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   2015| January-March  | Volume 18 | Issue 1  
    Online since January 1, 2015

 
 
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ORIGINAL ARTICLES
The role of point-of-care assessment of platelet function in predicting postoperative bleeding and transfusion requirements after coronary artery bypass grafting
Pankaj Kumar Mishra, Joyce Thekkudan, Raj Sahajanandan, Mike Gravenor, Suresh Lakshmanan, Khazi Mohammed Fayaz, Heyman Luckraz
January-March 2015, 18(1):45-51
DOI:10.4103/0971-9784.148321  PMID:25566711
Objective: Objective platelet function assessment after cardiac surgery can predict postoperative blood loss, guide transfusion requirements and discriminate the need for surgical re-exploration. We conducted this study to assess the predictive value of point-of-care testing platelet function using the Multiplate® device. Methods: Patients undergoing isolated coronary artery bypass grafting were prospectively recruited ( n = 84). Group A ( n = 42) patients were on anti-platelet therapy until surgery; patients in Group B ( n = 42) stopped anti-platelet treatment at least 5 days preoperatively. Multiplate® and thromboelastography (TEG) tests were performed in the perioperative period. Primary end-point was excessive bleeding (>2.5 ml/kg/h) within first 3 h postoperative. Secondary end-points included transfusion requirements, re-exploration rates, intensive care unit and in-hospital stays. Results: Patients in Group A had excessive bleeding (59% vs. 33%, P = 0.02), higher re-exploration rates (14% vs. 0%, P < 0.01) and higher rate of blood (41% vs. 14%, P < 0.01) and platelet (14% vs. 2%, P = 0.05) transfusions. On multivariate analysis, preoperative platelet function testing was the most significant predictor of excessive bleeding (odds ratio [OR]: 2.3, P = 0.08), need for blood (OR: 5.5, P < 0.01) and platelet transfusion (OR: 15.1, P < 0.01). Postoperative "ASPI test" best predicted the need for transfusion (sensitivity - 0.86) and excessive blood loss (sensitivity - 0.81). TEG results did not correlate well with any of these outcome measures. Conclusions: Peri-operative platelet functional assessment with Multiplate® was the strongest predictor for bleeding and transfusion requirements in patients on anti-platelet therapy until the time of surgery. Study registration: ISRCTN43298975 (http://www.controlled-trials.com/ISRCTN43298975/).
  6 3,178 253
CASE REPORTS
Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: Advantages of 3D TEE illustrated in three cases
Cindy J Wang, Cesar A Rodriguez Diaz, Muoi A Trinh
January-March 2015, 18(1):83-86
DOI:10.4103/0971-9784.148326  PMID:25566716
Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra-operatively, and it has the ability to provide continuous real-time information. Three-dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra-operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two-dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real-time 3D TEE during intra-operative management of a type A aortic dissection.
  2 1,259 151
JANAK MEHTA AWARD
Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: A single center experience in a developing economy
Rakhi Balachandran, Mahesh Kappanayil, Amitabh Chanchal Sen, Abhish Sudhakar, Suresh G Nair, GS Sunil, R Benedict Raj, Raman Krishna Kumar
January-March 2015, 18(1):52-57
DOI:10.4103/0971-9784.148322  PMID:25566712
Background: The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world. Objective: We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution. Methods: The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection. Results: The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance. Conclusions: The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.
  2 1,696 206
ORIGINAL ARTICLES
The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery
Dalia Abdelhamid Nasr, Hadeel Magdy Abdelhamid, Mai Mohsen, Ahmad Helmy Aly
January-March 2015, 18(1):15-20
DOI:10.4103/0971-9784.148314  PMID:25566704
Background: Median sternotomy, sternal spreading, and sternal wiring are the main causes of pain during the early recovery phase following cardiac surgery. Aim: This study was designed to evaluate the analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after parasternal block following cardiac surgery. Materials and Methods: The total of 40 patients (American Society of Anesthesiologist status II, III), 45-60 years old, undergoing coronary - artery bypass grafting were enrolled in this prospective, randomized, double-blind study. A presternal catheter was inserted with continuous infusion of 5 mL/h bupivacaine 0.25% (Group B) or normal saline (Group C) during the first 48 postoperative hrs. Primary outcomes were postoperative morphine requirements and pain scores, secondary outcomes were extubation time, postoperative respiratory parameters, incidence of wound infection, Intensive Care Unit (ICU) and hospital stay duration, and bupivacaine level in blood. Statistical Methods: Student's t-test was used to analyze the parametric data and Chi-square test for categorical variables. Results: During the postoperative 48 h, there was marked reduction in morphine requirements in Group B compared to Group C, (8.6 ± 0.94 mg vs. 18.83 ± 3.4 mg respectively, P = 0.2), lower postoperative pain scores, shorter extubation time (117 ± 10 min vs. 195 ± 19 min, respectively, P = 0.03), better respiratory parameters (PaO 2 /FiO 2, PaCO 2 and pH), with no incidence of wound infection, no differences in ICU or hospital stay duration. The plasma concentration of bupivacaine remained below the toxic threshold (at T24, 1.2 ug/ml ± 0.3 and T48 h 1.7 ± 0.3 ug/ml). Conclusion: Continuous presternal bupivacaine infusion has resulted in better postoperative analgesia, reduction in morphine requirements, shorter time to extubation, and better postoperative respiratory parameters than the control group.
  2 1,789 307
CASE REPORTS
Intractable hyperkalemia due to nicorandil induced potassium channel syndrome
Vivek Chowdhry, BB Mohanty
January-March 2015, 18(1):101-103
DOI:10.4103/0971-9784.148331  PMID:25566721
Nicorandil is a commonly used antianginal agent, which has both nitrate-like and ATP-sensitive potassium (K ATP ) channel activator properties. Activation of potassium channels by nicorandil causes expulsion of potassium ions into the extracellular space leading to membrane hyperpolarization, closure of voltage-gated calcium channels and finally vasodilatation. However, on the other hand, being an activator of K ATP channel, it can expel K + ions out of the cells and can cause hyperkalemia. Here, we report a case of nicorandil induced hyperkalemia unresponsive to medical treatment in a patient with diabetic nephropathy.
  1 1,465 168
Left ventricular mass: Myxoma or thrombus?
Monish S Raut, Arun Maheshwari, Sumir Dubey, Sandip Joshi
January-March 2015, 18(1):95-97
DOI:10.4103/0971-9784.148329  PMID:25566719
Patient with embolic episode should always be evaluated for cardiac mass. Mass in left ventricular can be a myxoma or thrombus even in a normal functioning heart . In either case, mobile mass with embolic potential should be surgically resected.
  1 2,669 182
ORIGINAL ARTICLE
Efficacy of tranexamic acid as compared to aprotinin in open heart surgery in children
Nagarajan Muthialu, Soundaravalli Balakrishnan, Rajani Sundar, Srinivasan Muralidharan
January-March 2015, 18(1):23-26
DOI:10.4103/0971-9784.148316  PMID:25566706
Background: Coagulopathy is a major issue in children undergoing high-risk pediatric cardiac surgery. Use of anti-fibrinolytics is well documented in adults, but recently there are questions raised about safety and effectiveness of their use on routine use. Tranexamic acid is a potent anti-fibrinolytic, but its role is not fully understood in children. This study aims to study the benefits tranexamic acid in controlling postoperative bleeding in pediatric cardiac surgical patients. Methods and Results: Fifty consecutive children who underwent cardiac surgery were randomized prospectively to receive either aprotinin (Group A; n = 24) or tranexamic acid (Group B; n = 26) from September 2009 to February 2010 were studied. Primary end points were early mortality, postoperative drainage, reoperation for bleeding and complications. Mean age and body weight was smaller in Group A (Age: 48.55 vs. 64.73 months; weight 10.75 vs. 14.80 kg) respectively. Group A had more cyanotic heart disease than Group B (87.5% vs. 76.92%). Mean cardiopulmonary bypass time (144.33 vs. 84.34 min) and aortic cross-clamp time (78.5 vs. 41.46 min) were significantly higher in group A. While the blood and products usage was significantly higher in Group A, there was no difference in indexed postoperative drainage in first 4, 8 and 12 h and postoperative coagulation parameters. Mean C-reactive protein was less in Group A than B and renal dysfunction was seen more in Group A (25% vs. 7.6%). Mortality in Group A was 16.66% and 7.6% in Group B. Conclusion: Anti-fibrinolytics have a definitive role in high-risk children who undergo open-heart surgery. Tranexamic acid is as equally effective as aprotinin with no additional increase in morbidity or mortality. Ultramini Abstract: Coagulopathy has been a major issue in pediatric cardiac surgery, and anti-fibrinolytics have been used fairly regularly in various settings. This study aims to evaluate the efficacy of tranexamic acid as compared against that of aprotinin in a randomized model. Tranexamic acid proves to be equally effective with less toxicity with no added mortality.
  1 1,588 233
ORIGINAL ARTICLES
Pediatric cardiac catheterization procedure with dexmedetomidine sedation: Radiographic airway patency assessment
Ashwini Thimmarayappa, Nivash Chandrasekaran, AM Jagadeesh, Shreedhar S Joshi
January-March 2015, 18(1):29-33
DOI:10.4103/0971-9784.148318  PMID:25566708
Aims: The aim of the study was to measure airway patency objectively during dexmedetomidine sedation under radiographic guidance in spontaneously breathing pediatric patients scheduled for cardiac catheterization procedures. Subjects and Methods: Thirty-five patients in the age group 5-10 years scheduled for cardiac catheterization procedures were enrolled. All study patients were given loading dose of dexmedetomidine at 1 mg/kg/min for 10 min and then maintenance dose of 1.5 mg/kg/h. Radiographic airway patency was assessed at the start of infusion (0 min) and after 30 min. Antero-posterior (AP) diameters were measured manually at the nasopharyngeal and retroglossal levels. Dynamic change in airway between inspiration and expiration was considered a measure of airway collapsibility. Patients were monitored for hemodynamics, recovery time and complications. Statistical Analysis: Student paired t-test was used for data analysis. P < 0.05 was considered significant. Results: Minimum and maximum AP diameters were compared at 0 and 30 min. Nasopharyngeal level showed significant reduction in the minimum (6.27 ± 1.09 vs. 4.26 ± 1.03, P < 0.0001) and maximum (6.51 ± 1.14 vs. 5.99 ± 1.03, P < 0.0001) diameters. Similarly retroglossal level showed significant reduction in the minimum (6.98 ± 1.09 vs. 5.27 ± 1.15, P < 0.0001) and maximum (7.49 ± 1.22 vs. 6.92 ± 1.12, P < 0.0003) diameters. The degree of collapsibility was greater at 30 min than baseline ( P < 0.0001). There was a significant decrease in heart rate ( P < 0.0001), and the average recovery time was 39.86 ± 12.22 min. Conclusion: Even though airway patency was maintained in all children sedated with dexmedetomidine, there were significant reductions in the upper airway dimensions measured, so all precautions to manage the airway failure should be taken.
  1 2,321 206
Efficacy of cardiac resynchronization with defibrillator insertion in patients undergone coronary artery bypass graft: A cohort study of cardiac function
Reza Karbasi Afshar, Mahdi Ramezani Binabaj, Mohammad Saeid Rezaee Zavareh, Amin Saburi, Reza Ajudani
January-March 2015, 18(1):34-38
DOI:10.4103/0971-9784.148319  PMID:25566709
Introduction: Cardiac resynchronization therapy (CRT) is a proven therapeutic method in selected patients with heart failure and systolic dysfunction which increases left ventricular function and patient survival. We designed a study that included patients undergoing coronary artery bypass graft (CABG), with and without CRT-defibrillator (CRT-D) inserting and then measured its effects on these two groups. Patients and Methods: Between 2010 and 2013, we conducted a prospective cohort study on 100 coronary artery disease patients where candidate for CABG. Then based on the receiving CRT-D, the patients were categorized in two groups; Group 1 ( n = 48, with CRT-D insertion before CABG) and Group 2 ( n = 52 without receiving CRT-D). Thereafter both of these groups were followed-up at 1-3 months after CABG for mortality, hospitalization, atrial fibrillation (AF), echocardiographic assessment, and New York Heart Association (NYHA) class level. Results: The mean age of participants in Group 1 (48 male) and in Group 2 (52 male) was 58 ± 13 and 57 ± 12 respectively. Difference between Groups 1 and 2 in cases of mean left ventricular ejection fraction (LVEF) changes and NYHA class level was significant ( P > 0.05). Hospitalization ( P = 0.008), mortality rate ( P = 0.007), and AF were significantly different between these two groups. Conclusions: The results showed that the increase in LVEF and patient's improvement according to NYHA-class was significant in the first group, and readmission, mortality rate and AF was increased significantly in the second group.
  1 978 143
BOOK REVIEW
Book review: Manual of extracorporeal membrane oxygenation in the ICU
K Muralidhar
January-March 2015, 18(1):117-117
  - 1,086 173
CASE REPORTS
Initial non-opioid based anesthesia in a parturient having severe aortic stenosis undergoing cesarean section with aortic valve replacement
Subrata Podder, Ajay Kumar, Sachin Mahajan, Pradip Kumar Saha
January-March 2015, 18(1):98-100
DOI:10.4103/0971-9784.148330  PMID:25566720
Pregnancy in presence of severe aortic stenosis (AS) causes worsening of symptoms needing further intervention. In the advanced stages of pregnancy, some patients may even require aortic valve replacement (AVR) and cesarean delivery in the same sitting. Opioid based general anesthesia for combined lower segment cesarean section (LSCS) with AVR has been described. However, the use of opioid may lead to fetal morbidity and need of respiratory support for the baby. We describe successful anesthetic management for LSCS with AVR in a >33 week gravida with severe AS and congestive heart failure. We avoided opioids till delivery of the baby AVR; the delivered neonate showed a normal APGAR score.
  - 1,393 175
Left ventricular rupture postmitral valve replacement: Surviving a catastrophe
Samarjit Bisoyi, Jitendu Mohanty, Raghunath Mohapatra, Debashish Nayak
January-March 2015, 18(1):87-90
DOI:10.4103/0971-9784.148327  PMID:25566717
One of the dreaded mechanical complications of mitral valve replacement (MVR) is rupture of the left ventricle (LV). This report describes the early diagnosis and successful repair of rupture of posterior wall of LV in an elderly patient who underwent MVR. We have discussed the risk factors and perioperative issues implicated in such complication. The anesthesiologist as an intra-operative echocardiographer can aid in identifying the patient at risk. Though important surgical steps are necessary to prevent the complication; nonetheless, the anesthesiologist needs to take key measures in the perioperative period.
  - 3,002 230
Postoperative rescue closure of patent foramen ovale in the clinical setting of acute hypoxemic respiratory failure and stroke following coronary artery bypass surgery
José L Díaz-Gómez, Eduardo Rodrigues, Monica Mordecai, John Moss, Richard C Agnew, Keith R Oken
January-March 2015, 18(1):91-94
DOI:10.4103/0971-9784.148328  
We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option.
  - 593 62
COMMENTARY
The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery: A commentary
Murali Chakravarthy
January-March 2015, 18(1):21-22
DOI:10.4103/0971-9784.148315  PMID:25566705
  - 1,030 139
Comparison of tranexamic acid with aprotinin in pediatric cardiac surgery
Sandeep Chauhan
January-March 2015, 18(1):27-28
DOI:10.4103/0971-9784.148317  PMID:25566707
  - 1,348 177
EDITORIAL
Evolutionary change: The new face of Annals of Cardiac Anesthesia
Poonam Malhotra Kapoor
January-March 2015, 18(1):1-3
DOI:10.4103/0971-9784.148311  PMID:25566701
  - 947 170
HEART TO HEART BLOG
Left ventricular false tendon in a patient undergoing mitral valve replacement
S Subash, Parimala Prasanna Simha, Amarja Nagre, Balaji Babu, AM Jagadeesh
January-March 2015, 18(1):108-110
DOI:10.4103/0971-9784.148335  PMID:25566725
  - 1,449 137
Double aortic arch as a source of airway obstruction in a child
Sambhunath Das, Vinitha V Nair, Balram Airan
January-March 2015, 18(1):111-112
DOI:10.4103/0971-9784.148336  PMID:25566726
Double aortic arch (DAA) is a congenital vascular anomaly. The diagnosis was difficult till the child was symptomatic, and other causes were ruled out. We present the interesting images of a child of respiratory distress because of tracheal compression from DAA.
  - 1,380 162
Sutureless left pulmonary vein augmentation for primary endoluminal pulmonary vein ostial stenosis: Role of pulmonary venous Doppler
Jitin Narula, Girish Tanwar, Usha Kiran, Velayoudham Devagourou
January-March 2015, 18(1):113-114
DOI:10.4103/0971-9784.148337  PMID:25566727
  - 802 97
INVITED EDITORIAL
Is cardiac anaesthesiologist the best person to look after cardiac critical care?
Yatin Mehta
January-March 2015, 18(1):4-7
DOI:10.4103/0971-9784.148312  PMID:25566702
  - 1,612 241
LETTERS TO EDITOR
In response to "positive end-expiratory pressure valve malfunctioning detected by capnographic and airway pressure waveform"
Poulami Choudhury, Subrata Kumar Singha
January-March 2015, 18(1):104-104
DOI:10.4103/0971-9784.148332  PMID:25566722
  - 666 97
Author's reply for comment on "positive end-expiratory pressure valve malfunctioning detected by capnographic and airway pressure waveform"
Sohan Lal Solanki, Jeson R Doctor, Vijaya P Patil, Meenal Rana
January-March 2015, 18(1):105-105
DOI:10.4103/0971-9784.148333  PMID:25566723
  - 628 85
Difficult venous catheterization in internal jugular vein
Monish S Raut, Maheshwari Arun
January-March 2015, 18(1):106-107
DOI:10.4103/0971-9784.148334  PMID:25566724
  - 949 139
ORIGINAL ARTICLES
Urinary neutrophil gelatinase-associated lipocalin time course during cardiac surgery
Elena Bignami, Elena Frati, Roberta Meroni, Marco Simonini, Ambra Licia Di Prima, Paolo Manunta, Alberto Zangrillo
January-March 2015, 18(1):39-44
DOI:10.4103/0971-9784.148320  PMID:25566710
Background: NGAL is one of the most promising AKI biomarkers in cardiac surgery. However, the best timing to dose it and the reference values are still matter of discussion. Aim of the Study: We performed a uNGAL perioperative time course, to better understand its perioperative kinetics and its role in AKI diagnosis. Setting of the Study: San Raffaele University Hospital, cardiac surgery department. Material and Methods: We enrolled in this prospective observational study 19 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Based on preoperative characteristics, they were divided in low-risk and high-risk patients. uNGAL measurements were collected at pre-defined times before, during, and up to 24 hours after surgery. Statistical Analysis: Data were analysed by use of SAS 1999-2001 program or IBM SPSS Statistics. Results: In low-risk patients, uNGAL had the highest value immediately after general anesthesia induction (basal dosage: uNGAL: 12.20ng×ml -1 , IQR 14.00). It later decreased significantly (3.40 ng×ml -1 , IQR 4.80; P = 0.006) during CPB, and finally return to its original value 24 hours after surgery. In high-risk patients, uNGAL increased immediately after surgery; it had the highest value on ICU arrival (38,20 ng×ml -1 ; IQR 133,10) and remained high for several hours. A difference in uNGAL levels between the two groups was already observed at the end of surgery, but it became statistically significant on ICU arrival (P = 0.002). Conclusion: This study helps to better understand the different kinetics of this new biomarker in low-risk and high-risk cardiac patients.
  - 1,462 177
Diastolic function and new-onset atrial fibrillation following cardiac surgery
David W Barbara, Kent H Rehfeldt, Juan N Pulido, Zhuo Li, Roger D White, Hartzell V Schaff, William J Mauermann
January-March 2015, 18(1):8-14
DOI:10.4103/0971-9784.148313  PMID:25566703
Background: Numerous studies have reported predictors of new-onset postoperative atrial fibrillation (POAF) following cardiac surgery, which is associated with increased length of stay, cost of care, morbidity, and mortality. The purpose of this study was to examine the association between preoperative diastolic function and occurrence of new-onset POAF in patients undergoing a variety of cardiac surgeries at a single institution. Methods: Using data from a prospective study from November 2007 to January 2010, a retrospective review was conducted. The diastolic function of each patient was determined from preoperative transthoracic echocardiograms. Occurrence of new-onset POAF was prospectively noted for each patient in the original study. Demographic and operative characteristics of the study population were analyzed to determine predictors of POAF. Results: Of 223 patients, 91 (40.8%) experienced new-onset POAF. Univariate predictors of POAF included increasing age, male gender, operations involving mitral valve repair/replacement, nonsmoking, hypertension, increased intraoperative pulmonary artery pressure, grade I diastolic dysfunction, abnormal diastolic function of any grade, decreased medial e', elevated medial E/e', and increased left atrial volume. Multivariate predictors of POAF included increasing age, increased left atrial volume, and elevated initial intraoperative pulmonary artery pressure. Even after exclusion of patients with hypertrophic obstructive cardiomyopathy or those undergoing mitral valve operations, diastolic dysfunction was not a multivariate predictor of POAF. Conclusions: In the patient population studied here, preoperative diastolic dysfunction was not predictive of POAF. In addition to increasing age, initial intraoperative pulmonary artery systolic pressure and left atrial volume were both significant multivariate predictors of POAF.
  - 1,971 262
REVIEW ARTICLES
Three-dimensional echocardiographic assessment of atrial septal defects
Charles German, Navin C Nanda
January-March 2015, 18(1):69-73
DOI:10.4103/0971-9784.148324  PMID:25566714
Echocardiography provides a useful tool in the diagnosis of many congenital heart diseases, including atrial septal defects, and aids in further delineating treatment options. Although two-dimensional echocardiography has been the standard of care in this regard, technological advancements have made three-dimensional echocardiography possible, and the images obtained in this new imaging modality are able to accurately portray the morphology, location, dimensions, and dynamic changes of defects and many other heart structures during the cardiac cycle.
  - 1,688 295
Statistics in clinical research: Important considerations
Howard Barkan
January-March 2015, 18(1):74-82
DOI:10.4103/0971-9784.148325  PMID:25566715
Statistical analysis is one of the foundations of evidence-based clinical practice, a key in conducting new clinical research and in evaluating and applying prior research. In this paper, we review the choice of statistical procedures, analyses of the associations among variables and techniques used when the clinical processes being examined are still in process. We discuss methods for building predictive models in clinical situations, and ways to assess the stability of these models and other quantitative conclusions. Techniques for comparing independent events are distinguished from those used with events in a causal chain or otherwise linked. Attention then turns to study design, to the determination of the sample size needed to make a given comparison, and to statistically negative studies.
  - 3,367 338
TUTORIAL
Anesthetic issues for robotic cardiac surgery
Wendy K Bernstein, Andrew Walker
January-March 2015, 18(1):58-68
DOI:10.4103/0971-9784.148323  PMID:25566713
As innovative technology continues to be developed and is implemented into the realm of cardiac surgery, surgical teams, cardiothoracic anesthesiologists, and health centers are constantly looking for methods to improve patient outcomes and satisfaction. One of the more recent developments in cardiac surgical practice is minimally invasive robotic surgery. Its use has been documented in numerous publications, and its use has proliferated significantly over the past 15 years. The anesthesiology team must continue to develop and perfect special techniques to manage these patients perioperatively including lung isolation techniques and transesophageal echocardiography (TEE). This review article of recent scientific data and personal experience serves to explain some of the challenges, which the anesthetic team must manage, including patient and procedural factors, complications from one-lung ventilation (OLV) including hypoxia and hypercapnia, capnothorax, percutaneous cannulation for cardiopulmonary bypass, TEE guidance, as well as methods of intraoperative monitoring and analgesia. As existing minimally invasive techniques are perfected, and newer innovations are demonstrated, it is imperative that the cardiothoracic anesthesiologist must improve and maintain skills to guide these patients safely through the robotic procedure.
  - 2,973 363
VIDEO COMMENTARIES
Imaging The Aorta
Dheeraj Arora, Yatin Mehta
January-March 2015, 18(1):115-115
PMID:25566728
  - 780 124
Imaging The Right Ventricle
Poonam Malhotra Kapoor, Jitin Narula, Usha Kiran
January-March 2015, 18(1):116-116
PMID:25566729
  - 838 137