly with extracardiac channel connecting ascending aorta to the ventricle. It presents early in life due to congestive cardiac failure. We present a case of ALVT with unusual morphology in an 11-year-old male child with palpitations and dyspnea. We also describe the transesophageal echocardiography evaluation of ALVT.
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A rare case report of early myocardial ischemia after coronary artery bypass surgery due to mechanical compression of vein graft by pericardial drainage tube: Role of transesophageal echocardiography p. 100
Srinath Damodaran, Krishna Prasad Gourav, Azeez Aspari, Vikas Kumar, Parveen Negi, Sunder Lal Negi
DOI:10.4103/aca.ACA_233_18  
New onset regional wall motion abnormality(RWMA) following coronary artery bypass grafting adversely affects the patient outcome. Early detection and addressing the cause of RWMA improves overall morbidity and mortality of the patient. We report a rare case of early myocardial ischemia detected by intraoperative transesophageal echocardiography due to mechanical compression of a vein graft by a pericardial drain tube.
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Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography p. 103
Krishna P Gourav, Azeez Aspari, Vamsidhar Amburu, Shyam S Thingnam, Sunder Negi
DOI:10.4103/aca.ACA_238_18  
Iatrogenic valvular regurgitation following cardiac surgery has been reported as a result of leaflet perforation or entrapment. Due to its central location, the aortic valve is one of the most vulnerable structures for iatrogenic injuries. Proper assessment of the aortic valve by transesophageal echocardiography(TEE) should be done after a cardiac surgery in the periaortic area. We hereby report a case of iatrogenic aortic regurgitation which was developed after primary closure of perimembranous ventricular septal defect. It was timely diagnosed by TEE after termination of cardiopulmonary bypass and helped in further management.
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Improving hemodynamics–Prolonged intra-aortic balloon pump usage in posterior ventricular septal rupture with right ventricle dysfunction p. 106
Karthik Raman, Thapo T Desugari, S Sowmya, Samuel S Angula, Kalaichelvan Uthayakumaran, Anbarasu Mohanraj
DOI:10.4103/aca.ACA_50_19  
The associated mortality and morbidity of posterior ventricular septal rupture(VSR) is quite high increasing to almost 80% due to severe right ventricle dysfunction and pulmonary artery hypertension. Herein, we present a case of posterior VSR due to inferior wall myocardial infarction who underwent surgery. Premature removal of intra-aortic balloon pump(IABP) led to hemodynamic deterioration and he was salvaged with prolonged and prompt re-institution of IABP. This case also highlights the importance of IABP in right ventricle failure.
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Systolic anterior motion of the mitral chordae tendineae as a possible etiology for a significant left ventricular outflow tract obstruction p. 109
Ali Hosseinsabet, Tahereh Davarpasand
DOI:10.4103/aca.ACA_20_19  
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Incidentally detected biventricular noncompaction cardiomyopathy p. 110
Tahereh Davarpasand, Ali Hosseinsabet
DOI:10.4103/aca.ACA_225_18  
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