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   2010| May-August  | Volume 13 | Issue 2  
    Online since May 3, 2010

 
 
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REVIEW ARTICLES
Pregnancy and non-valvular heart disease - Anesthetic considerations
Gaurab Maitra, Saikat Sengupta, Amitava Rudra, Saurabh Debnath
May-August 2010, 13(2):102-109
DOI:10.4103/0971-9784.62933  PMID:20442539
Non-valvular heart disease is an important cause of cardiac disease in pregnancy and presents a unique challenge to the anesthesiologist during labor and delivery. A keen understanding of the underlying pathophysiology, in addition to the altered physiology of pregnancy, is the key to managing such patients. Disease-specific goals of management may help preserve the hemodynamic and ventilatory parameters within an acceptable limit and a successful conduct of labor and postpartum period
  11,691 2,001 3
Fast-tracking in pediatric cardiac surgery - The current standing
Alexander JC Mittnacht, Ingrid Hollinger
May-August 2010, 13(2):92-101
DOI:10.4103/0971-9784.62930  PMID:20442538
Fast-tracking in cardiac surgery refers to the concept of early extubation, mobilization and hospital discharge in an effort to reduce costs and perioperative morbidity. With careful patient selection, fast-tracking can be performed in many patients undergoing surgery for congenital heart disease (CHD). In order to accomplish this safely, a multidisciplinary coordinated approach is necessary. This manuscript reviews currently used anesthetic techniques, patient selection, and available information about the safety and patient outcome associated with this approach.
  11,093 1,702 14
TUTORIAL
Anesthesia for robotic cardiac surgery: An amalgam of technology and skill
Sandeep Chauhan, Subin Sukesan
May-August 2010, 13(2):169-175
DOI:10.4103/0971-9784.62947  PMID:20442552
The surgical procedures performed with robtic assitance and the scope for its future assistance is endless. To keep pace with the developing technologies in this field it is imperative for the cardiac anesthesiologists to have aworking knowledge of these systems, recognize potential complications and formulate an anesthetic plan to provide safe patient care. Challenges posed by the use of robotic systems include, long surgical times, problems with one lung anesthesia in presence of coronary artery disease, minimally invasive percutaneous cardiopulmonary bypass management and expertise in Trans-Esophageal Echocardiography. A long list of cardiac surgeries are performed with the use of robotic assistance, and the list is continuously growing as surgical innovation crosses new boundaries. Current research in robotic cardiac surgery like beating heart off pump intracardic repair, prototype epicardial crawling device, robotic fetal techniques etc. are in the stage of animal experimentation, but holds a lot of promise in future
  9,464 746 15
EDITORIALS
Perioperative management of pulmonary hypertension
Deepak K Tempe
May-August 2010, 13(2):89-91
DOI:10.4103/0971-9784.62926  PMID:20442537
  7,608 1,303 1
BRIEF COMMUNICATION
Periodontal diseases: A risk factor to cardiovascular disease
Rajiv Saini, Santosh Saini, Sugandha R Saini
May-August 2010, 13(2):159-161
DOI:10.4103/0971-9784.62936  PMID:20442548
  6,790 687 6
ORIGINAL ARTICLES
Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: A pilot study
Thomas M Hemmerling, Carmelo Minardi, Cedrick Zaouter, Nicolas Noiseux, Ignatio Prieto
May-August 2010, 13(2):116-122
DOI:10.4103/0971-9784.62938  PMID:20442541
Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher's exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.
  5,974 669 5
CASE REPORTS
Anesthetic management for surgical repair of Ebstein's anomaly along with coexistent Wolff-Parkinson-White syndrome in a patient with severe mitral stenosis
Prabhat Kumar Sinha, Bhupesh Kumar, Praveen Kerala Varma
May-August 2010, 13(2):154-158
DOI:10.4103/0971-9784.62934  PMID:20442547
Ebstein's anomaly (EA) is the most common cause of congenital tricuspid regurgitation. The associated anomalies commonly seen are atrial septal defect or patent foramen ovale and accessory conduction pathways. Its association with coexisting mitral stenosis (MS) has uncommonly been described. The hemodynamic consequences and anesthetic implications, of a combination of EA and rheumatic MS, have not so far been discussed in the literature. We report successful anesthetic management of a repair of EA and mitral valve replacement in a patient with coexisting Wolff-Parkinson-White (WPW) syndrome.
  5,686 459 1
JANAK MEHTA AWARDS
Echocardiographic evaluation and comparison of the effects of isoflurane, sevoflurane and desflurane on left ventricular relaxation indices in patients with diastolic dysfunction
Subhendu Sarkar, Rahul GuhaBiswas, Emmanuel Rupert
May-August 2010, 13(2):130-137
DOI:10.4103/0971-9784.62945  PMID:20442543
This prospective randomized study aims to evaluate and compare the effects of isoflurane, sevoflurane and desflurane (study drugs) on left ventricular (LV) diastolic function in patients with impaired LV relaxation due to ischemic heart disease using transesophageal Doppler echocardiography. After approval of the local ethics committee and informed consent, 45 patients scheduled for coronary artery bypass grafting surgery were enrolled in the study. Patients were selected by a preoperative Transthoracic Echocardiographic diagnosis of impaired relaxation or Grade 1 Diastolic Dysfunction. They randomly received fentanyl and midazolam anesthesia with 1 MAC of isoflurane (n=16), sevoflurane (n=14) or desflurane (n=15). Hemodynamic parameters and TEE derived ventricular diastolic relaxation indices before and after the study drug administration were compared. LV filling pressures were kept constant throughout the study period to exclude the effect of the loading conditions on diastolic function. Four patients in the sevoflurane group and three in the desflurane group were excluded from the study, after baseline TEE examination revealed normal diastolic filling pattern. All the three study drugs significantly reduced the systemic vascular resistance index with a significant increase in cardiac index. Mean arterial pressure was reduced by all the drugs, although the decrease was not statistically significant. Hemodynamic changes were comparable between all the three groups. In terms of LV relaxation indices, all three agents led to a significant improvement in diastolic function. Transmitral and Tissue Doppler E/A and Em/Am ratios improved significantly Transmitral and Tissue Doppler E/A and Em/Am ratios improved significantly accompanied by a significant decrease in deceleration time and isovolumetric relaxation time. The effect of all three agents on diastolic relaxation parameters was comparable. In conclusion , Isoflurane, sevoflurane and desflurane, do not appear to have a detrimental effect in patients with early diastolic dysfunction. On the contrary, these inhalational agents actually improve the LV relaxation. A significant reduction in afterload produced by these vapors can be a possible reason for these findings. The positive effect of these inhalational agents on LV relaxation can have a profound effect on the perioperative anesthetic management of patients with diastolic dysfunction.
  4,631 599 8
Acute hemodynamic effects of inhaled nitroglycerine, intravenous nitroglycerine, and their combination with intravenous dobutamine in patients with secondary pulmonary hypertension
Banashree Mandal, Poonam Malhotra Kapoor, Ujjwal Chowdhury, Usha Kiran, Minati Choudhury
May-August 2010, 13(2):138-144
DOI:10.4103/0971-9784.62946  PMID:20442544
Objectives: The presence of pulmonary artery hypertension (PAH) affects the prognosis of patients; therefore, it is important to treat it. The aim of this study is to compare the acute hemodynamic effects of inhaled nitroglycerine (iNTG), intravenous nitroglycerine (IV NTG) alone and their combination with intravenous dobutamine (IV DOB) during the early postoperative period, in patients with PAH undergoing mitral valve or double valve replacement surgery. Materials and Methods: In the study, 40 patients with secondary PAH were administered iNTG 2.5 μg/kg/min, IV NTG 2.5 μg/kg/min, a combination of iNTG 2.5 μg/kg/min + IV DOB 10 μg/kg/min, and IV NTG 2.5 μg/kg/min + IV DOB 10 μg/kg/min for 10 minutes each following valve replacement surgery, in random order. The hemodynamic parameters were recorded before (T0) and immediately after the intervention. (T1). Results: iNTG effectively decreased mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance index (PVRI), and the PVR / SVR ratio, without affecting arterial pressures, systemic vascular resistance or mixed venous oxygen saturation (SvO 2 ). IV NTG produced both systemic and pulmonary vasodilation along with a significant fall in SvO 2 . The combination of iNTG and IV DOB caused a significant decrease in mPAP and PVRI, with no significant change in SVRI, PVR / SVR ratio, and SvO 2 . A combination of IV NTG + IV DOB caused both pulmonary and systemic vasodilatation with a significant decrease in SvO 2 . None of the drugs caused any significant change in the cardiac index. Conclusion: All drugs were of similar efficacy in reducing the pulmonary vascular resistance index. Only iNTG produced selective pulmonary vasodilatation, while IV NTG and its combination with IV dobutamine had a significant concomitant systemic vasodilatory effect.
  4,700 474 10
ORIGINAL ARTICLES
Comparison of three dose regimens of aprotinin in infants undergoing the arterial switch operation
Yashwant S Verma, Sandeep Chauhan, Akshay K Bisoi, Parag Gharde, Usha Kiran, Sambhu N Das
May-August 2010, 13(2):110-115
DOI:10.4103/0971-9784.62935  PMID:20442540
To determine the most effective dose regimen of aprotinin for infants undergoing arterial switch operation for transposition of the great arteries in reducing blood loss and postoperative packed red blood cell (PRBC) requirements. A total of 24 infants scheduled for arterial switch operation for transposition of the great arteries were included in the study. The infants were randomly assigned to one of the three groups. Group I (n = 8) patients received aprotinin in a dose of 20,000 kallikrein inhibiting units (KIU)/kg after induction of anesthesia, 20,000 KIU/kg was added to the pump prime, and 20,000 KIU/kg/hour infusion for three hours after weaning from bypass; group II (n = 8) patients received aprotinin 30,000 KIU/kg after induction of anesthesia, 30,000 KIU/kg was added to the pump prime and 30,000 KIU/Kg/hour infusion for three hours after weaning from bypass; group III patients (n = 8) received aprotinin 40,000 KIU/kg after induction of anesthesia, 40,000 KIU/kg was added to the pump prime and 40,000 KIU/kg/hour infusion for three hours after weaning from bypass. Postoperatively, the cumulative hourly blood loss and PRBC requirements were noted up to 24 hours from the time of admission in the intensive care unit (ICU). Use of blood and blood products were noted. Coagulation parameters such as hematocrit, activated clotting time (ACT), fibrinogen, prothrombin time (PT), international normalized ratio (INR), platelet count, and fibrin degradation products (FDP) were investigated before cardiopulmonary bypass (CPB), after protamine administration, and at four hours postoperatively in the ICU. The number of infants reexplored for increased mediastinal drainage was recorded. Renal functions were monitored by measuring urine output (hourly) and serum urea (mg%) and serum creatinine (mg%) at 24 hours. The sternal closure time was comparable in all the three groups. Cumulative blood loss (ml/kg/24 hours) was greatest in group I (17.30 ± 7.7), least in group III (8.14 ± 3.17), whereas in group II, it was 16.45 ± 6.33 (P = 0.019 group I versus group III; (P = 0.036 group II versus group III). Postoperative PRBC requirements were significantly less in high dose group III (P = 0.008, group I versus III; p = 0.116, group II versus group III) . Tests for coagulation performed at four hours postoperatively, viz. ACT, PT, INR, FDP, and platelets were comparable in the three groups. Urine output on CPB was comparable in all the groups. Serum urea and creatinine showed no significant difference between the three groups twenty four hours postoperatively. Aprotinin dosage regimen of 40,000 KIU/kg at induction, in CPB prime and postoperatively for three hours was most effective in reducing postoperative blood loss and PRBC transfusion requirements. Aprotinin does not have any adverse effect on renal function.
  3,712 398 4
CASE REPORTS
Atrial septal defect closure on cardiopulmonary bypass in a sickle cell anemia: Role of hydroxyurea and partial exchange transfusion
Kundan Sandugir Gosavi, Sananta Kumar Dash, Bharat N Shah, CB Upasani
May-August 2010, 13(2):145-147
DOI:10.4103/0971-9784.62927  PMID:20442545
Partial exchange transfusion during cardiopulmonary bypass, while conducting cardiac surgery may be a useful technique in patients with high level of sickle hemoglobin. Along with this preoperative use of hydroxyurea and alternative analgesic modalities such as transcutaneous electrical nerve stimulation in postoperative period may be beneficial, in our opinion. A 16-year-old female of Turner's syndrome having sickle cell anemia scheduled for closure of arterial septal defect on cardiopulmonary bypass was managed with partial exchange transfusion and warm cardioplegia.
  3,767 305 5
EDITORIALS
Errors in cardiac anesthesia - A deterrent to patient safety
Murali Chakravarthy
May-August 2010, 13(2):87-88
DOI:10.4103/0971-9784.62925  PMID:20442536
  3,275 624 1
LETTERS TO EDITOR
Dynamic RVOT obstruction after transatrial/transpulmonary repair of valvular and infundibular pulmonary stenosis and VSD closure: Role of dobutamine/epinephrine infusion
Praveen Kumar Neema, Manikandan Sethuraman, Subrat Singha, Ramesh Chandra Rathod
May-August 2010, 13(2):176-178
DOI:10.4103/0971-9784.62943  PMID:20442553
  3,647 239 1
INTERESTING IMAGES
A rare case of myxoma in the right ventricular outflow tract extending to the pulmonary artery
Deepak K Tempe, Devesh Dutta, Harpreet Minhas, Mukesh Garg, Sanjula Virmani
May-August 2010, 13(2):167-168
DOI:10.4103/0971-9784.62944  PMID:20442551
  3,625 241 6
ORIGINAL ARTICLES
Comparison of B-type natriuretic peptide and left ventricular dysfunction in patients with constrictive pericarditis undergoing pericardiectomy
Poonam Malhotra Kapoor, Vikram Aggarwal, Ujjwal Chowdhury, Minati Choudhury, Sarvesh Pal Singh, Usha Kiran
May-August 2010, 13(2):123-129
DOI:10.4103/0971-9784.62942  PMID:20442542
Chronic constrictive pericarditis (CCP) due to tuberculosis has high morbidity and mortality in the periopeartive period following pericardiectomy because of left ventricular (LV) dysfunction. Brain-type natriuretic peptide (BNP) is considered a marker for both LV systolic and diastolic dysfunction. We undertook this prospective study in 24 patients, to measure the BNP levels and to compare it with transmitral Doppler flow velocities, that is, the E/A ratio (E = initial peak velocity during early diastolic filling and A = late peak flow velocity during atrial systole), as a marker of diastolic function and systolic parameters, pre- and post-pericardiectomy, at the time of discharge. The latter parameters have been taken as a flow velocity across the mitral valve on a transthoracic echo. There was a significant decrease in the mean values of log BNP (6.19 ± 0.33 to 4.65 ± 0.14) (P = 0.001) and E/A ratio (1.81 ± 0.21 to 1.01 ± 0.14) (P = 0.001) post pericardiectomy, with a positive correlation, r = 0.896 and 0.837, respectively, between the two values at both the time periods. There was significant improvement in the systolic parameters of the LV function, that is, stroke volume index, cardiac index, systemic vascular resistance index, and delivered oxygen index. However, no correlation was observed between these values and the BNP levels. We believe that BNP can be used as a marker for LV diastolic dysfunction in place of the E/A ratio in patients with CCP, undergoing pericardiectomy. However, more studies have to be performed for validation of the same.
  3,529 326 2
ECHO TUTORIAL
Transesophageal echocardiaography evaluation of thoracic aorta
Hema C Nair
May-August 2010, 13(2):186-186
DOI:10.4103/0971-9784.62928  PMID:20442558
Trans-esophageal echocardiaography is a sensitive, minimally invasive, diagnostic tool which gives real time functional image of the aorta. It helps in the diagnosis of pathologies of aorta like atherosclerosis, aneurysm and aortic dissection.
  3,090 385 1
CASE REPORTS
Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography
Shrinivas Gadhinglajkar, Rupa Sreedhar, Jayakumar Karunakaran, Manoranjan Misra, Ganesh Somasundaram, Thomas Mathew
May-August 2010, 13(2):148-153
DOI:10.4103/0971-9784.62929  PMID:20442546
A pacing system infection may lead to infective endocarditis and systemic sepsis. Tricuspid valve surgery may be required if the valve is severely damaged in the process of endocarditis. Although, cardiopulmonary bypass is the safe choice for performing right-heart procedures, it may carry risk of inducing systemic inflammatory response and multi-organ dysfunction. Some studies have advocated TV surgery without institution of CPB. We report tricuspid valve excision using the off-pump inflow occlusion technique in a 68-year-old man. We also describe role of intra-operative TEE as a monitoring tool at different stages of the surgical procedure. .
  3,176 203 1
INTERESTING IMAGES
TEE images of adult anomalous left coronary artery from pulmonary artery
Sanjay Goel, Kanwar Aditya Baloria, Nandini Selot, Bishnu Panigrahi
May-August 2010, 13(2):162-164
DOI:10.4103/0971-9784.62939  PMID:20442549
  2,722 234 -
A large angiosarcoma of the right atrium involving tricuspid valve and right ventricle
Mridu Paban Nath, Naresh Dhawan, Sandeep Chauhan, Usha Kiran
May-August 2010, 13(2):165-166
DOI:10.4103/0971-9784.62941  PMID:20442550
  2,661 188 -
LETTERS TO EDITOR
Intraoperative evaluation of left atrial myxoma using real-time 3D transesophageal echocardiography
Shrinivas Gadhinglajkar, Rupa Sreedhar
May-August 2010, 13(2):180-181
DOI:10.4103/0971-9784.62937  PMID:20442555
  2,231 186 2
Catastrophic course of free floating right heart thrombus in elective surgery
Khalid Samad, Muhammad Faisal Khan, Rehan Qureshi, M Qamarul Hoda, Hameed Ullah
May-August 2010, 13(2):178-179
DOI:10.4103/0971-9784.62940  PMID:20442554
  2,225 165 1
Pulsus alternans after aortic valve replacement: Intraoperative recognition and role of TEE
Shrinivas Gadhinglajkar, Rupa Sreedhar, Aveek Jayant
May-August 2010, 13(2):181-184
DOI:10.4103/0971-9784.62932  PMID:20442556
  2,096 158 2
Emergency resuscitative dialysis: The importance of identification of cannulation site
P Bhaskar Rao, Mohan Gurjar, Afzal Azim, Arvind K Baronia
May-August 2010, 13(2):184-185
DOI:10.4103/0971-9784.62931  PMID:20442557
  2,034 169 -