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   2014| January-March  | Volume 17 | Issue 1  
    Online since January 2, 2014

 
 
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ORIGINAL ARTICLE
Anesthesia management for MitraClip device implantation
Harikrishnan Kothandan, Ho Vui Kian, Yeo Khung Keong, Hwang Nian Chih
January-March 2014, 17(1):17-22
DOI:10.4103/0971-9784.124126  PMID:24401297
Aims and Objectives: Percutaneous MitraClip implantation has been demonstrated as an alternative procedure in high-risk patients with symptomatic severe mitral regurgitation (MR) who are not suitable (or) denied mitral valve repair/replacement due to excessive co morbidity. The MitraClip implantation was performed under general anesthesia and with 3-dimensional transesophageal echocardiography (TEE) and fluoroscopic guidance. Materials and Methods: Peri-operative patient data were extracted from the electronic and paper medical records of 21 patients who underwent MitraClip implantations. Results: Four MitraClip implantation were performed in the catheterization laboratory; remaining 17 were performed in the hybrid operating theatre. In 2 patients, procedure was aborted, in one due to migration of the Chiari network into the left atrium and in second one, the leaflets and chords of the mitral valve torn during clipping resulting in consideration for open surgery. In the remaining 19 patients, MitraClip was implanted and the patients showed acute reduction of severe MR to mild-moderate MR. All the patients had invasive blood pressure monitoring and the initial six patients had central venous catheterization prior to the procedure. Intravenous heparin was administered after the guiding catheter was introduced through the inter-atrial septum and activated clotting time was maintained beyond 250 s throughout the procedure. Protamine was administered at the end of the procedure. All the patients were monitored in the intensive care unit after the procedure. Conclusions: Percutaneous MitraClip implantation is a feasible alternative in high-risk patients with symptomatic severe MR. Anesthesia management requirements are similar to open surgical mitral valve repair or replacement. TEE plays a vital role during the MitraClip implantation.
  9,135 586 2
REVIEW ARTICLES
Cardiopulmonary bypass in pregnancy
Mukul Chandra Kapoor
January-March 2014, 17(1):33-39
DOI:10.4103/0971-9784.124133  PMID:24401299
Cardiac surgery carried out on cardiopulmonary bypass (CPB) in a pregnant woman is associated with poor neonatal outcomes although maternal outcomes are similar to cardiac surgery in non-pregnant women. Most adverse maternal and fetal outcomes from cardiac surgery during pregnancy are attributed to effects of CPB. The CPB is associated with utero-placental hypoperfusion due to a number of factors, which may translate into low fetal cardiac output, hypoxia and even death. Better maternal and fetal outcomes may be achieved by early pre-operative optimization of maternal cardiovascular status, use of perioperative fetal monitoring, optimization of CPB, delivery of a viable fetus before the operation and scheduling cardiac surgery on an elective basis during the second trimester.
  8,100 987 2
CASE REPORTS
Cardiac surgery during pregnancy: Continuous fetal monitoring using umbilical artery Doppler flow velocity indices
Manisha Mishra, Ravindra Sawhney, Anil Kumar, Kumar Ramesh Bapna, Vijay Kohli, Harpreet Wasir, Naresh Trehan
January-March 2014, 17(1):46-51
DOI:10.4103/0971-9784.124141  PMID:24401303
The fetal death rate associated with cardiac surgery with cardiopulmonary bypass (CPB) is as high as 9.5-29%. We report continuous monitoring of fetal heart rate and umbilical artery flow-velocity waveforms by transvaginal ultrasonography and their analyses in relation to events of the CPB in two cases in second trimester of pregnancy undergoing mitral valve replacement. Our findings suggest that the transition of circulation from corporeal to extracorporeal is the most important event during surgery; the associated decrease in mean arterial pressure (MAP) at this stage potentially has deleterious effects on the fetus, which get aggravated with the use of vasopressors. We suggest careful management of CPB at this stage, which include partial controlled CPB at initiation and gradual transition to full CPB; this strategy maintains high MAP and avoids the use of vasopressors. Maternal and fetal monitoring can timely recognize the potential problems and provide window for the required treatment.
  3,884 329 2
REVIEW ARTICLES
Multimodal neuromonitoring in pediatric cardiac anesthesia
Alexander J. C. Mittnacht, Cesar Rodriguez-Diaz
January-March 2014, 17(1):25-32
DOI:10.4103/0971-9784.124130  PMID:24401298
Despite significant improvements in overall outcome, neurological injury remains a feared complication following pediatric congenital heart surgery (CHS). Only if adverse events are detected early enough, can effective actions be initiated preventing potentially serious injury. The multifactorial etiology of neurological injury in CHS patients makes it unlikely that one single monitoring modality will be effective in capturing all possible threats. Improving current and developing new technologies and combining them according to the concept of multimodal monitoring may allow for early detection and possible intervention with the goal to further improve neurological outcome in children undergoing CHS.
  3,202 406 1
CASE REPORTS
Emergency mitral valve replacement for acute severe mitral regurgitation following balloon mitral valvotomy: Pathophysiology of hemodynamic collapse and peri-operative management issues
Praveen Reddy Bayya, Praveen Kerala Varma, Suneel Puthuvassery Raman, Praveen Kumar Neema
January-March 2014, 17(1):52-55
DOI:10.4103/0971-9784.124143  PMID:24401304
Severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV) needing emergent mitral valve replacement is a rare complication. The unrelieved mitral stenosis is compounded by severe MR leading to acute rise in pulmonary hypertension and right ventricular afterload, decreased coronary perfusion, ischemia and right ventricular failure. Associated septal shift and falling left ventricular preload leads to a vicious cycle of myocardial ischemia and hemodynamic collapse and needs to be addressed emergently before the onset of end organ damage. In this report, we describe the pathophysiology of hemodynamic collapse and peri-operative management issues in a case of mitral valve replacement for acute severe MR following BMV.
  2,532 286 -
INTERESTING IMAGES
Unicommissural unicuspid aortic valve
Mario Montealegre-Gallegos, Omair Shakil, Luyang Jiang, Feroze Mahmood
January-March 2014, 17(1):40-41
DOI:10.4103/0971-9784.124135  PMID:24401300
  2,488 164 -
CASE REPORTS
Management of a case of left tracheal sleeve pneumonectomy under cardiopulmonary bypass: Anesthesia perspectives
Aman Jyoti, Arun Maheshwari, Ganesh Shivnani, Arvind Kumar
January-March 2014, 17(1):62-66
DOI:10.4103/0971-9784.124147  PMID:24401307
The lung tumors with carinal involvement are frequently managed with tracheal sleeve pneumonectomy and tracheobronchial anastomosis without use of cardiopulmonary bypass (CPB). Various modes of ventilation have been described during tracheal resection and anastomosis. Use of CPB during this period allows the procedure to be conducted in a more controlled way. We performed tracheal sleeve pneumonectomy for adenoid cystic carcinoma of left lung involving carina. The surgery was performed in two stages. In the first stage, left pneumonectomy was performed and in the second stage after 48 h, tracheobronchial resection and anastomosis was performed under CPB. Second stage was delayed to avoid excessive bleeding (due to heparinization) from the extensive vascular raw area left after pneumonectomy. Meticulous peri-operative planning and optimal post-operative care helped in successful management of a complex case, which is associated with high morbidity and mortality.
  2,387 158 -
LETTERS TO EDITOR
Unexplained desaturation following a Glenn shunt
G Girish, Saket Agarwal, Vishnu Datt, AS Tomar, DK Satsangi
January-March 2014, 17(1):74-75
DOI:10.4103/0971-9784.124162  PMID:24401311
  2,333 205 1
Preanesthesia assessment clinic for cardiac surgery by cardiac anesthesiologist: A practice statement
Madhur Malik, Amar M Panchal, Kesava K Dev
January-March 2014, 17(1):77-78
DOI:10.4103/0971-9784.124167  PMID:24401313
  2,042 376 -
CASE REPORTS
Localized pericardial tamponade: Does it always need exploration?
Monish S Raut, Arun Maheshwari, Ganesh Shivnani
January-March 2014, 17(1):67-69
DOI:10.4103/0971-9784.124149  PMID:24401308
A 48-year-old female patient underwent coronary artery bypass surgery. One-hour after surgery, the patient developed hemodynamic instability. Transthoracic echocardiography (TTE) was inconclusive. Transesophageal echocardiography (TEE) was performed and it revealed localised collection around right atrium. In spite of the evidence of localized tamponade, wait and watch policy was employed rather than re-exploring the patient emergently. The patient recovered uneventfully. If hemodynamics remain stable and there is no fall in hematocrit and no increase in effusion on TEE/TTE examination, then localized tamponade can be managed conservatively without reexploring the patient.
  2,080 186 -
LETTERS TO EDITOR
Accidental cannulation of aberrant radial artery
N Sathish, SR Prasad, KS Nagesh, AM Jagadeesh
January-March 2014, 17(1):76-77
DOI:10.4103/0971-9784.124165  PMID:24401312
  2,110 150 -
ORIGINAL ARTICLE
Correlation of cardiac output and sevoflurane required to maintain anesthetic depth targeted with entropy index
Andrei E Bautin, Ann V Siganevich, Elena Y Malaya, Evgenii A Khomenko, Mikhail L Gordeev, Vladislav N Solntsev
January-March 2014, 17(1):4-7
DOI:10.4103/0971-9784.124115  PMID:24401295
Aims and Objectives: We investigated the correlation of reduced cardiac output on required sevoflurane to maintain targeted anesthesia depth. Materials and Methods: 36 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively included in the study. Inspired sevoflurane concentration was adjusted to ensure state entropy index < 40. Analgesia was provided by either boluses of fentanyl 200 μg or continuous infusion of fentanyl 5 μg/kg/h; the total dose of fentanyl administered in the patients was not different (fentanyl boluses 6.5 ± 0.3 μg/kg/h vs. fentanyl infusion 5 μg/kg/h). Cardiac-index (CI), end tidal sevoflurane (ETsev) and entropy index were measured simultaneously at 1-5 min after sternotomy, during internal mammary artery harvesting and during pericardiotomy. 108 sets of variables (entropy index, ETsev, CI) were recorded from 36 subjects at three time points; 13 sets were excluded due to technical drawbacks in measurements. 95 data sets were eligible for analysis. Sixty-five data sets measured in patients with target state entropy index were analyzed to establish the relationship between CI and ETsev. Results: We did not find a linear correlation between ETsev and CI in patients with target entropy index (correlation coefficient = 0.18, P = 0.14). The ETsev necessary to maintain the target level of anesthesia was lower in patients with CI ≤ 2.2 l/min/m 2 (1.15% ± 0.28%) than patients with CI > 2.2 l/min/m 2 (1.37% ± 0.31%), P = 0.01. Conclusion: Relationship between CI and ETsev required for maintaining target level of anesthesia is non-linear. Patients with CI ≤ 2.2 l/min/m 2 need lower levels of the ETsev for maintenance of the target anesthesia at an entropy index < 40.
  1,959 240 1
EDITORIAL
Cardiopulmonary bypass during pregnancy - Fetal demise: An enigma
Praveen Kumar Neema
January-March 2014, 17(1):1-3
DOI:10.4103/0971-9784.124111  PMID:24401294
  1,911 286 -
INTERESTING IMAGES
Real and pseudo clot in left atrial appendage
Monish S Raut, Arun Maheshwari, Sujay Shad
January-March 2014, 17(1):42-43
DOI:10.4103/0971-9784.124137  PMID:24401301
  2,066 0 1
CASE REPORTS
Stroke associated with left atrial mass: Association of cerebral aneurysm with left atrial myxoma!
Shashi Srivastava, Prabhat Tewari
January-March 2014, 17(1):56-58
DOI:10.4103/0971-9784.124144  PMID:24401305
Association of LA myxoma with cerebral aneurysm is rare. We describe a patient who had LA mass and cerebral aneurysm and developed stroke. The patient underwent clipping of the cerebral aneurysm. We discuss the pathology of the association and the anesthetic management.
  1,688 161 1
Management of high-risk reentry sternotomy in an infant for repair of a giant pseudoaneurysm of the right ventricular outflow tract
Bryan G Maxwell, Lisa Wise-Faberowski
January-March 2014, 17(1):59-61
DOI:10.4103/0971-9784.124145  PMID:24401306
Improved survival from congenital heart disease has led to an increasing need for complex reoperation by reentrant sternotomy. Peripheral cannulation and initiation of cardiopulmonary bypass prior to sternotomy to avoid the risk of cardiac injury and massive hemorrhage is an option in adults and larger children, but femoral vessel size precludes this strategy in infants. We describe the management of a high-risk reentry sternotomy in an infant for repair of a giant pseudoaneurysm after prior homograft repair of tetralogy of Fallot, using surgical dissection for suprasternal cannulation of the innominate artery and subxyphoid cannulation of the inferior vena cava.
  1,640 120 -
ORIGINAL ARTICLE
The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection
Ayda Türköz, Şule Turgut Balcı, Hülya Gönen, Özlem Çınar, Emre Özker, Rıza Türköz
January-March 2014, 17(1):10-15
DOI:10.4103/0971-9784.124122  PMID:24401296
Aims and Objectives: We used near-infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO 2 ) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO 2 when compared with other ventilation modes. Materials and Methods: 20 consecutive patients undergoing BDG were included. We measured SctO 2 during three ventilator modes (intermittent positive-pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). Results: There was no change in SctO 2 in IPPV and SIMV modes; the SctO 2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) ( P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) ( P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) ( P < 0.01). Conclusions: The SctO 2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.
  1,565 167 2
INTERESTING IMAGES
Transesophageal echocardiographic image of partial aortic disruption
Dharmesh Radheshyam Agrawal, Mohammed Rehan Sayeed
January-March 2014, 17(1):44-45
DOI:10.4103/0971-9784.124138  PMID:24401302
  1,296 131 -
LETTERS TO EDITOR
In response to "Anaphylaxis during intravenous administration of amiodarone" Is amiodarone the best choice for management of atrial fibrillation?
Indira Malik
January-March 2014, 17(1):70-71
DOI:10.4103/0971-9784.124153  PMID:24401309
  1,271 149 -
INVITED COMMENTARY
Modes of ventilation, cerebral oximetry, and bidirectional Glenn procedure
Muralidhar Kanchi
January-March 2014, 17(1):15-16
  1,232 175 -
LETTERS TO EDITOR
In response to "Posterior mediastinal mass: Do we need to worry much ?"
Subrata Kumar Singha, Narendra Kuber Bodhey
January-March 2014, 17(1):72-73
DOI:10.4103/0971-9784.124158  PMID:24401310
  1,025 117 1
INVITED COMMENTARY
Adaptive responsiveness of anesthesiologists to the rapidly expanding hybrid cardiovascular procedures: MitraClip, the percutaneous Alfieri
Balachundhar Subramaniam, Kathirvel Subramaniam
January-March 2014, 17(1):23-24
  902 110 -
Time to manage gas based on research
David Canty
January-March 2014, 17(1):7-9
  900 109 -
LETTERS TO EDITOR
Authors' reply
Hızır Okuyan, Cihan Altın, Okan Arıhan
January-March 2014, 17(1):71-72
DOI:10.4103/0971-9784.124157  
  847 85 -
Authors' reply
Parin Lalwani, Rajiv Chawla, Mritunjay Kumar, Akhilesh S Tomar, Padmalatha Raman
January-March 2014, 17(1):73-74
DOI:10.4103/0971-9784.124160  
  754 88 -