Annals of Cardiac Anaesthesia : 2013 - 16(2)

Acute aortic dissection: Pitfalls in the diagnosis

Praveen Kumar Neema — Fri,29 Mar 2013

Praveen Kumar Neema

Annals of Cardiac Anaesthesia 2013 16(2):83-85

Incidence and implications of coronary artery disease in patients undergoing valvular heart surgery: The Indian scenario

Deepak K Tempe — Fri,29 Mar 2013

Deepak K Tempe, Sanjula Virmani, Rupak Gupta, Vishnu Datt, Chandrashekhar Joshi, Aastha Dhingra, Rahul Dutta, Harpreet Singh Minhas

Annals of Cardiac Anaesthesia 2013 16(2):86-91

Aims and Objectives: We evaluated the incidence and implications of coronary artery disease (CAD) in patients above 40 years presenting for valve surgery. Materials and Methods: Between January 2009 and December 2010, coronary angiography (CAG) was performed in all such patients ( n = 140). Results: Coronaries were normal in 119 (Group I), and diseased in 21 (Group II). In Group II, 11 patients were < 50 years, 3 were between 51 and 60 years and 7 were > 61 years. In 8 of these, only valve replacement was performed. Coronary artery bypass grafting (CABG) and aortic valve replacement was performed in 10, CABG and mitral valve replacement in 2 and CABG with mitral and aortic valve replacement in one. The number of vessels grafted in these 13 patients was 1.54 ± 0.66. Hypertension and diabetes were significant ( P < 0.05) in this group. The mortality was significant in Group II (11 vs. 6, P < 0.05). Six patients died in Group II, 5 had severe aortic stenosis and severe left ventricular hypertrophy; the sixth patient had severe mitral stenosis and was in CHF. The predominant cause of death was congestive heart failure (CHF). Conclusions: Fifteen percentage of these patients had CAD. CAG should be performed routinely in these patients while presenting for valve surgery. Combined CABG and valve replacement carries high mortality (28.5%), especially in patients with aortic stenosis. The study suggests that the cardio-protective measures should be applied more rigorously in this subset of patients.

Invited Commentary

Harish Ramakrishna — Fri,29 Mar 2013

Harish Ramakrishna

Annals of Cardiac Anaesthesia 2013 16(2):92-93

Effect of levosimendan on hemodynamic changes in patients undergoing off-pump coronary artery bypass grafting: A randomized controlled study

Rajesh Kumar Kodalli — Fri,29 Mar 2013

Rajesh Kumar Kodalli, Ayya Syama Sundar, Mahesh Vakamudi, Harish Ravulapali, Sushma Nandipati, Nivash Chandrasekaran, Ranjith Baskar Karthekeyan

Annals of Cardiac Anaesthesia 2013 16(2):94-99

Aims and Objective: We tested the hypothesis that use of levosimendan would be associated with better perioperative hemodynamics and cardiac function during off-pump coronary artery bypass grafting (OPCAB) in patients with good left ventricular function. Materials and Methods: Thirty patients scheduled for OPCAB were randomized in a double-blind manner to receive either levosimendan 0.1 μg/kg/min or placebo after induction of general anesthesia. The hemodynamic variables were measured after induction of anesthesia, at 6 minute after application of tissue stabilizer for the anastomoses of left anterior descending artery, diagonal artery, left circumflex artery, and right coronary artery and at 6, 12, 18, and 24 hours after completion of surgery. Results: Compared with placebo group, cardiac index (CI) was significantly higher and systemic vascular resistance index (SVRI) was significantly lower at 6, 12, 18, and 24 hour after surgery in levosimendan group. Norepinephrine was infused in 60% of the patients in the levosimendan group compared to 6.7% in the control group ( P < 0.05). Lactate and mixed venous oxygen saturation were not significantly different between groups. Conclusions: Levosimendan significantly increased CI and decreased SVRI after OPCAB but it did not show any outcome benefit in terms of duration of ventilation and intensive care unit stay.

Invited Commentary

Mukul Chandra Kapoor — Fri,29 Mar 2013

Mukul Chandra Kapoor

Annals of Cardiac Anaesthesia 2013 16(2):99-101

Impact of monitoring cerebral oxygen saturation on the outcome of patients undergoing open heart surgery

BS Mohandas — Fri,29 Mar 2013

BS Mohandas, AM Jagadeesh, SB Vikram

Annals of Cardiac Anaesthesia 2013 16(2):102-106

Aims and Objectives: We studied the usefulness of regional cerebral oxygen saturation (rSO 2 ) monitoring during cardiopulmonary bypass (CPB) and evaluated effects of cerebral oxygen desaturation on the postoperative neurological outcome. Materials and Methods: 100 patients were randomly allocated to either control or intervention group. In the control group rSO 2 was recorded continuously, but the attending anesthesiologist was blinded. In the intervention group specific interventions were initiated in case of cerebral desaturation. Neurocognitive testing was done using a simplified antisaccadic eye movement test (ASEM) and mini-mental state examination (MMSE). Data was analyzed using Chi-square test, and unpaired t-test. Results: In both the groups rSO 2 declined during CPB. The decrease in rSO 2 was significant ( P < 0.001) in the control group compared to the intervention group. In the intervention group the rSO 2 mainly responded to an increase in mean arterial pressure. The area under the curve below threshold rSO 2 was significantly more ( P < 0.0001) in the control group compared to intervention group and a significant decrease in the MMSE and ASEM scores occurred in control group at one week and three months postoperatively. Conclusions: Monitoring of rSO 2 during CPB can significantly decrease the incidence of postoperative neurocognitive decline.

Action is the foundational key to all success" (Pablo Picasso)

Alexander J.C. Mittnacht — Fri,29 Mar 2013

Alexander J.C. Mittnacht

Annals of Cardiac Anaesthesia 2013 16(2):107-108

The efficacy of caudal dexmedetomidine on stress response and postoperative pain in pediatric cardiac surgery

Dalia Abdelhamid Nasr — Fri,29 Mar 2013

Dalia Abdelhamid Nasr, Hadeel Magdy Abdelhamid

Annals of Cardiac Anaesthesia 2013 16(2):109-114

Aims and objectives: We studied efficacy of caudal dexmedetomidine (DEX) on attenuation of perioperative stress response and postoperative pain in pediatric patients undergoing cardiac surgery. Materials and Methods: Forty patients, (ASA II, III), 1-3-years old were randomly allocated into two groups; group BD received caudal bupivacaine 0.25%, 2.5 mg/kg and DEX 0.5 μg/kg and group BF received bupivacaine 2.5 mg/kg and fentanyl 1 μg/kg. Results: Serum cortisol and blood glucose levels increased in both groups but increases were significantly less in group BD. Poststernotomy cortisol level (ug/dl) was 55.3 ± 5.1 vs. 90.4 ± 6.5; after cardio-pulmonary bypass (CPB) 84.1 ± 6.2 vs. 153.1 ± 8.5; after operation 78.3 ± 8.1 vs. 150.2 ± 9.8. Poststernotomy blood glucose level (mg/dl) was 93.6 ± 7.2 vs. 125.6 ± 5.5; after CPB 115.3 ± 3.7 vs. 175.3 ± 10.4; and after operation 97.3 2 ± 3 vs. 162.2 ± 12. Heart rate and mean arterial pressure decreased significantly after caudal block in group BD relative to the baseline and compared with group BF ( P < 0.05). Group BD had lower pain scores at first hour 2 ± 0.7 vs. 3 ± 1.1 ( P = 0.04); second hour 1.9 ± 0.5 vs. 3.7 ± 0.8, ( P = 0.008); fourth hour 2.4 ± 0.8 vs. 4.3 ± 0.5 ( P = 0.03); and eighth hour 2.5 ± 0.5 vs. 4.2 ± 1.1 ( P = 0.03). Conclusions: Caudal DEX attenuated stress response to surgical trauma and provided better postoperative analgesia.

Is caudal dexmedetomidine in pediatric cardiac surgery a novel idea?

Vipul Krishen Sharma — Fri,29 Mar 2013

Vipul Krishen Sharma

Annals of Cardiac Anaesthesia 2013 16(2):115-116

Antifibrinolytics in cardiac surgery

Achal Dhir — Fri,29 Mar 2013

Achal Dhir

Annals of Cardiac Anaesthesia 2013 16(2):117-125

Cardiac surgery exerts a significant strain on the blood bank services and is a model example in which a multi-modal blood-conservation strategy is recommended. Significant bleeding during cardiac surgery, enough to cause re-exploration and/or blood transfusion, increases morbidity and mortality. Hyper-fibrinolysis is one of the important contributors to increased bleeding. This knowledge has led to the use of anti-fibrinolytic agents especially in procedures performed under cardiopulmonary bypass. Nothing has been more controversial in recent times than the aprotinin controversy. Since the withdrawal of aprotinin from the world market, the choice of antifibrinolytic agents has been limited to lysine analogues either tranexamic acid (TA) or epsilon amino caproic acid (EACA). While proponents of aprotinin still argue against its non-availability. Health Canada has approved its use, albeit under very strict regulations. Antifibrinolytic agents are not without side effects and act like double-edged swords, the stronger the anti-fibrinolytic activity, the more serious the side effects. Aprotinin is the strongest in reducing blood loss, blood transfusion, and possibly, return to the operating room after cardiac surgery. EACA is the least effective, while TA is somewhere in between. Additionally, aprotinin has been implicated in increased mortality and maximum side effects. TA has been shown to increase seizure activity, whereas, EACA seems to have the least side effects. Apparently, these agents do not differentiate between pathological and physiological fibrinolysis and prevent all forms of fibrinolysis leading to possible thrombotic side effects. It would seem prudent to select the right agent knowing its risk-benefit profile for a given patient, under the given circumstances.

Aortic dissection: To be or not to be?

Kanwar Aditya Baloria — Fri,29 Mar 2013

Kanwar Aditya Baloria, Achal Dhir, Biju Pillai, Nandini Selot

Annals of Cardiac Anaesthesia 2013 16(2):126-128

Patients with acute aortic dissection present with such varied symptoms that diagnosis becomes difficult. Various imaging techniques like computed tomography angiography (CTA), magnetic resonance imaging and ultrasonography are used to diagnose this entity, but they too have their limitations. We present a case, which was falsely diagnosed as acute aortic dissection by CTA, which resulted in patient undergoing sternotomy.

Mitral regurgitation jet around neoannulus: Mitral valve replacement in erysipelothrix rhusiopathiae endocarditis

Rahul Basu — Fri,29 Mar 2013

Rahul Basu, Prabhat Tewari

Annals of Cardiac Anaesthesia 2013 16(2):129-132

A 50-year-old male presented with erysipelothrix rhusiopathiae (ER) endocarditis of the mitral valve, severe mitral regurgitation, and heart failure. The ER endocarditis destroyed the native mitral annulus therefore a new annulus was created for the suspension of the mitral bioprosthesis. Postoperative neoannulus dehiscence and leak prompted to redo surgery where transesophageal echocardiography (TEE) played an important role in pointing out the exact location of perineoannular leaks for repair.

An unusual cause of intraoperative acute superior vena cava syndrome

Adam W Amundson — Fri,29 Mar 2013

Adam W Amundson, Juan N Pulido, Geoffrey L Hayward

Annals of Cardiac Anaesthesia 2013 16(2):133-136

Acute intraoperative superior vena cava (SVC) syndrome is an exceedingly rare complication in the cardiac surgical population. We describe the case of a 71-year-old female undergoing multi-vessel coronary artery bypass grafting who developed acute intraoperative SVC syndrome following internal thoracic artery harvest retractor placement. Her symptoms included severe plethora, facial engorgement and scleral edema, which was associated with hypotension and severe elevation of central venous pressure. Transesophageal echocardiography was crucial in the diagnosis, management, and optimal retractor placement ensuring adequate SVC flow. Potential causes of intraoperative SVC syndrome are reviewed as well as management options.

Technology: An aid to clinical judgement

Radhika Govindasamy — Fri,29 Mar 2013

Radhika Govindasamy, Palaniappan Manickam, Ganesh Gopalakrishnan, S Muralidharan

Annals of Cardiac Anaesthesia 2013 16(2):137-139

Complete removal of renal cell tumor with thrombus which extends above the diaphragm often necessitates use of cardiopulmonary bypass. Transesophageal echocardiography (TEE) can play an important role in delineating the extent of tumor growth. We describe a patient with renal cell carcinoma with thrombosis invading into the right ventricle and its complete removal with the aid of TEE.

Perioperative management of tracheobronchial injury following blunt trauma

Nilesh M Juvekar — Fri,29 Mar 2013

Nilesh M Juvekar, Sharmila S Deshpande, Anand Nadkarni, Shreedhar Kanitkar

Annals of Cardiac Anaesthesia 2013 16(2):140-143

We describe tracheobronchial injury (TBI) in a 17-year-old teenager following blunt trauma resulting from a road traffic accident. The patient presented to a peripheral hospital with swelling over the neck and face associated with bilateral pneumothorax for which bilateral intercostal drains were inserted and the patient was transferred to our institute. Fiber-optic videobronchoscopy (FOB) was performed, the trachea and bronchi were visualized, and the site and extent of injury was assessed. Spontaneous respiration was maintained till assessment of the airway. Then the patient was anesthetized with propofol and paralyzed using succinylcholine and a double-lumen endobronchial tube was inserted; thereafter, the adequacy of controlled manual ventilation and air-leak through intercostal drains was assessed and the patient was transferred to operating room (OR) for repair of the airway injury. The OR was kept ready during FOB to manage any catastrophe. This case describes the need for proper preparation and communication between health care team members to manage all possible scenarios of traumatic TBI.

A rare case of a left atrial hemangioma mimicking a myxoma

Saikat Bandyopadhyay — Fri,29 Mar 2013

Saikat Bandyopadhyay, Ratan Kumar Das, Ashima Bhelotkar, Tanmay Acharia

Annals of Cardiac Anaesthesia 2013 16(2):144-146

A 68-year-old gentleman presented with a recent history of exertional dyspnea associated with anginal chest pain. Transthoracic echocardiography revealed a well-circumscribed mass in the left atrium attached to the inter-atrial septum. A provisional diagnosis of left atrial (LA) myxoma was made. Coronary angiography revealed significant single-vessel disease. The patient underwent coronary artery bypass grafting and resection of the LA tumor. The histopathological diagnosis of the tumor came out to be a cardiac hemangioma.

Cardiac surgery in a patient with immunological thrombocytopenic purpura: Complications and precautions

Vivek Chowdhry — Fri,29 Mar 2013

Vivek Chowdhry, BB Mohanty, Dash Probodh

Annals of Cardiac Anaesthesia 2013 16(2):147-150

Immune thrombocytopenic purpura (ITP) patients are at high-risk for bleeding complications during and after cardiac surgeries involving cardiopulmonary bypass. We report a patient with ITP with severe coronary artery disease and mitral valve regurgitation who underwent uncomplicated coronary artery bypass grafting and mitral valve replacement. Three weeks later, the patient was readmitted in a very low general condition with signs of pericardial tamponade. We describe our experience of managing the case.

Agenesis of the lung

Devesh Dutta — Fri,29 Mar 2013

Devesh Dutta, Anil Karlekar, Ravindra Saxena

Annals of Cardiac Anaesthesia 2013 16(2):151-152

Giant aortic root after previous aortic valve replacement

Apostolos Roubelakis — Fri,29 Mar 2013

Apostolos Roubelakis, Dimos Karangelis, Markku Kaarne

Annals of Cardiac Anaesthesia 2013 16(2):153-154

In response to, 'Magnets and implantable cardioverter defibrillators'

Somsri Wiwanitkit — Fri,29 Mar 2013

Somsri Wiwanitkit, Viroj Wiwanitkit

Annals of Cardiac Anaesthesia 2013 16(2):155-155

Activated clotting time tube malfunction: A rare cause of heparin overdose

Bhupesh Kumar — Fri,29 Mar 2013

Bhupesh Kumar, Ashok Kumar Badamali

Annals of Cardiac Anaesthesia 2013 16(2):155-156

Anesthetic implications in Holt-Oram Syndrome

Ajmer Singh — Fri,29 Mar 2013

Ajmer Singh, Vikrant S Pathania, Samir Girotra, Krishna S Iyer

Annals of Cardiac Anaesthesia 2013 16(2):157-158

An unusual case of high central venous pressure

Michele Zasa — Fri,29 Mar 2013

Michele Zasa, Antonella Vezzani, Annachiara Aldrovandi

Annals of Cardiac Anaesthesia 2013 16(2):158-160

Whistling from deep within!

Prakash K Dubey — Fri,29 Mar 2013

Prakash K Dubey, Rakesh K Singh

Annals of Cardiac Anaesthesia 2013 16(2):160-160