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   2010| September-December  | Volume 13 | Issue 3  
    Online since September 6, 2010

 
 
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CASE REPORTS
Perioperative anesthetic management of patients with hypertrophic cardiomyopathy for noncardiac surgery: A case series
Rajendra K Sahoo, Sananta K Dash, Pradeep S Raut, Usha R Badole, Chitra B Upasani
September-December 2010, 13(3):253-256
DOI:10.4103/0971-9784.69049  PMID:20826969
Hypertrophic cardiomyopathy with or without left ventricular outflow tract obstruction is characterized by asymmetric hypertrophy of the interventricular septum causing intermittent obstruction of the left ventricular outflow tract. Because Hypertrophic cardiomyopathy is the most common genetic cardiovascular disease, it may present to the anesthesiologist more often than anticipated, sometimes in undiagnosed form during routine preoperative visit. Surgery and anesthesia often complicate the perioperative outcome if adequate monitoring and proper care are not taken. Therefore, a complete understanding of the pathophysiology, hemodynamic changes and anesthetic implications is needed for successful perioperative outcome. We hereby describe the perioperative management of three patients with Hypertrophic cardiomyopathy for different surgical procedures.
  49,640 1,915 4
REVIEW ARTICLES
Atrial fibrillation after cardiac surgery
Suresh G Nair
September-December 2010, 13(3):196-205
DOI:10.4103/0971-9784.69047  PMID:20826960
Once considered as nothing more than a nuisance after cardiac surgery, the importance of postoperative atrial fibrillation (POAF) has been realized in the last decade, primarily because of the morbidity associated with the condition. Numerous causative factors have been described without any single factor being singled out as the cause of this complication. POAF has been associated with stroke, renal failure and congestive heart failure, although it is difficult to state whether POAF is directly responsible for these complications. Guidelines have been formulated for prevention of POAF. However, very few cardiothoracic centers follow any form of protocol to prevent POAF. Routine use of prophylaxis would subject all patients to the side effects of anti-arrhythmic drugs, while only a minority of the patients do actually develop this problem postoperatively. Withdrawal of beta blockers in the postoperative period has been implicated as one of the major causes of POAF. Amiodarone, calcium channel blockers and a variety of other pharmacological agents have been used for the prevention of POAF. Atrial pacing is a non-pharmacological measure which has gained popularity in the prevention of POAF. There is considerable controversy regarding whether rate control is superior to rhythm control in the treatment of established atrial fibrillation (AF). Amiodarone plays a central role in both rate control and rhythm control in postoperative AF. Newer drugs like dronedarone and ranazoline are likely to come into the market in the coming years.
  21,641 1,519 13
Sugammadex - A short review and clinical recommendations for the cardiac anesthesiologist
Thomas M Hemmerling, Cedrick Zaouter, Goetz Geldner, Dirk Nauheimer
September-December 2010, 13(3):206-216
DOI:10.4103/0971-9784.69052  PMID:20826961
This review outlines the basic pharmacodynamic and pharmacokinetic properties of sugammadex for the cardiac anesthesiologist. It describes the different clinical scenarios when sugammadex can be used during cardiac surgery and gives clinical recommendations. Sugammadex is a unique reversal drug that binds a chemical complex with rocuronium and vecuronium, by which the neuromuscular blockade is quickly reversed. It is free of any clinical side-effects and doses of 2 mg/kg or more reliably reverse neuromuscular blockade within 5-15 min, depending on the depth of the neuromuscular blockade. Doses below 2 mg/kg should be avoided at any time because of the inherent risk of recurarization. Sugammadex should not replace good clinical practice - titration of neuromuscular blocking drugs to clinical needs and objective monitoring of neuromuscular blockade in the operating room or intensive care unit. Neuromuscular transmission should be determined in all patients before sugammadex is considered and 5 min after its administration to ensure that extubation is performed with normal neuromuscular transmission.
  17,893 1,342 16
LETTERS TO EDITOR
Anesthetic management of patent ductus arteriosus - Not always an easy option
Sarvesh P Singh, Sandeep Chauhan, Usha Kiran
September-December 2010, 13(3):263-264
DOI:10.4103/0971-9784.69061  PMID:20826973
  12,297 891 1
ORIGINAL ARTICLES
A randomized trial of anesthetic induction agents in patients with coronary artery disease and left ventricular dysfunction
Raveen Singh, Minati Choudhury, Poonam Malhotra Kapoor, Usha Kiran
September-December 2010, 13(3):217-223
DOI:10.4103/0971-9784.69057  PMID:20826962
The deleterious effects of anesthetic agents in patients suffering from coronary artery disease are well known. The risk increases when a patient has compromised ventricular function. There is a paucity of literature regarding the choice of the suitable agent to avoid deleterious effects in such patients. The use of etomidate and propofol has been considered superior to other intravenous anesthetic agents in these groups of patients. The aim of the present study is to compare the hemodynamic effects of anesthesia induction with etomidate, thiopentone, propofol, and midazolam in patients with coronary artery disease and left ventricular dysfunction. This randomized clinical trail was conducted at the All Indian Institute of Medical Sciences, New Delhi, India. Sixty patients with coronary artery disease and left ventricular dysfunction (ejection fraction < 45%) scheduled for elective coronary artery bypass surgery participated in this study. After stabilization baseline hemodynamic data stroke volume variation and systemic vascular resistance index were recorded for all patients (Flo Trac TM sensor with Vigileo cardiac output monitor used for hemodynamic monitoring). The patients were randomly alloted to one of the four groups and the intravenous induction agent was administered for over 60 - 90 seconds (Group E - Etomidate 0.2 mg/Kg; Group M - Midazolam 0.15 mg/Kg; Group T - Thiopentone 5 mg/Kg; Group P - Propofol 1.5 mg/Kg). Hemodynamic data were recorded at one minute intervals starting from induction till seven minutes after intubation, - the end point of the present study. There was a significant decrease in the heart rate in comparison to the baseline(-7 to -15%, P = 0.001), mean arterial pressure (-27 to -32%, P = 0.001), cardiac index (-36 to -38%, P = 0.001), and stroke volume index (-27 to -34%, P = 0.001) after induction in all four groups. The hemodynamic response was similar in all the four groups. There was no significant change in central venous pressure and stroke volume variation (SVV) during induction and intubation, while the effects on the systemic vascular resistance index (SVRI) were variable. The midazolam group was the most effective in preventing intubation stress (tachycardia,hypertension). The change from baseline values in heart rate (+ 4%, P = 0.12) and mean arterial pressure (-1%, P = 0.77) after intubation were not statistically significant in the midazolam group. The etomidate group was the least effective of all the four groups in minimizing stress response, with statistically significant increase from baseline in both heart rate (P = 0.001) and mean arterial pressure (P = 0.001) at 1 minute after intubation. All the four anesthetic agents were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction despite a 30 - 40% decrease in the cardiac index. Clinician experience along with knowledge of the potential interactions (e.g., premedication, concurrent opioid use) is needed to determine hemodynamic stability during anesthetic induction in these patients with ventricular dysfunction.
  9,269 1,198 12
CASE REPORTS
Cardiac herniation following completion pneumonectomy for bronchiectasis
Shrinivas Gadhinglajkar, Shivananda Siddappa, Rupa Sreedhar, Unnikrishnan Madathipat
September-December 2010, 13(3):249-252
DOI:10.4103/0971-9784.69045  PMID:20826968
Sporadic reports on cardiac herniation are available in the literature; most of them had followed intrapericardial pneumonectomies for malignant pulmonary tumors. We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic bronchiectasis. A 35-year-old male patient was operated for left completion pneumonectomy. A 6 cm Χ 4 cm area of adherent pericardium near the obtuse margin of heart was removed during surgery. During head-end elevation of the bed in postoperative intensive care unit, patient got accidentally tilted to the left side, which resulted in ventricular fibrillation. Chest cavity was re-opened for cardiopulmonary resuscitation. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall. During surgical re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the immediate postoperative period. Patients had infection of the left thoracic cavity after 5 weeks, for which he was subjected to thoracoplasty and omentopexy. Prompt recognition with timely intervention is life saving from cardiac herniation. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.
  9,029 215 5
Anesthetic management of a patient with hypertrophic obstructive cardiomyopathy with dual-chamber pacemaker undergoing transurethral resection of the prostate
Amit Jain, Kajal Jain, Hemant Bhagat, Kishore Mangal, Yatinder Batra
September-December 2010, 13(3):246-248
DOI:10.4103/0971-9784.69043  PMID:20826967
We describe the anesthetic management of a patient with hypertrophic obstructive cardiomyopathy with dual-chamber pacemaker undergoing transurethral resection of the prostate. Anesthetic challenges included prevention and management of perioperative arrhythmias, maintenance of adequate preload, afterload and heart rate to relieve left ventricular outflow tract obstruction and considerations related to the presence of dual-chamber pacemaker and TURP. We recommend preoperative reprogramming of the DDD pacemaker, avoidance of magnet application during the procedure, application of electrosurgical unit current returning pad to the anterior aspect of the thigh, especially if monopolar cautery is used, use of central venous pressure line for estimation of preload and careful titration of anesthetic drugs to maintain stable hemodynamics.
  8,297 431 3
EDITORIALS
Establishing a new cardiac surgical unit: Challenges and solutions
Yatin Mehta, Yash Paul Bhatia
September-December 2010, 13(3):192-195
DOI:10.4103/0971-9784.69039  PMID:20826959
  7,232 699 -
ORIGINAL ARTICLES
Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease
Yatin Mehta, Mayank Vats, Munish Sharma, Reetesh Arora, Naresh Trehan
September-December 2010, 13(3):224-230
DOI:10.4103/0971-9784.69062  PMID:20826963
The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia.
  5,946 443 15
Is EuroSCORE applicable to Indian patients undergoing cardiac surgery?
Madhur Malik, Sandeep Chauhan, Vishwas Malik, Parag Gharde, Usha Kiran, RM Pandey
September-December 2010, 13(3):241-245
DOI:10.4103/0971-9784.69082  PMID:20826966
Indian patients undergoing cardiac surgery have different demographics, clinical profile as well as risk profile, compared to the western population. The purpose of this study was to validate the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification model in Indian patients undergoing cardiac surgery in a single cardiac center. Data from 1000 consecutive adult patients undergoing cardiac surgery (coronary artery bypass grafting or valve surgery) were prospectively collected as per the EuroSCORE model. The model's validity was assessed on the basis of its calibration power (Hosmer-Lemeshow test) and discriminatory power [area under receiver operating characteristic curve]. The patients were divided into three risk groups on the basis of their EuroSCORE. The Hosmer-Lemeshow test revealed a good calibration power (P = 0.73) and the area under the ROC curve was 0.8278, suggesting a good discriminative power. The predicted mortality was similar to observed mortality in low- and moderate-risk patients but the observed mortality in high-risk patients (15.6%) was double that of predicted mortality (7.5%). The risk factors prevalent in European population were not observed in Indian population. EuroSCORE accurately predicts mortality in low and moderate-risk Indian patients undergoing cardiac surgery but is less predictive for high-risk Indian patients. Updating and improvisation of EuroSCORE by incorporation of risk factors associated with rheumatic valvular heart disease which is more prevalent in India, may enable it to accurately predict mortality in high-risk patients also.
  4,986 429 11
INTERESTING IMAGES
Interesting TEE image
Muralidhar Kanchi
September-December 2010, 13(3):260-260
DOI:10.4103/0971-9784.69055  PMID:20826971
  3,615 235 -
EDITORIALS
Neuromuscular blockade and outcome in cardiac anesthesia
Thomas M Hemmerling, Cedrick Zaouter
September-December 2010, 13(3):189-191
DOI:10.4103/0971-9784.69035  PMID:20826958
  3,428 414 3
LETTERS TO EDITOR
Correlation between central venous-arterial carbon dioxide tension gradient and cardiac index changes following fluid therapy
Alexandre Yazigi, Hicham Abou-Zeid, Fadia Haddad, Samia Madi-Jebara, Gemma Hayeck, Khalil Jabbour
September-December 2010, 13(3):269-271
DOI:10.4103/0971-9784.69079  PMID:20826979
  3,498 309 7
An unusual case of thoracic gossypiboma
Rakhi K Retnamma, Suresh G Nair, B Umadethan, P Manoj
September-December 2010, 13(3):261-263
DOI:10.4103/0971-9784.69059  PMID:20826972
  3,438 166 3
ORIGINAL ARTICLES
Intraoperative anastomotic site detection and assessment of LIMA-to-LAD anastomosis by epicardial ultrasound in off-pump coronary artery bypass grafting - A prospective single-blinded study
Harish Babu Ravulapalli, Ranjith B Karthekeyan, Mahesh Vakumudi, Ramesh Srigiri, Richard Saldanha, Sajith Sulaiman
September-December 2010, 13(3):231-235
DOI:10.4103/0971-9784.69069  PMID:20826964
The study was done to detect the optimal site of left anterior descending (LAD) artery for grafting and for the assessment of geometrical and anatomical characteristics of left internal mammary artery (LIMA)-to-LAD artery anastomosis in elective off-pump coronary artery bypass grafting surgery. Fifteen consecutive patients who underwent coronary artery bypass graft (CABG) were included in the study. All the operations were performed by a single surgeon. Epicardial ultrasound probe was placed at the site of grafting for scanning and the site of anastomosis selected. The anticipated target site selected by the surgeon was scanned for patency, size, septal perforator branches, and presence of plaque and calcification. The surgeon identified the LAD artery in 12 patients. In three patients, the LAD artery was not visible. However, with epicardial ultrasound, the LAD artery was identified in all patients. In 6 of 15 patients, the anticipated target anastomotic site was changed to a clear segment either due to the presence of perforators or plaques or calcifications. In all 15 patients, the surgeon scored the anastomosis as good, based on his or her experience independent of the ultrasound image. The anastomotic score by the cardiac anesthesiologist showed 5 anastomoses with satisfactory results and 10 anastomoses with good results. The study demonstrates that epicardial ultrasound scanning with a 10-MHz transducer provides reliable information in choosing the proper anastomotic site and allows proper visualization of LIMA-to-LAD anastomosis. All these measurements are easily obtained without risk of any complications and the method is not time consuming.
  2,991 192 1
LETTERS TO EDITOR
Kounis syndrome - The killer for Williams syndrome?
Nicholas G Kounis, Grigorios Tsigkas, George Almpanis, Andreas Mazarakis, George N Kounis
September-December 2010, 13(3):265-266
DOI:10.4103/0971-9784.69065  PMID:20826975
  2,945 202 6
ORIGINAL ARTICLES
Controlled transient respiratory arrest along with rapid right ventricular pacing for improving balloon stability during balloon valvuloplasty in pediatric patients with congenital aortic stenosis - A retrospective case series analysis
Sampa Dutta Gupta, Soumi Das, Tapas Ghose, Achyut Sarkar, Anupam Goswami, Sudeshna Kundu
September-December 2010, 13(3):236-240
DOI:10.4103/0971-9784.69076  PMID:20826965
Rapid right ventricular pacing is safe, effective, and established method to provide balloon stability during balloon aortic valvuloplasty (BAV). Controlled transient respiratory arrest at this point of time may further reduce left ventricular stroke volume, providing an additional benefit to maintain balloon stability. Two groups were studied. Among the 10 patients, five had rapid pacing alone (Group A), while the other five were provided with cessation of positive pressure breathing as well (Group B). The outcomes of BAV in the two groups of patients were studied. One patient in Group A had failed balloon dilatation even after the fourth attempt, while in Group B there were no failures. The peak systolic gradient reduction was higher in Group B (70.05% in comparison to 52.16% of group A). In Group A, five subjects developed aortic regurgitation (grade 2 in four and grade 3 in one, while no grade 3 aortic regurgitation developed in any patient in Group B). Controlled transient respiratory arrest along with rapid ventricular pacing may be effective in maintaining balloon stability and improve the outcome of BAV.
  2,788 161 2
CASE REPORTS
Congenital hypopituitarism: Monitoring after coronary artery bypass grafting
Stavros Siminelakis, Angeliki Kotsanti, Nikolaos G Baikoussis, Maria Andrikoula, Eleni Bairaktari, George Papadopoulos
September-December 2010, 13(3):257-259
DOI:10.4103/0971-9784.69051  PMID:20826970
Cardiovascular disease in patients with congenital hypopituitarism is not rare; however, there is a lack of reports referring to cardiac interventions in such patients. We present a 76-year-old man with complete pituitary hormone deficiency, who presented with recurrent events of unstable angina. He had a significant stenosis of the left anterior descending artery and he underwent off-pump coronary artery bypass. Our aim is to present the successful management of this patient with congenital hypopituitarism who underwent cardiac surgery and to review the relevant literature.
  2,634 152 -
LETTERS TO EDITOR
Prevention of cardiac arrest due to anesthesia in Williams syndrome
Viroj Wiwanitkit
September-December 2010, 13(3):269-269
DOI:10.4103/0971-9784.69075  PMID:20826980
  2,518 183 -
Anesthesia for noncardiac surgery in infant with undiagnosed single ventricle
Satyen Parida, RM Mohan, Ravindra R Bhat, Sandeep K Mishra, Ashok S Badhe
September-December 2010, 13(3):266-267
DOI:10.4103/0971-9784.69068  PMID:20826976
  2,007 172 2
To evaluate the heart or not in emergency neurosurgical head-injured patients with ST elevation
Amit Jain, Neeti Dogra, Kishore Mangal
September-December 2010, 13(3):268-269
DOI:10.4103/0971-9784.69073  PMID:20826978
  1,714 124 1
End to end anastomosis of an injured left anterior descending coronary artery
Akhlesh S Tomar, Saket Agarwal, Aditya Singh, Shivsagar Mandiye, Devesh Dutta, Vishnu Datt
September-December 2010, 13(3):267-268
DOI:10.4103/0971-9784.69071  PMID:20826977
  1,697 97 -
Post-operative management of endarterectomy
Viroj Wiwanitkit
September-December 2010, 13(3):264-264
DOI:10.4103/0971-9784.69063  PMID:20826974
  1,569 152 -