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   Table of Contents - Current issue
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July-September 2020
Volume 23 | Issue 3
Page Nos. 255-381

Online since Friday, July 17, 2020

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Are humans so vulnerable? They are! Highly accessed article p. 255
Prabhat Tewari
DOI:10.4103/aca.ACA_164_20  PMID:32687076
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EDITORIAL Top

The current status of EuroSCORE II in predicting operative mortality following cardiac surgery Highly accessed article p. 256
Sudhakar Subramani
DOI:10.4103/aca.ACA_32_19  PMID:32687077
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Anticoagulants and immunosuppressants in COVID-19: Bullets to Defeat MicroCLOTS Highly accessed article p. 258
S Turi, P Nardelli, G Landoni
DOI:10.4103/aca.ACA_126_20  PMID:32687078
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Depth of anesthesia monitoring in cardiac surgery—Standard of care soon? Highly accessed article p. 260
Mukul Chandra Kapoor
DOI:10.4103/aca.ACA_141_19  PMID:32687079
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REVIEW ARTICLE Top

Nuclear investigative techniques and their interpretation in the heart and vascular disease Highly accessed article p. 262
Manish Ora, Sanjay Gambhir
DOI:10.4103/aca.ACA_54_19  PMID:32687080
Over the last several decades, myocardial perfusion imaging with single photon emission tomography and positron emission tomography has been a mainstay for the evaluation of patients with known or suspected coronary artery disease non-invasively. Technical advances in imaging modalities and radiopharmaceutical have revolutionaries the understanding of pathogenesis and management of various diseases. In this article, we shall discuss the various available imaging nuclear medicine techniques, radiopharmaceutical, and common indications. In the era of “precision medicine,” imaging has to be patient centered. We will briefly review the upcoming areas of nuclear medicine imaging apart from perfusion imaging, such as advances in myocardial blood flow quantitation and molecular imaging.
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ORIGINAL ARTICLES Top

The role of entropy monitoring in reducing propofol requirements during open heart surgeries. A prospective randomized study p. 272
Ahmed Said Elgebaly, Mona B El Mourad, Sameh Mohamad Fathy
DOI:10.4103/aca.ACA_184_18  PMID:32687081
Background: Hypotension, which is commonly associated with propofol induction of general anesthesia in coronary artery bypass grafting (CABG) surgery, may cause adverse consequences in patients with coronary artery diseases undergoing this type of surgeries. The clinical absence of verbal response and eyelash reflex was used as an endpoint for hypnosis. Spectral entropy, as a novel monitoring method for the endpoint of hypnosis, affect the dose of required anesthetic agents for induction as well as the hemodynamic profile during general anesthesia in CABG surgery. Aims: We hypothesized that entropy monitoring might reduce the dose of propofol required for induction of anesthesia during CABG surgery and could maintain hemodynamic stability when compared with the conventional clinical monitoring. Materials and Methods: Sixty adult patients of both sexes, aged 30–60 years, ASA II and III, and scheduled for CABG surgery were enrolled in this prospective, controlled, randomized, double-blind study. These patients were randomly divided into two equal groups to receive intravenous propofol for induction of anesthesia guided by either the patients' clinical response (Group I) or by entropy monitoring (Group II). The total dose of propofol used for induction of anesthesia was recorded. Hemodynamic parameters and entropy values were also recorded. Results: Propofol consumption was significantly reduced in Group II than Group I (P = 0.000*). Heart rate showed no statistical significance between the two groups, whereas the mean arterial pressure significantly decreased at induction in group I compared to Group II (P = 0.000*). The entropy values were significantly lower in Group I than Group II at induction (P = 0.036* for state entropy; 0.002* for response entropy). However, during intubation, and after 1 and 5 min, entropy indices displayed a significant increase in Group I than Group II. Conclusions: Entropy monitoring significantly reduced the dose of propofol required for induction of anesthesia and maintained hemodynamic stability compared to the conventional clinical monitoring during CABG surgeries.
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Comparison of the additive, logistic european system for cardiac operative risk (EuroSCORE) with the EuroSCORE 2 to predict mortality in high-risk cardiac surgery p. 277
Laura Guillet, Pierre H Moury, Damien Bedague, Michel Durand, Cécile Martin, Jean F Payen, Olivier Chavanon, Pierre Albaladejo
DOI:10.4103/aca.ACA_209_18  PMID:32687082
Background: The aim of this study was to compare the new EuroSCORE (ES) 2 prediction model in high-risk patients with the 2 other oldest additive ES (aES) and logistic ES (lES). Methods: Consecutive adult patients undergoing all cardiac surgery except heart transplantation and left ventricular assist device were included. The 3 risk scores were collected before surgery. We defined 4 high-risk groups of patients, patients ≥80 years, combined cardiac surgery, surgery of the thoracic aorta, and emergency cardiac surgery, and 2 low-risk groups, valve surgery and coronary artery bypass surgery. The predicted value of each score has been assessed by the area under the receiver operating characteristics curve (AUC). Results: The study had included 3301 patients. Thirty-day mortality was 3.9% (95% confidence interval (CI), 3.3 − 4.6%). The AUC of ES2 was 0.81 (0.77 − 0.84), 0.82 (0.78 − 0.85), 0.70 (0.64 − 0.76), 0.79 (0.74 − 0.83), 0.85 (0.83 − 0.87), and 0.88 (0.86 − 0.90) for octogenarians, thoracic aortic surgery, combined surgery, emergency surgery, coronary surgery, and valve surgery, respectively. These ES2 AUC values were higher than those obtained with the aES for octogenarians, and with the lES for octogenarians and valve surgery. The ES2 calibration was better than the aES and lES calibration for the whole population, and low-risk groups. The ES2 calibration was superior to aES and lES in high-risk groups, except for octogenarians and thoracic aortic surgery compared to lES. Conclusion: In high-risk cardiac surgery patients, ES2 only marginally improve the predicted 30-day mortality in comparison to other ES.
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Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO p. 283
P Hemamalini, Prabhat Dutta, Sandeep Attawar
DOI:10.4103/aca.ACA_75_19  PMID:32687083
The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80%) placed under fluoroscopy required repositioning whereas one cannula (20%) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.
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The accuracy of electrical cardiometry for the noninvasive determination of cardiac output before and after lung surgeries compared to transthoracic echocardiography p. 288
Ahmed S Elgebaly, Atteia G Anwar, Sameh M Fathy, Ayman Sallam, Yaser Elbarbary
DOI:10.4103/aca.ACA_196_18  PMID:32687084
Background: The anatomical changes associated with lung surgeries may decrease cardiac output and heart function. Therefore, monitoring of cardiac output (CO) is of significant value in these patients for clinical decision-making. Objective: This study is to evaluate the reliability of electrical cardiometry (EC) for the noninvasive continuous determination of CO after lobectomy or pneumonectomy compared to transthoracic echocardiography (TTE). Patients and Methods: This study was carried out on 60 patients, age ≥18 years scheduled for elective lung surgery (lobectomy or pneumonectomy). All patients underwent simultaneous measurement by EC using the ICON_ device and by TTE by measuring left ventricle outflow tract diameter (LVOT) and velocity time integral (VTI). Heart rate (HR), systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), stroke volume index (SVI), CO, and cardiac index (CI) were measured 1 day before the surgery and 7 days after the surgery. Results: There was no significant difference between TTE and EC regarding preoperative and postoperative HR, SV, SVI, CO, and CI. There was a strong positive correlation between TTE and EC as regard preoperative and postoperative HR, SV, SVI, CO, and CI. Bland and Altman analysis showed low bias with accepted limits of agreement of HR, SV, SVI, CO, and CI. Postoperative readings showed a significant increase in HR and a significant decrease in SV and CO (either by TTE or EC), SBP, and DBP as compared to preoperative reading. Conclusion: Compared to the TTE, EC provides accurate and reliable CO, SV, and HR measurements before and even after lung surgeries.
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Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students p. 293
Conrad Hempel, Edwin Turton, Elham Hasheminejad, Carmine Bevilacqua, Gunther Hempel, Jörg Ender, Daisy Rotzoll
DOI:10.4103/aca.ACA_51_19  PMID:32687085
Introduction: Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination. Subject and Methods: A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups. Results: Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students. Conclusions: Both teaching methods are effective and lead to the intended level of knowledge and skills.
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Routine preoperative doppler ultrasound examination of arterial system in patients undergoing cardiac surgery is beneficial: A retrospective study p. 298
Murali Chakravarthy, Dattatreya Prabhakumar, Benak Shivalingappa, Sonali Rao, Sumant Padgaonkar, Rajathadri Hosur, Chidananda Harivelam, Vivek Jawali
DOI:10.4103/aca.ACA_18_19  PMID:32687086
Background: Presence of peripheral vascular disease enhances surgical risk in cardiac surgical patients. Prior knowledge of peripheral arterial disease may help the physician make changes in the monitoring and cardiopulmonary bypass cannulation plans. It is claimed that the incidence of peripheral vascular disease in cardiac surgical patients ranges from 11 to 30%. Aims: This study was conducted to understand the characteristics of peripheral vascular disease and their implication on cardiac surgery. Settings and Design: This was a prospective study undertaken in a tertiary referral hospital. Materials and Methods: All adult patients who underwent cardiac surgery during the period of six months were included. A Doppler examination of the neck, upper limb, abdomen and lower limb was carried out by our inhouse radiologist. The incidence of peripheral vascular disease, the implication on invasive pressure monitoring site and cannulation for cardiopulmonary bypass or intraaortic balloon pump or extracorporeal membrane oxygenation were made note of. Results: During the said period, six hundred twenty eight patients underwent cardiac surgery, of whom five hundred and sixty-one patients who underwent CABG surgery. All these were subjected to Doppler examination. We observed peripheral arterial disease in 105 patients (20%). In general men suffered from PAD more often than women. Monitoring site of invasive arterial pressure, the choice of beating heart surgery, insertion of intraaortic balloon pump, femoral arterial route for cardiopulmonary bypass were some of the decision that were altered. Conclusions: Performing Doppler examination in cardiac surgical patients may yield important data that might prevent complications and support patient safety.
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Evaluation of arterial stiffness in cardiac surgical patients using applanation tonometry p. 302
Federico Franchi, Gioia Baldini, Marco Mautone, Fabio S Taccone, Paolo De Santis, Alessandra Rocco, Luca Marchetti, Sabino Scolletta
DOI:10.4103/aca.ACA_207_18  PMID:32687087
Context: Applanation tonometry enables the noninvasive analysis of arterial pressure wave morphology. Applanation tonometry provides the augmentation index (AIx, %), an index of arterial stiffness that partially reflects arterial-ventricular (A-V) coupling. In addition, applanation tonometry provides the dP/dt (rate of intraventricular pressure variation over time), which reflects myocardial contractility, and the sub-endocardial viability ratio (SEVR, %), which is an indicator of myocardial oxygen supply and demand. There are no data on how cardiac surgery can modify these tonometry-derived indexes. Aim: The aim was to assess changes in AIx, dP/dt, and SEVR in patients undergoing cardiac surgery. Subjects and Methods: This observational study was conducted at the University Hospital of Siena. We studied 32 patients before cardiac surgery in intensive care unit (ICU) on admission and at ICU discharge. We measured AIx, dP/dt, and SEVR using applanation tonometry (SphygmoCor). Changes in variables over time were evaluated by analysis of variance for repeated measurements. Results: AIx decreased significantly from T1 [28.8%, interquartile range (IQR) 21.6–36.6%] to T2 (16.2% IQR 8.1–22.4%) and T3 (14.5% IQR 7.9–23.6%) (P = 0.01). dP/dt increased significantly from T1 (635 mmHg/ms, IQR 534–756 mmHg/ms) to T3 (751 mmHg/ms, IQR 651–1013 mmHg/ms; P = 0.03). The SEVR was lower at T2 than at T1, but returned toward T1 values by T3. Conclusions: Cardiac surgery was associated with an improvement in arterial stiffness, A-V coupling, and myocardial contractility as assessed using applanation tonometry. The results suggest, however, a transient imbalance between myocardial oxygen supply and demand in the immediate postoperative period.
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Comparison of postoperative cognitive decline in patients undergoing conventional vs miniaturized cardiopulmonary bypass: A randomized, controlled trial p. 309
Ke Yuhe, Sophia Tsong Huey Chew, An Shing Ang, Roderica Rui Ge Ng, Nantawan Boonkiangwong, Weiling Liu, Anastasia Han Hao Toh, Michael George Caleb, Roger Chun Man Ho, Lian Kah Ti
DOI:10.4103/aca.ACA_192_18  PMID:32687088
Background: Neurocognitive dysfunction is a common complication of coronary artery bypass grafting (CABG) with incidence of 19–38%. The miniaturized cardiopulmonary bypass (MCPB) system was developed to reduce hemodilution and inflammation and provides better cerebral protection than conventional cardiopulmonary bypass (CCPB). In a meta-analysis, MCPB was associated with a 10-fold reduction in the incidence of strokes. However, its effect on postoperative cognitive decline (POCD) is unknown. We assessed if MCPB decreases POCD after CABG and compared the risk factors. Methods: A total of 71 Asian patients presenting for elective CABG at a tertiary center were enrolled. They were randomly assigned to MCPB (n = 36) or CCPB group (n = 35) and followed up in a single-blinded, prospective, randomized controlled trial. The primary outcome was POCD as measured by the repeatable battery of neuropsychological status (RBANS). Inflammatory markers (tumor necrosis factor-alpha and interleukin-6), hematocrit levels, and neutron-specific enolase (NSE) levels were studied. Results: Overall, the incidence of POCD at 3 months was 50%, and this was not significantly different between both groups (51.4 vs 50.0%, P = 0.90). Having <6 years of formal education [risk ratio (RR) = 3.014, 95% confidence interval (CI) = 1.054–8.618, P = 0.040] was significantly associated with POCD in the CCPB group, while the lowest hematocrit during cardiopulmonary bypass was independently associated with POCD in the MCPB group (RR = 0.931, 95% CI = 0.868–0.998, P = 0.044). The postoperative inflammatory markers and NSE levels were similar between the two groups. Conclusions: This study shows that the MCPB was not superior to CCPB with cell salvage and biocompatible tubing with regard to the neurocognitive outcomes measured by the RBANS.
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Translation, cultural adaptation, and validation of the duke activity status index in the hindi language p. 315
Nishith Govil, Kumar Parag, Barun Kumar, Hariom Khandelwal, Ruchi Dua, Pudi Sivaji
DOI:10.4103/0971-9784.282667  PMID:32687089
Background: The Duke Activity Status Index (DASI) is a validated questionnaire in English to assess the functional capacity (FC) of patients with cardiovascular disease (CVD). Aim: The aim of the study is to translate, cross-culturally adapt, and validate the DASI in Hindi. Settings and Study Design: Observational validation study. Methodology: Different translators translated the DASI into Hindi and then back-translated it into English. Validation for feasibility and psychometric properties of translated questionnaire was done on 200 adults, Hindi-speaking patients with CVD, who were advised exercise testing by a cardiologist. Statistical Analysis: Internal consistency (Cronbach's α) and test–retest reliability (Pearson's correlation coefficient) were calculated. Construct (correlation with the Canadian Cardiovascular Society Classification [CCSC] for angina and exercise capacity with treadmill testing [TMT]) and content validity (time taken to fill the questionnaire, ease of understanding the questionnaire items, and comprehensibility) were calculated.P < 0.05 was considered significant. Results: The Cronbach's α for internal consistency was 0.78, which indicates adequate relatedness among the items of questionnaire, and the test–retest reliability was 0.65 (P < 0.05). A significant correlation between CCSC (r = −0.60) and TMT (r = 0.56) was found. The median time taken by the respondents to fill the questionnaire was 4 min. Of all the respondents, 95.74% of the respondents agreed that the Hindi questionnaire was easy to comprehend and 97.87% patients correlated the translated items to their daily physical activity. Conclusions: The Hindi translated and culturally adapted version of the DASI is reliable, valid, and feasible to assess the FC in the Hindi-speaking CVD patients.
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Intensive care and anesthesia management for HARPOON beating heart mitral valve repair p. 321
Paul Diprose, Katheryn J Fogg, Demetrio Pittarello, James S Gammie, Michael N D'Ambra
DOI:10.4103/aca.ACA_200_18  PMID:32687090
Patients with severe mitral valve regurgitation secondary to degenerative disease are known to benefit from mitral valve repair surgery. Novel techniques for achieving mitral valve repair on the beating heart have been developed and are being introduced into clinical practice. The HARPOON Beating Heart Mitral Valve Repair System (MVRS) in recent studies has demonstrated efficacy and safety for the repair of degenerative mitral valve disease on the beating heart. The device uses transoesophageal echocardiographic guidance to implant artificial expanded polytetrafluoroethylene (ePTFE) cords on prolapsed mitral valve leaflets in the beating heart. It requires general anaesthesia and there are specific intensive care and anaesthesia considerations for the safe management of these cases. This article describes the general principles of intensive care and anaesthesia management employed for the initial patients treated with the HARPOON Beating Heart MVRS, the outcomes for these patients, and the potential challenges for the future management of these cases.
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Pharmacological preconditioning with intralipid in patients undergoing off-pump coronary artery bypass surgery p. 327
Gegal Pruthi, Naveen G Singh, PS Nagaraja, Rohini Mayur Balaji, N Manjunatha, PK Choudhary, M Kurinchi Raja
DOI:10.4103/aca.ACA_251_18  PMID:32687091
Aims and Objectives: The objective of the study was to determine the preconditioning myocardial protective effects of intralipid (IL) in off-pump coronary artery bypass (OPCAB) surgery by measuring highly sensitive troponin T (hsTnT) and cardiac-specific creatine kinase (CK-MB) as markers of myocardial injury. Materials and Methods: Thirty patients, scheduled to undergo elective OPCAB surgery, were randomly assigned to the IL group (n = 15) or control (C) group (n = 15); the IL group received an infusion of 20% IL 2 ml/kg, 30 min prior to revascularization and the control group received an equivalent volume of normal saline. Serum levels of hsTnT and CK-MB were measured before surgery and at 6 h, 24 h, 48 h, and 72 h postoperatively. Also, intraoperative hemodynamic parameters, inotrope use, ventilatory hours, ICU stay, postoperative left ventricular ejection fraction, postoperative lipid profile, renal and hepatic function tests were measured. Results: The hsTnT values at the 24 h, 48 h, and 72 h in IL group were significantly lower as compared with the control group. The decline in plasma levels of CK-MB mirrored the hsTnT levels post revascularization at 24 h and 48 h in the IL group compared with the control group; however, at 72 h, level was comparable in both the groups. None of the treated patients had abnormal lipid metabolism, deranged renal, and hepatic function. Conclusion: The study revealed Intralipid as a safe pharmacological preconditioning agent for OPCAB surgeries which can reduce the postischemic myocardial injury indicated by the reduction in postischemic cardiac enzymes hsTnT and CK-MB.
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INTERESTING IMAGES Top

Intraoperative 2D and 3D transesophageal echocardiographic assessment of cor triatriatum with ostium secundum atrial septal defect in an adult patient p. 332
Rahul Shabadi, Pushkar Desai, Suresh Chengode
DOI:10.4103/aca.ACA_131_19  PMID:32687092
Cor triatriatum is a rare congenital cardiac anomaly. Majority of the cases present in the childhood with an incidence of 0.4%. However, we report a case of cor triatrium sinister with ostium secundum atrial septal defect (ASD) in a 39-year-old female. The intraoperative 3D transesophageal echocardiography (TEE) offers an advantage over 2D TEE in visualizing the interatrial septum and the attachments of the fibromuscular accessory membrane in the left atrium (LA), which could help in surgical decision-making in this patient.
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Right atrial cavernous hemangioma Highly accessed article p. 335
Manikappa Shashikanth, Sandler Nicola, Chen Yi, Smith Julian
DOI:10.4103/aca.ACA_58_19  PMID:32687093
Benign cardiac hemangiomas are rare tumors that may present in or out side of the heart, epicardium being the most common site. Echocardiography is the method of choice in diagnosing cardiac masses and though 3D TEE may seem to add exact information about the location, the time constraint in doing a comprehensive examination along with 3D rendering inside operation room may become an hindrance.
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Right ventricular outflow tract obstruction due to a leiomyosarcoma p. 338
Nicholas Suraci, Jason Hoyos, Diego Baruqui, Orlando Santana
DOI:10.4103/aca.ACA_89_19  PMID:32687094
A 65-year-old female presenting with worsening dyspnea and notable weight loss were found to have a systolic murmur on physical examination. On workup with computed tomography (CT) angiogram, a solid mass was found extending from the inferior vena cava into the right ventricle. Transesophageal echocardiography demonstrated this mass extension causing right ventricular outflow tract obstruction. After surgical removal, the pathology of the mass was endometrial leiomyosarcoma.
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BRIEF COMMUNICATION Top

A brief guidance for cardiologists for resource containment measures to mitigate anticipated shortages of n-95 filtering facepiece respirators during COVID-19 pandemic p. 340
Prerna Kapoor, Aditya Kapoor, Afzal Azim
DOI:10.4103/aca.ACA_97_20  PMID:32687095
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CASE REPORTS Top

JARVIK 2000 implantation in adolescent heart: A transesophageal echo experience p. 344
P Hemamalini, Prabhat Dutta, Sandeep Attawar
DOI:10.4103/aca.ACA_191_18  PMID:32687096
Left ventricular assist devices (LVAD) have gained widespread use as an effective clinical therapy for patients with heart failure (INTERMACS 1-5) and are the standard of care for bridging patients to cardiac transplantation. Pre-implantation transesophageal echocardiography (TEE) allows interrogation of all cardiac structures and identifies potential problems such as intracardiac shunts, thrombi, aortic insufficiency, and right ventricular dysfunction that need palliation. Post-implantation exam helps in weaning from cardiopulmonary bypass (CPB) and successful LVAD initiation. ICU monitoring with TEE guides optimal intervention and should be considered in selected patients. TEE will continue to remain vital to successful outcomes in LVAD patients.
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Perioperative anesthetic management of an 18-month-old pediatric patient with a congenital coronary fistula between the left circumflex coronary artery and coronary sinus: Report of a rare case p. 347
Beth A VanderWielen, Yuanxu J Dong, Shelly B Borden
DOI:10.4103/aca.ACA_127_19  PMID:32687097
We present a case of an 18-month-old, 8.69 kg, female, who presented with a coronary fistula between the left circumflex coronary artery and coronary sinus (CS) for remote computed tomography (CT) imaging and transcatheter closure. This is the fifth published case report to describe this congenital anomaly and the first to discuss general anesthesia (GA) and the hemodynamic management considerations for the anesthesiologist.
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Repeat reteplase therapy in a patient with recurrent prosthetic tricuspid valve thrombosis after trido multiple valve replacement p. 351
Hasan Haghaninejad, Somaye Fallahzade, Mohammadreza Pagardkar
DOI:10.4103/aca.ACA_228_18  PMID:32687098
Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication. It has an incidence of 6.1% in developing countries and 0.3%–1.3% in developed countries. The first-line treatment for the right-sided PVT is fibrinolytic therapy with streptokinase or recombinant tissue plasminogen activators, but there are limited cases that were treated with recombinant plasminogen activators. A 57-year-old female with a history of Trido valve surgery and persistent atrial fibrillation rhythm was hospitalized for recurrent tricuspid mechanical valve thrombosis multiple times. The patient was treated with fibrinolytics successfully three times. We report a rare case of recurrent tricuspid mechanical valve thrombosis that is treated with IV reteplase twice.
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Massive air embolism during off-pump CABG: A case report p. 354
Swapnil Verma, Upadhayula Srinivas, Priyanka Mittal, Anand Kumar Sathpathy
DOI:10.4103/aca.ACA_190_18  PMID:32687099
Off-pump coronary artery bypass grafting (OPCAB), although devoid of the morbidity associated with cardiopulmonary bypass (CPB), has its own technical difficulties. Achieving optimum tissue stabilization on a beating heart along with hemodynamic fragility due to extreme positioning also complicates the anesthetic management. In addition, it is difficult to obtain a clear surgical field in the presence of arteriotomy. The use of catheter-directed high-flow gas blower (mister blower) helps achieve a clear surgical field to a great extent. However, there have been reported cases of arterial and pulmonary embolism caused by these high-flow gas blowers. The present case reports a case of massive venous air embolism caused by the use of mister blower.
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Systolic anterior motion of mitral valve following resection of subaortic membrane and intracardiac repair of tetralogy of fallot p. 357
Krishna Prasad Gourav, Bhupesh Kumar, Imran Bhat, Anand K Mishra
DOI:10.4103/aca.ACA_194_18  PMID:32687100
Systolic anterior motion (SAM) of the mitral valve is commonly observed in patients with hypertrophic obstructive cardiomyopathy and in few patients after mitral valve repair or aortic valve replacement. It may cause significant hemodynamic instability due to left ventricular outflow tract (LVOT) obstruction and resulting mitral regurgitation. Subaortic septal bulge is considered as a one of the risk factor for the development of SAM as it narrows the LVOT. We report a case of tetralogy of fallot with subaortic septal bulge who developed SAM of the anterior mitral leaflet, intraoperatively, after resection of a subaortic membrane.
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Suspicion of penetrating cardiac injury: Curing or caring? p. 361
Nicolas Imbert, Vania Tacher, Roman Mounier, Mathieu Martin
DOI:10.4103/aca.ACA_214_18  PMID:32687101
Identifying penetrating cardiac injury in hemodynamically stable patients can be challenging especially when the patient has no signs of cardiac tamponade and no pericardial effusion identified on transthoracic echocardiography. In this case report, we discuss both penetrating cardiac injuries diagnosis algorithm and treatment strategies. At present, it is difficult to refer to general guidelines transposable from one center to another. We report the paramount importance of multidisciplinary management with experienced teams to face any possible pitfalls in traumatology especially in the context of penetrating cardiac injury.
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Rare case of tracheal bronchus in a patient posted for minimal invasive cardiac surgery p. 364
Dibyendu Khan, Saikat Sengupta, Sushan Mukhopadhyay, Gautam Pati
DOI:10.4103/aca.ACA_215_18  PMID:32687102
The tracheal bronchus is a rare congenital anomaly which occurs as a result of an additional tracheal outgrowth early in the embryonic life. It originates more commonly from the right wall of the trachea, above the carina. It is usually asymptomatic but may cause recurrent pneumonia, chronic bronchitis, or bronchiectasis. Here, we present the case of a 57-year-old lady posted for minimally invasive coronary surgery who was incidentally found to have an accessory bronchus during establishing one lung ventilation. The clinical implications of such a scenario is highlighted.
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Successful management of hypothermic cardiopulmonary bypass in a malignant hyperthermia susceptible patient p. 367
Shvetank Agarwal, Kevin Graham, Simon Kigwana, Manuel Castresana
DOI:10.4103/aca.ACA_245_18  PMID:32687103
Malignant hyperthermia (MH) is a potentially lethal reaction in those that are genetically predisposed, frequently triggered by inhaled anesthetics. MH is often difficult to diagnose because it is accompanied by signs and symptoms that are shared with other disorders. The diagnosis is further obscured in cardiac surgical patients, as the signs of MH can be masked by the cardiopulmonary bypass circuit (CPB) and the use of induced hypothermia. In this case-report, we describe the successful anesthetic management of a 65-year-old MH-susceptible female, confirmed via caffeine halothane contracture test, with aortic regurgitation and ascending aortic dilatation who underwent a Bentall procedure. We have also identified certain key measures for the safe anesthetic management of these patients.
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LETTERS TO EDITORS Top

Immediate hemodynamic and gaseous exchange; effect of Bi-Level positive airway pressure after cardiac surgery: Our insight to Hamid et al.'s study p. 372
Habib M R Karim, Gil Gonçalves, Antonio M Esquinas
DOI:10.4103/aca.ACA_40_20  PMID:32687104
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In response to letter title “Immediate hemodynamic and gaseous exchange effect of bi-level positive airway pressure after cardiac surgery: Our insight to Hamid et al.'s study” p. 373
Mohammad Hamid, Mohammad I Akhtar, Saba Ahmed
DOI:10.4103/aca.ACA_57_20  PMID:32687105
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Comment on: Anesthesiologists and job satisfaction in cardiac cath lab: Do we need guidelines? p. 374
Surender Deora, Pradeep Kumar Bhatia
DOI:10.4103/aca.ACA_89_20  PMID:32687106
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Response for - Letter to editor Comment on: Anesthesiologists and job satisfaction in cardiac cath lab: Do we need guidelines? p. 375
Ajita Suhrid Annachhatre
DOI:10.4103/aca.ACA_116_20  PMID:32687107
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ORIGINAL ARTICLES Top

Connection between the right upper pulmonary vein to the superior vena cava in a patient with a secundum-type atrial septal defect p. 376
Ali Hosseinsabet
DOI:10.4103/aca.ACA_213_18  PMID:32687108
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LETTERS TO EDITORS Top

Double trouble: Airway management in a patient with a massive anterior mediastinal tumor complicated by a thyroid mass p. 377
Prakash K Dubey, Ganesh K Ram
DOI:10.4103/aca.ACA_201_18  PMID:32687109
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Smartphone smart apps – Breaking the communication barriers p. 379
Manu Thomas, Gaurav Sindwani, Aditi Suri
DOI:10.4103/aca.ACA_24_19  PMID:32687110
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INTERESTING IMAGES Top

A rare case of injury to aorto-mitral curtain during mitral valve replacement surgery p. 380
Indranil Biswas, Ravi S Singh, Amarnath Ghosh, Poornima Sivakumar
DOI:10.4103/aca.ACA_185_18  PMID:32687111
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