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   2016| Oct-Dec  | Volume 19 | Issue 4  
    Online since October 7, 2016

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Annual fes­tival PULSE-2016 at AIIMS, New Delhi

Oct-Dec 2016, 19(4):765-765
  - 307 37
Aortic valve homograft for revision surgery - transesophageal echocardiography considerations
Arindam Choudhury, Rohan Magoon, Poonam Malhotra Kapoor, P Rajashekar
Oct-Dec 2016, 19(4):752-753
DOI:10.4103/0971-9784.191553  PMID:27716714
Aortic root surgical anatomy and knowledge of the various homograft implantation techniques is of paramount importance to the attending anesthesiologist for echocardiographic correlation, estimation and accurately predicting aortic annular dimensions for the valve replacement in a case of diseased homograft.
  - 848 69
Transesophageal echo diagnosis of perioperative unusual transient left ventricular apical ballooning syndrome
Hugo Andrés Mantilla, Felix Ramón Montes, William F Amaya
Oct-Dec 2016, 19(4):733-736
DOI:10.4103/0971-9784.191572  PMID:27716708
Stress cardiomyopathy, or Takotsubo syndrome, is a widely recognized cardiac pathology with a clinical presentation similar to acute coronary syndrome and related to physical or emotional stress. Perioperatively, it is challenging to identify it given the variety of forms and scenarios in which it can present. We describe a 22-year-old patient with an atypical presentation of Takotsubo syndrome during anesthesia induction, which highlights the usefulness of transesophageal echocardiography for the initial diagnosis.
  - 1,063 107
Valve-in-valve-in homograft: A case of a repeat transcatheter aortic valve replacement in a patient with an aortic homograft
Kimberly Naden Hollander, Mario Montealegre-Gallegos, Feroze Mahmood
Oct-Dec 2016, 19(4):737-739
DOI:10.4103/0971-9784.191575  PMID:27716709
In recent years, the use of transcatheter aortic valve replacement (TAVR) has extended beyond the treatment of native aortic valve stenosis in patients with high surgical risk. TAVR is increasingly being performed for bioprosthetic aortic valve failure, i.e., the valve-in-valve (VIV) procedure. Establishing the success of a VIV procedure can be challenging in these cases. Furthermore, the limited availability of prostheses sizes further complicates the management of these patients. We present an unusual case of a repeat TAVR in a patient who previously had a VIV procedure in an aortic homograft.
  - 833 69
Transesophageal echocardiography-guided thrombectomy of intracardiac renal cell carcinoma without cardiopulmonary bypass
Fouad Ghazi Souki, Michael Demos, Lilibeth Fermin, Gaetano Ciancio
Oct-Dec 2016, 19(4):740-743
DOI:10.4103/0971-9784.191571  PMID:27716710
Advanced renal cell carcinoma (RCC) resection has important anesthetic management implications, particularly when tumor extends, suprahepatic, into the right atrium. Use of transesophageal echocardiogram (TEE) is essential in identifying tumor extension and guiding resection. Latest surgical approach avoids venovenous and cardiopulmonary bypass yet requires special precautions and interventions on the anesthesiologist's part. We present a case of Level IV RCC resected without cardiopulmonary bypass and salvaged by TEE guidance and detection of residual intracardiac tumor.
  - 1,025 86
Critical decision of operability in congenital heart disease patient with severe pulmonary hypertension
Raja Joshi, Rajat Kalra, Neeraj Kumar, Neeraj Aggarwal, Reena K Joshi, Mridul Aggarwal, Rakesh Pandey
Oct-Dec 2016, 19(4):744-746
DOI:10.4103/0971-9784.191561  PMID:27716711
Repair of congenital heart disease in the presence of high pulmonary pressure has always been a contentious issue. Pulmonary vascular resistance (PVR) is considered important for establishing operability in these patients. However, PVR estimation is not always accurate and cannot solely be relied upon to make critical decision of operability. Clinical examination, chest X-ray, and echocardiography are also important indicators of pulmonary vascular disease. Knowledge of pits and falls of each investigation is important for appropriate management in these patients. We present a case report of successfully operated, 6-year-old child with anomalous origin of the right pulmonary artery from aorta, deemed inoperable on the basis of PVR estimation.
  - 1,217 149
A lethal tension pneumothorax during minimally invasive coronary artery bypass surgery: Can transesophageal echocardiography pick it?
Dharmesh Radheshyam Agrawal, Sathyaki Purushottam Nambala
Oct-Dec 2016, 19(4):747-749
DOI:10.4103/0971-9784.191543  PMID:27716712
Minimally invasive cardiac surgery is establishing itself as the standard of care across the world. MICS CABG is currently performed in only a few centers. Hemodynamics disturbances are peculiar during MICS CABG due to space constraints. We report a 70-year-old man who underwent MICS CABG who developed tension pneumothorax during revascularization that was diagnosed in a novel way.
  - 1,193 57
Anesthetic management of patent ductus arteriosus in adults
Shital Rajesh Shinde, Shakuntala Basantwani, Bharati Tendolkar
Oct-Dec 2016, 19(4):750-751
DOI:10.4103/0971-9784.191547  PMID:27716713
Patent ductus arteriosus (PDA) is an extracardiac left to right shunt. It should be corrected at an early age, but some patients may survive into adult life even without repair. Anesthetic management for adult patients with PDA poses many challenges for the anesthesiologist due to alterations in the cardiopulmonary physiology. We report successful anesthesia management of a case of an adult patient of PDA with moderate pulmonary artery hypertension with infective endarteritis (two large mobile vegetations at the pulmonary end of the duct).
  - 1,373 154
From the Editor's desk
Poonam Malhotra Kapoor
Oct-Dec 2016, 19(4):575-575
DOI:10.4103/0971-9784.191560  PMID:27716682
  - 731 63
Perioperative transesophageal echocardiography: State of the art 2016
Garima Arora, Navin C Nanda
Oct-Dec 2016, 19(4):576-579
DOI:10.4103/0971-9784.191555  PMID:27716683
  - 964 165
Recent trends on hemodynamic monitoring in cardiac surgery
Dheeraj Arora, Yatin Mehta
Oct-Dec 2016, 19(4):580-583
DOI:10.4103/0971-9784.191557  PMID:27716684
  - 2,365 340
Role of hybrid operating room in surgery for the right atrial thrombus, pulmonary thrombi, and ventricular septal rupture after myocardial infarction
Ajmer Singh, Yatin Mehta, Rajiv Parakh, Vijay Kohli, Naresh Trehan
Oct-Dec 2016, 19(4):717-721
DOI:10.4103/0971-9784.191573  PMID:27716704
Free-floating right heart thrombi are uncommon and need emergency treatment in view of their tendency to dislodge and cause pulmonary embolism. We report a successful surgical management of a patient who had large mobile right atrial thrombus, bilateral pulmonary thrombi, coronary artery disease, and postmyocardial infarction ventricular septal rupture (VSR). The patient underwent coronary angiography, inferior vena cava filter placement, removal of thrombi from the right atrium and pulmonary arteries, repair of VSR, and coronary artery bypass graft surgery in a hybrid operating room.
  - 1,212 77
Windsock deformity of interatrial septum
Keerthi Chigurupati, Kirubanand Senniappan, Shrinivas Gadhinglajkar, Rupa Sreedhar, Thomas Mathew
Oct-Dec 2016, 19(4):722-723
DOI:10.4103/0971-9784.191565  PMID:27716705
Classical “Windsock deformity” is associated with ruptured aneurysmal sinus of Valsalva. The echocardiographic definition for Atrial septal aneurysm (ASA) in children based on dimensions is lacking. Rupture of an ASA, though uncommon, may lead to cardiac failure due to acute RV volume overload. An untreated ASA may be complicated with thrombus formation.
  - 804 75
Double valve replacement in a patient with implantable cardioverter defibrillator with severe left ventricular dysfunction
Girish Manjunath, Prakash Rao, Nagendra Prakash, BK Shivaram
Oct-Dec 2016, 19(4):724-727
DOI:10.4103/0971-9784.191566  PMID:27716706
Recent data from landmark trials suggest that the indications for cardiac pacing and implantable cardioverter defibrillators (ICDs) are set to expand to include heart failure, sleep-disordered breathing, and possibly routine implantation in patients with myocardial infarction and poor ventricular function.[1] This will inevitably result in more patients with cardiac devices undergoing surgeries. Perioperative electromagnetic interference and their potential effects on ICDs pose considerable challenges to the anesthesiologists.[2] We present a case of a patient with automatic ICD with severe left ventricular dysfunction posted for double valve replacement.
  - 842 62
Left ventricular mass: A tumor or a thrombus diagnostic dilemma
US Dinesh Kumar, Shyam Prasad Shetty, KR Sujay, Murugesh Wali
Oct-Dec 2016, 19(4):728-732
DOI:10.4103/0971-9784.191551  PMID:27716707
Left ventricular (LV) mass is a rare condition, of which the most common is thrombus. Echocardiography is a very useful modality of investigation to evaluate the LV mass. We are reporting a case of LV mass presenting with neurological symptom. The diagnosis of this mass was dilemma as the echocardiographic features were favoring tumor as well as thrombi. Mass (a) measuring 3.8 cm × 1.9 cm attached to the left ventricle apex appeared to be pedunculated tumor and mass (b) measuring 2.4 cm × 1.8 cm attached to the chordae of anterior mitral leaflet resembled a thrombus or an embolized tumor entangled in the chordae. A differential diagnosis for the LV mass is thrombus, tumors such as fibroma, and vegetation. Preoperative detection of a thrombus leads to an alteration in surgical steps. A large and mobile thrombus with or without a hemodynamic alteration is an indication for surgical removal to prevent stroke, myocardial infarction, mesenteric ischemia, renal infarction, gangrene of the limbs, and mortality.
  - 1,626 97
Symmetrical peripheral gangrene associated with cardiac surgery
Rajinder Singh Rawat
Oct-Dec 2016, 19(4):754-756
DOI:10.4103/0971-9784.191546  PMID:27716715
  - 1,217 65
Sepsis in heart transplant recipients: Is the new definition applicable?
Sarvesh Pal Singh
Oct-Dec 2016, 19(4):757-757
DOI:10.4103/0971-9784.191544  PMID:27716716
  - 669 68
Catatonic stupor after off-pump coronary artery bypass grafting
Vivek Chowdhry, Suvakanta Biswal, Bipin B Mohanty, Pradyut Bhuyan
Oct-Dec 2016, 19(4):758-759
DOI:10.4103/0971-9784.191574  PMID:27716717
  - 789 54
Arterialization of central venous pressure waveform
Monish S Raut, Arun Maheshwari, Manish Sharma, Sandeep Joshi, Arun Kumar, Akshay Gupta, Himanshu Goyal
Oct-Dec 2016, 19(4):760-761
DOI:10.4103/0971-9784.191556  PMID:27716718
  - 973 77
Airway management: High flow nasal oxygenation
Ajay Kumar, Patel Malay Hemantlal, Yatin Mehta
Oct-Dec 2016, 19(4):762-764
DOI:10.4103/0971-9784.191549  PMID:27716719
  - 1,233 108
Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography
Andrea Radinovic, Patrizio Mazzone, Giovanni Landoni, Eustachio Agricola, Damiano Regazzoli, Paolo Della Bella
Oct-Dec 2016, 19(4):589-593
DOI:10.4103/0971-9784.191548  PMID:27716687
Background: Left atrial catheterization through transseptal puncture is frequently performed in cardiac catheterization procedures. Appropriate transseptal puncture is critical to achieve procedural success. Aims: The aim of the study is to evaluate the feasibility of selective transseptal punctures, using a modified radiofrequency (RF) transseptal needle and transesophageal echocardiography (TEE), in different types of procedures that require specific sites of left atrial catheterization. Setting and Design: This was an observational trial in a cardiac catheterization laboratory of a teaching hospital. Materials and Methods: Patients undergoing different percutaneous procedures requiring atrial transseptal puncture such as atrial fibrillation (AF) ablation, left atrial appendage (LAA) occlusion, and mitral valve repair were included in the study. All procedures were guided by TEE and an RF transseptal needle targeting a specific region of the septum to perform the puncture. Statistical Analysis: The statistical analysis was descriptive only. Results: RF-assisted transseptal punctures were performed in six consecutive patients who underwent AF ablation (two patients), LAA closure (two patients), and mitral valve repair (two patients). In all patients, transseptal punctures were performed successfully at the desired site. No adverse events or complications were observed. Conclusions: Selective transseptal puncture, using TEE and an RF needle, is a feasible technique that can be used in multiple approaches requiring a precise site of access for left atrial catheterization.
  - 2,718 189
Accidental arterial puncture during right internal jugular vein cannulation in cardiac surgical patients
Madan Mohan Maddali, Venkitaramanan Arun, Al-Ajmi Ahmed Wala, Maher Jaffer Al-Bahrani, Cheskey Manoj Jayatilaka, Arora Ram Nishant
Oct-Dec 2016, 19(4):594-598
DOI:10.4103/0971-9784.191568  PMID:27716688
Background: The primary aim of this study was to compare the incidence of accidental arterial puncture during right internal jugular vein (RIJV) cannulation with and without ultrasound guidance (USG). The secondary end points were to assess if USG improves the chances of successful first pass cannulation and if BMI has an impact on incidence of arterial puncture and the number of attempts that are to be made for successful cannulation. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Material and methods: 255 consecutive adult and pediatric cardiac surgical patients were included. In Group I (n = 124) USG was used for the right internal jugular vein cannulation and in Group II (n = 81) it was not used. There were 135 adult patients and 70 pediatric patients. Statistical analysis: Demographic and categorical data were analyzed using Student 't' test and chi- square test was used for qualitative variables. Results: The overall incidence of accidental arterial puncture in the entire study population was significantly higher when ultrasound guidance was not used (P< 0.001). In subgroup analysis, incidence of arterial puncture was significant in both adult (P = 0.03) and pediatric patients (P< 0.001) without USG. First attempt cannulation was more often possible in pediatric patients under USG (P = 0.03). In adult patients USG did not improve first attempt cannulation except in underweight patients. Conclusions: USG helped in the avoidance of inadvertent arterial puncture during RIJV cannulation and simultaneously improved the chances of first attempt cannulation in pediatric and in underweight adult cardiac surgical patients.
  - 1,650 114
Tricuspid annulus: A spatial and temporal analysis
Ziyad O Knio, Mario Montealegre-Gallegos, Lu Yeh, Bilal Chaudary, Jelliffe Jeganathan, Robina Matyal, Kamal R Khabbaz, David C Liu, Venkatachalam Senthilnathan, Feroze Mahmood
Oct-Dec 2016, 19(4):599-605
DOI:10.4103/0971-9784.191569  PMID:27716689
Background: Traditional two-dimensional (2D) echocardiographic evaluation of tricuspid annulus (TA) dilation is based on single-frame measurements of the septolateral (S-L) dimension. This may not represent either the axis or the extent of dynamism through the entire cardiac cycle. In this study, we used real-time 3D transesophageal echocardiography (TEE) to analyze geometric changes in multiple axes of the TA throughout the cardiac cycle in patients without right ventricular abnormalities. Materials and Methods: R-wave-gated 3D TEE images of the TA were acquired in 39 patients undergoing cardiovascular surgery. The patients with abnormal right ventricular/tricuspid structure or function were excluded from the study. For each patient, eight points along the TA were traced in the 3D dataset and used to reconstruct the TA at four stages of the cardiac cycle (end- and mid-systole, end- and mid-diastole). Statistical analyses were applied to determine whether TA area, perimeter, axes, and planarity changed significantly over each stage of the cardiac cycle. Results: TA area (P = 0.012) and perimeter (P = 0.024) both changed significantly over the cardiac cycle. Of all the axes, only the posterolateral-anteroseptal demonstrated significant dynamism (P < 0.001). There was also a significant displacement in the vertical axis between the points and the regression plane in end-systole (P < 0.001), mid-diastole (P = 0.014), and mid-systole (P < 0.001). Conclusions: The TA demonstrates selective dynamism over the cardiac cycle, and its axis of maximal dynamism is different from the axis (S-L) that is routinely measured with 2D TEE.
  - 1,257 86
The myocardial protective effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery
Rabie Soliman, Gomaa Zohry
Oct-Dec 2016, 19(4):606-613
DOI:10.4103/0971-9784.191570  PMID:27716690
Objective: The aim of the study was to assess the effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery. Design: A randomized prospective study. Setting: Cairo University, Egypt. Materials and Methods: The study included 150 patients undergoing aortic vascular surgery. Intervention: The patients were classified into two groups (n = 75). Group D: The patients received a loading dose of 1 μg/kg dexmedetomidine over 15 min before induction and maintained as an infusion of 0.3 μg/kg/h to the end of the procedure. Group C: The patients received an equal volume of normal saline. The medication was prepared by the nursing staff and given to anesthetist blindly. Measurements: The monitors included the heart rate, mean arterial blood pressure, central venous pressure, electrocardiogram (ECG), serum troponin I level, end-tidal sevoflurane, and total dose of morphine in addition transthoracic echocardiography to the postoperative in cases with elevated serum troponin I level. Main Results: The dexmedetomidine decreased heart rate and minimized the changes in blood pressure compared to control group (P < 0.05). Furthermore, it decreased the incidence of myocardial ischemia reflected by troponin I level, ECG changes, and the development of new regional wall motion abnormalities (P < 0.05). Dexmedetomidine decreased the requirement for nitroglycerin and norepinephrine compared to control group (P < 0.05). The incidence of hypotension and bradycardia was significantly higher with dexmedetomidine (P < 0.05). Conclusion: The dexmedetomidine is safe and effective in patients undergoing aortic vascular surgery. It decreases the changes in heart rate and blood pressure during the procedures. It provides cardiac protection in high-risk patients reflected by decreasing the incidence of myocardial ischemia and serum level of troponin. The main side effects of dexmedetomidine were hypotension and bradycardia.
  - 1,010 134
The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery
Nagat S El-Shmaa, Doaa El Amrousy, Wael El Feky
Oct-Dec 2016, 19(4):614-620
DOI:10.4103/0971-9784.191564  PMID:27716691
Objective: The objective of this study was to assess the effectiveness of pre-emptive dexmedetomidine versus amiodarone in preventing junctional ectopic tachycardia (JET) in pediatric cardiac surgery. Design: This is a prospective, controlled study. Setting: This study was carried out at a single university hospital. Subjects and Methods: Ninety patients of both sexes, American Society of Anesthesiologists Physical Status II and III, age range from 2 to 18 years, and scheduled for elective cardiac surgery for congenital and acquired heart diseases were selected as the study participants. Interventions: Patients were randomized into three groups (30 each). Group I received dexmedetomidine 1 mcg/kg diluted in 100 ml of normal saline intravenously (IV) over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 0.5 mcg/kg/h infusion for 72 h postoperative, Group II received amiodarone 5 mg/kg diluted in 100 ml of normal saline IV over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 10–15 mcg/kg/h infusion for 72 h postoperative, and Group III received 100 ml of normal saline IV. Primary outcome was the incidence of postoperative JET. Secondary outcomes included vasoactive-inotropic score, ventilation time (VT), pediatric cardiac care unit stay, hospital length of stay, and perioperative mortality. Measurements and Main Results: The incidence of JET was significantly reduced in Group I and Group II (P = 0.004) compared to Group III. Heart rate while coming off from cardiopulmonary bypass (CPB) was significantly low in Group I compared to Group II and Group III (P = 0.000). Mean VT, mean duration of Intensive Care Unit stay, and length of hospital stay (day) were significantly short (P = 0.000) in Group I and Group II compared to Group III (P = 0.000). Conclusion: Perioperative use of dexmedetomidine and amiodarone is associated with significantly decreased incidence of JET as compared to placebo without significant side effects.
  - 1,387 133
Comparison between marked versus unmarked introducer needle in real-time ultrasound-guided central vein cannulation: A prospective randomized study
Tanmoy Ghatak, Ratender Kumar Singh, Arvind Kumar Baronia
Oct-Dec 2016, 19(4):621-625
DOI:10.4103/0971-9784.191563  PMID:27716692
Introduction: Introducer needle tip is not clearly visible during the real-time ultrasound (US)-guided central vein cannulation (CVC). Blind tip leads to mechanical complications. This study was designed to evaluate whether real-time US-guided CVC with a marked introducer needle is superior to the existing unmarked needle. Methodology: Sixty-two critically ill patients aged 18–60 years of either sex were included in the study. The patients were randomized into two groups based on whether a marked or unmarked introducer needle was used. Both groups underwent real-time US-guided CVC by a single experienced operator. Aseptically, introducer needle was indented with markings spaced 0.5 cm (single marking) and every 1 cm (double marking). This needle was used in the marked group. Approximate depths (centimeter) of the anterior and posterior wall of the internal jugular vein, anterior wall of the internal carotid artery, and lung pleura were appreciated from the midpoint of the probe in short-axis view at the level of the cricoid cartilage. Access time (seconds) was recorded using a stopwatch. A number of attempts and complications such as arterial puncture, hematoma, and pneumothorax of either procedure were compared. Results: Both marked needle and unmarked needle groups were comparable with regard to age, gender, severity scores, platelet counts, prothrombin time, and distance from the midpoint of the probe to the vein, artery, and pleura and skin-to-guide wire insertion access time. However, an average number of attempts (P = 0.03) and complications such as hematoma were significantly lower (P = 0.02) with the marked introducer needle group. Pneumothorax was not reported in any of the groups.Conclusion: Our study supports the idea that marked introducer needle can further reduce the iatrogenic complications of US-guided CVC.
  - 1,411 108
Effect of antiplatelet therapy on mortality and acute lung injury in critically ill patients: A systematic review and meta-analysis
Divyanshu Mohananey, Jaskaran Sethi, Pedro A Villablanca, Muhammad S Ali, Rohit Kumar, Anushka Baruah, Nirmanmoh Bhatia, Sahil Agrawal, Zeeshan Hussain, Fadi E Shamoun, John T Augoustides, Harish Ramakrishna
Oct-Dec 2016, 19(4):626-637
DOI:10.4103/0971-9784.191576  PMID:27716693
Aim: Platelet function is intricately linked to the pathophysiology of critical Illness, and some studies have shown that antiplatelet therapy (APT) may decrease mortality and incidence of acute respiratory distress syndrome (ARDS) in these patients. Our objective was to understand the efficacy of APT by conducting a meta-analysis. Materials and Methods: We conducted a meta-analysis using PubMed, Central, Embase, The Cochrane Central Register, the Website, and Google Scholar. Studies were included if they investigated critically ill patients receiving antiplatelet therapy and mentioned the outcomes being studied (mortality, duration of hospitalization, ARDS, and need for mechanical ventilation). Results: We found that there was a significant reduction in all-cause mortality in patients on APT compared to control (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.70–0.97). Both the incidence of acute lung injury/ARDS (OR: 0.67; 95% CI: 0.57–0.78) and need for mechanical ventilation (OR: 0.74; 95% CI: 0.60–0.91) were lower in the antiplatelet group. No significant difference in duration of hospitalization was observed between the two groups (standardized mean difference: −0.02; 95% CI: −0.11–0.07). Conclusion: Our meta-analysis suggests that critically ill patients who are on APT have an improved survival, decreased incidence of ARDS, and decreased need for mechanical ventilation.
  - 1,446 130
Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker-based study”
Poonam Malhotra Kapoor, Rohan Magoon, Rajinder Rawat, Yatin Mehta
Oct-Dec 2016, 19(4):638-682
DOI:10.4103/0971-9784.191552  PMID:27716694
Goal-directed therapy (GDT) encompasses guidance of intravenous (IV) fluid and vasopressor/inotropic therapy by cardiac output or similar parameters to help in early recognition and management of high-risk cardiac surgical patients. With the aim of establishing the utility of perioperative GDT using robust clinical and biochemical outcomes, we conducted the present study. This multicenter randomized controlled study included 130 patients of either sex, with European system for cardiac operative risk evaluation ≥3 undergoing coronary artery bypass grafting on cardiopulmonary bypass. The patients were randomly divided into the control and GDT group. All the participants received standardized care; arterial pressure monitored through radial artery, central venous pressure (CVP) through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour, and frequent arterial blood gas (ABG) analysis. In addition, cardiac index (CI) monitoring using FloTrac™ and continuous central venous oxygen saturation (ScVO2) using PreSep™ were used in patients in the GDT group. Our aim was to maintain the CI at 2.5–4.2 L/min/m2, stroke volume index 30–65 ml/beat/m2, systemic vascular resistance index 1500–2500 dynes/s/cm5/m2, oxygen delivery index 450–600 ml/min/m2, continuous ScVO2 >70%, and stroke volume variation <10%; in addition to the control group parameters such as CVP 6–8 mmHg, mean arterial pressure 90–105 mmHg, normal ABG values, oxygen saturation, hematocrit value >30%, and urine output >1 ml/kg/h. The aims were achieved by altering the administration of IV fluids and doses of inotropes or vasodilators. The data of sixty patients in each group were analyzed in view of ten exclusions. The average duration of ventilation (19.89 ± 3.96 vs. 18.05 ± 4.53 h, P = 0.025), hospital stay (7.94 ± 1.64 vs. 7.17 ± 1.93 days, P = 0.025), and Intensive Care Unit (ICU) stay (3.74 ± 0.59 vs. 3.41 ± 0.75 days, P = 0.012) was significantly less in the GDT group, compared to the control group. The extra volume added and the number of inotropic dose adjustments were significantly more in the GDT group. The two groups did not differ in duration of inotropic use, mortality, and other complications. The perioperative continuation of GDT affected the early decline in the lactate levels after 6 h in ICU, whereas the control group demonstrated a settling lactate only after 12 h. Similarly, the GDT group had significantly lower levels of brain natriuretic peptide, neutrophil gelatinase-associated lipocalin levels as compared to the control. The study clearly depicts the advantage of GDT for a favorable postoperative outcome in high-risk cardiac surgical patients.
  - 1,326 228
Variations of transesophageal echocardiography practices in India: A survey by Indian College of Cardiac Anaesthesia
Deepak Prakash Borde, Antony George, Shreedhar Joshi, Suresh Nair, Thomas Koshy, Uday Gandhe, Murali Chakravarthy
Oct-Dec 2016, 19(4):646-652
DOI:10.4103/0971-9784.191580  PMID:27716695
Context: Use of perioperative transesophageal echocardiography (TEE) has expanded in India. Despite attempts to standardize the practice of TEE in cardiac surgical procedures, variation in practice and application exists. This is the first online survey by Indian College of Cardiac Anaesthesia, research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA). Aims: We hypothesized that variations in practice of intraoperative TEE exist among centers and this survey aimed at analyzing them. Settings and Design: This is an online survey conducted among members of the IACTA. Subjects and Methods: All members of IACTA were contacted using online questionnaire fielded using SurveyMonkey™ software. There were 21 questions over four pages evaluating infrastructure, documentation of TEE, experience and accreditation of anesthesiologist performing TEE, and finally impact of TEE on clinical practice. Questions were also asked about national TEE workshop conducted by the IACTA, and suggestions were invited by members on overseas training. Results: Response rate was 29.7% (382/1222). 53.9% were from high-volume centers (>500 cases annually). TEE machine/probe was available to 75.9% of the respondents and those in high-volume centers had easier (86.9%) access. There was poor documentation of preoperative consent (23.3%) as well as TEE findings (66%). Only 18.2% of responders were board qualified. Almost 90% of the responders felt surgeons respected their TEE diagnosis. Around half of the responders felt that new intraoperative findings by TEE were considered in decision-making in most of the cases and 70% of the responders reported that surgical plan was altered based on TEE finding more than 10 times in the last year. Despite this, only 5% of the responders in this survey were monetarily awarded for performing impactful skill of TEE. Majority (57%) felt that there is no need for overseas training for Indian cardiac anesthesiologists. Conclusions: In this survey of members of the IACTA, use of TEE has increased substantially, but still a lot of variations in practice patterns exist in India. There is urgent need for improving TEE certification and upgrade documentation standards, motivate use of TTE across all centers, promote awareness and usefulness of TEE use among surgical fraternity, monitor impact of TEE, and support separate remuneration policy in India.
  - 822 95
Early enteral nutrition therapy in congenital cardiac repair postoperatively: A randomized, controlled pilot study
Manoj Kumar Sahu, Anuradha Singal, Ramesh Menon, Sarvesh Pal Singh, Alka Mohan, Mala Manral, Divya Singh, V Devagouru, Sachin Talwar, Shiv Kumar Choudhary
Oct-Dec 2016, 19(4):653-661
DOI:10.4103/0971-9784.191550  PMID:27716696
Background and Objectives: Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery. Methodology: Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee's approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium-chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra- and post-operative variables such as cardiopulmonary bypass and aortic cross-clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software. Results: The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0.20) than those in the intervention group. Similarly, infants in control group stayed for longer duration in the ICU (13.2 ± 8.9 days) and hospital (16.5 ± 9.8 days) as compared to the intervention group (11.0 ± 6.1 days; 14.1 ± 7.0 days) (P = 0.14 and 0.17, respectively). The LOIS and LOHS were decreased by 2.2 and 2.4 days, respectively, in the intervention group compared to control group. The infection rate (3/25; 5/25) and mortality rate (1/25; 2/25) were lower in the intervention group than those in the control group. The energy intake in the intervention group was 40 kcal more (i.e., 127.2 ± 56.1 kcal vs. 87.1 ± 38.3 kcal) than the control group on the 10th postoperative day. Conclusions: Early enteral/oral feeding after cardiac surgery is feasible and recommended. In addition, enriching the EBM is helpful in achieving the maximum possible calorie intake in the postoperative period. EN therapy might help in providing adequate nutrition, and it decreases ventilation duration, infection rate, LOIS, LOHS, and mortality.
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Effect of prophylaxis of magnesium sulfate for reduction of postcardiac surgery arrhythmia: Randomized clinical trial
Bahman Naghipour, Gholamreza Faridaalaee, Kamran Shadvar, Eissa Bilehjani, Ashkan Heyat Khabaz, Solmaz Fakhari
Oct-Dec 2016, 19(4):662-667
DOI:10.4103/0971-9784.191577  PMID:27716697
Background: Arrhythmia is a common complication after heart surgery and is a major source of morbidity and mortality. Aims: This study aimed to study the effect of magnesium sulfate (MgSO4) for reduction of postcardiac surgery arrhythmia. Setting and Design: This study is performed in the cardiac operating room and Intensive Care Unit (ICU) of Shahid Madani Hospital of Tabriz (Iran) between January 1, 2014, and September 30, 2014. This study is a double-blind, randomized controlled trial. Materials and Methods: In Group 1 (group magnesium [Mg]), eighty patients received 30 mg/kg MgSO4in 500 cc normal saline and in Group 2 (group control), eighty patients received 500 cc normal saline alone. Statistical Analysis: The occurrence of arrhythmia was compared between groups by Chi-square and Fisher's exact test. In addition, surgical time, length of ICU stay, and length of hospital stay were compared by independent t-test. P< 0.05 was considered as significant. Results: There was a significant difference in the incidence of arrhythmia between two groups (P = 0.037). The length of ICU stay was 3.4 ± 1.4 and 3.73 ± 1.77 days in group MgSO4and control group, respectively, and there was no statistically significant difference between two groups (P = 0.2). Conclusion: Mg significantly decreases the incidence of all type of postcardiac surgery arrhythmia and hospital length of stay at patients undergo cardiac surgery. We offer prophylactic administration of Mg at patients undergo cardiac surgery.
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Hyperlactatemia in patients undergoing adult cardiac surgery under cardiopulmonary bypass: Causative factors and its effect on surgical outcome
Rakesh Naik, Gladdy George, Sathappan Karuppiah, Madhu Andrew Philip
Oct-Dec 2016, 19(4):668-675
DOI:10.4103/0971-9784.191579  PMID:27716698
Objectives of the Study: To identify the factors causing high lactate levels in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) and to assess the association between high blood lactate levels and postoperative morbidity and mortality. Methods: A retrospective observational study including 370 patients who underwent cardiac surgeries under cardiopulmonary bypass. The patients were divided into 2 groups based on serum lactate levels; those with serum lactate levels greater than or equal to 4 mmol/L considered as hyperlactatemia and those with serum lactate levels less than 4 mmol/L. Blood lactate samples were collected intraoperatively and postoperatively in the ICU. Preoperative and intraoperative risk factors for hyperlactatemia were identified using the highest intraoperative value of lactate. The postoperative morbidity and mortality associated with hyperlactatemia was studied using the overall (intraoperative and postoperative values) peak lactate levels. Preoperative clinical data, perioperative events and postoperative morbidity and mortality were recorded. Results: Intraoperative peak blood lactate levels of 4.0 mmol/L or more were present in 158 patients (42.7%). Females had higher peak intra operative lactate levels (P = 0.011). There was significant correlation between CPB time (Pearson correlation coefficient r = 0.024; P = 0.003) and aortic cross clamp time (r = 0.02, P = 0.007) with peak intraoperative blood lactate levels. Patients with hyperlactatemia had significantly higher rate of postoperative morbidity like atrial fibrillation (19.9% vs. 5.3%; P = 0.004), prolonged requirement of inotropes (34% vs. 11.8%; P = 0.001), longer stay in the ICU (P = 0.013) and hospital (P = 0.001). Conclusions: Hyperlactatemia had significant association with post-operative morbidity. Detection of hyperlactatemia in the perioperative period should be considered as an indicator of inadequate tissue oxygen delivery and must be aggressively corrected.
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Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery
Meredith Degnan, Jessica Brodt, Yiliam Rodriguez-Blanco
Oct-Dec 2016, 19(4):676-686
DOI:10.4103/0971-9784.191545  PMID:27716699
Aim: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery. Materials and Methods: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality. Statistical Analysis: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable. Results: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure. Conclusion: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.
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The formation of bronchocutaneous fistulae due to retained epicardial pacing wires: A literature review
Vasileios Patris, Michalis Argiriou, Agni-Leila Salem, Konstantinos Giakoumidakis, Nikolaos G Baikoussis, Christos Charitos
Oct-Dec 2016, 19(4):683-686
DOI:10.4103/0971-9784.191567  PMID:27716700
Temporary epicardial pacing wires during open-heart surgery are routinely used both for diagnostic and treatment purposes. In complicated cases where patients are unstable or the wires are difficult to remove, the pacing wires are cut at the skin level and allowed to retract by themselves. This procedure rarely causes complications. However, there have been cases reporting that retained pacing wires are linked to the formation of sterno-bronchial fistulae, which may present a while after the date of operation and are usually infected. This review aims to study the cases presenting sterno-bronchial fistulae due to retained epicardial pacing wires and to highlight the important factors associated with these. It is important to note these complications, as fistulae may cause a variety of problems to the patient if undiagnosed and left untreated. With the aid of scans such as fistulography, fistulae can be identified and treated and will improve the patients' health dramatically.
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Cardiac surgery-associated acute kidney injury
Christian Ortega-Loubon, Manuel Fernández-Molina, Yolanda Carrascal-Hinojal, Enrique Fulquet-Carreras
Oct-Dec 2016, 19(4):687-698
DOI:10.4103/0971-9784.191578  PMID:27716701
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a well-recognized complication resulting with the higher morbid-mortality after cardiac surgery. In its most severe form, it increases the odds ratio of operative mortality 3–8-fold, length of stay in the Intensive Care Unit and hospital, and costs of care. Early diagnosis is critical for an optimal treatment of this complication. Just as the identification and correction of preoperative risk factors, the use of prophylactic measures during and after surgery to optimize renal function is essential to improve postoperative morbidity and mortality of these patients. Cardiopulmonary bypass produces an increased in tubular damage markers. Their measurement may be the most sensitive means of early detection of AKI because serum creatinine changes occur 48 h to 7 days after the original insult. Tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 are most promising as an early diagnostic tool. However, the ideal noninvasive, specific, sensitive, reproducible biomarker for the detection of AKI within 24 h is still not found. This article provides a review of the different perspectives of the CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, postoperative management, and treatment. We searched the electronic databases, MEDLINE, PubMed, EMBASE using search terms relevant including pathogenesis, risk factors, diagnosis, biomarkers, classification, postoperative management, and treatment, in order to provide an exhaustive review of the different perspectives of the CSA-AKI.
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Global end-diastolic volume an emerging preload marker vis-a-vis other markers - Have we reached our goal?
PM Kapoor, Vandana Bhardwaj, Amita Sharma, Usha Kiran
Oct-Dec 2016, 19(4):699-704
DOI:10.4103/0971-9784.191554  PMID:27716702
A reliable estimation of cardiac preload is helpful in the management of severe circulatory dysfunction. The estimation of cardiac preload has evolved from nuclear angiography, pulmonary artery catheterization to echocardiography, and transpulmonary thermodilution (TPTD). Global end-diastolic volume (GEDV) is the combined end-diastolic volumes of all the four cardiac chambers. GEDV has been demonstrated to be a reliable preload marker in comparison with traditionally used pulmonary artery catheter-derived pressure preload parameters. Recently, a new TPTD system called EV1000™ has been developed and introduced into the expanding field of advanced hemodynamic monitoring. GEDV has emerged as a better preload marker than its previous conventional counterparts. The advantage of it being measured by minimum invasive methods such as PiCCO™ and newly developed EV1000™ system makes it a promising bedside advanced hemodynamic parameter.
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Strategies for blood conservation in pediatric cardiac surgery
Sarvesh Pal Singh
Oct-Dec 2016, 19(4):705-716
DOI:10.4103/0971-9784.191562  PMID:27716703
Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.
  - 2,136 323
Platelet aggregometry interpretation using ROTEM – PART – II
Vandana Bhardwaj, Poonam Malhotra Kapoor
Oct-Dec 2016, 19(4):584-586
DOI:10.4103/0971-9784.191559  PMID:27716685
  - 1,719 151
Transesophageal echocardiography in an atrioventricular septal defect
Rohan Magoon, Arindam Choudhury, Amita Sharma, Poonam Malhotra Kapoor
Oct-Dec 2016, 19(4):587-588
DOI:10.4103/0971-9784.191558  PMID:27716686
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