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   Table of Contents - Current issue
October-December 2020
Volume 23 | Issue 4
Page Nos. 383-546

Online since Monday, October 19, 2020

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Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 1: The problem; nomenclature; delirium and postoperative neurocognitive disorder; and the role of cardiac surgery and anesthesia Highly accessed article p. 383
Mukul C Kapoor
The association with cardiac surgery with cognitive decline was first reported in the 1960s after the introduction of coronary artery surgery. The incidence in cognitive decline was thought to be more after cardiac surgery, especially with the use of the cardiopulmonary bypass. Anesthesia and surgery are both associated with cognitive decline but many other factors appear to contribute its genesis. On-pump surgery, microembolization during manipulation of the heart and great vessels, temperature changes, pH changes, and altered cerebral perfusion, during cardiac surgery, have all been blamed for this. Postoperative cognitive decline is associated with poor clinical outcomes and higher mortality. Several studies have been conducted in the last decade to determine the genesis of this malady. Current evidence is absolving cardiac surgery and anesthesia to be the primary causes per se of cognitive dysfunction.
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Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction Highly accessed article p. 391
Mukul C Kapoor
Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.
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Covid 19 and its cardiovascular effects Highly accessed article p. 401
Amit Rastogi, Prabhat Tewari
COVID-19 pandemic is mainly related with the pulmonary problems initially but now as the pandemic is growing it is observed that almost all organ systems of the body are affected. Up to 20-30% patients who are admitted in Covid hospitals are showing cardiovascular involvement. Severity of cardiovascular disease in a COVID-19 patient depends whether a patient is having pre-existing cardiac disease or not. Patients with pre-existing cardiac disease have more severe infection and associated mortality. Severe COVID-19 infection shows close association with myocardial damage and various arrythmias. The cardiovascular involvement occurs by either engagement directly with the angiotensin converting enzyme 2 or indirectly by the effect of inflammatory mediators which are generated as a result of viral-host response to infection. The COVID-19 disease is said to produce a wide spectrum of affliction ranging between even asymptomatic patient to Cardiovascular syndrome. Even after recovering from COVID-19 patients can reappear in the hospital with cardiomyopathies and arrythmias.
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Measurement of aortic root dimensions by transesophageal echocardiography in adult patients undergoing cardiac surgery Highly accessed article p. 409
Wiriya Maisat, Prasert Sawasdiwipachai, Walaiporn Aroonrat, Saowaphak Lapmahapaisan
Background: Normal aortic root dimensions were established from studies from Western countries. As the body size is significantly associated with the aortic root dimensions, Thai populations may have smaller aortic root diameters. Aims: To elucidate the aortic root dimensions using transesophageal echocardiography (TEE) in adult patients undergoing cardiac surgery. Settings and Design: A retrospective cohort study including 150 patients aged >18 years undergoing cardiac surgery. Materials and Methods: Aortic root dimensions (annulus, sinus of Valsalva, sinotubular junction (STJ), and proximal ascending aorta) were measured using two-dimensional TEE. Patients with aortic-root related pathology were excluded. Results: Men constituted 60% of the study population; the mean age was 61.9 ± 12.6 years, and mean body surface area (BSA) was 1.7 ± 0.2 m2. The absolute dimensions for the annulus, sinus of Valsalva, STJ, and proximal ascending aorta were 22.3 ± 3.4, 32.6 ± 3.9, 26.4 ± 3.3, and 29.3 ± 3.1 mm, respectively, in men (12.9 ± 1.6, 18.8 ± 2.6, 15.2 ± 2.1, and 17.9 ± 2.7 mm, respectively, after adjusting for BSA) and 20.3 ± 2.2, 29.8 ± 3.6, 23.8 ± 2.6, and 27.1 ± 3.1 mm, respectively, in women (13.5 ± 2.0, 19.8 ± 2.3, 15.8 ± 2.5, and 17.0 ± 2.1 mm, respectively, after adjusting for BSA). The absolute aortic root diameters were significantly greater in men at all levels (P < 0.001). The BSA-adjusted diameters were similar for both sexes at the annulus (P = 0.076) and STJ (P = 0.076), except for the sinus of Valsalva (P = 0.010) and proximal ascending aorta (P = 0.006). Conclusion: This study reports reference values of aortic root dimensions by TEE. The body size should be considered when comparing the aortic root dimensions of Thai populations with the standard normal values.
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Quantitative estimation of LIMA blood flow between extraluminal papavarine vs extraluminal papavarine plus intraluminal vasodilator cocktail in CABG patients Highly accessed article p. 414
Vivek V Pillai, Renjith Sreekanthan, Jayakumar Karunakaran
Objective: In this study, we aimed at a comparative quantitative estimation of the difference in LIMA blood flow between LIMAs treated with topical papaverine alone and LIMAs treated with a combination of topical papaverine plus an intraluminal cocktail of papaverine, nitroglycerine, and milrinone. Methods: Nearly 50 consecutive patients with similar demographics undergoing elective on-pump CABG were recruited for the study. After pedicled LIMA harvest, topical papaverine was sprayed on the pedicle and kept enveloped in papaverine soaked gauze. LIMA flow was then estimated. Later, intraluminal vasodilator solution of papaverine, NTG, milrinone, and heparinized blood were instilled in LIMA, and LIMA flows were estimated. Results: The mean LIMA flows with topical papaverine alone was 47.19 mL/min whereas the mean LIMA flows with topical papaverine plus intraluminal cocktail was 104 mL/min. There was a significant difference between the two flows as their mean was 56.815 mL/min and the paired t-test for significance had a P value of 0.0001. Conclusion: There was a significant difference in the LIMA flow when the LIMA had been treated with the intraluminal instillation of the vasodilator cocktail in addition to the topical application of papaverine solution. Therefore, intraluminal vasodilator cocktail of milrinone, NTG, and papaverine mixed with heparinized blood in addition to topical papaverine is a simple and effective method for LIMA preparation in CABG.
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Gender difference in long- and short-term outcomes of off-pump coronary endarterectomy p. 419
Feridoun Sabzi, Atefeh Asadmobini
Background: The role of gender in the selection of the most effective method for treatment of patients with diffused coronary artery diseases remains a matter of debate. This study thus evaluated the effect of gender on long- and short-term outcomes of off-pump coronary endarterectomy (CE). Methods: This was a single-center retrospective study of patients who had undergone coronary artery bypass graft (CABG). The patients were divided into two groups, the CABG and the CABG + CE group, and further stratified into male and female. Long-term survival for each group was estimated by Kaplan–Meier analysis with log-rank testing. In addition, Cox regression analyses of each gender were also carried out to identify the predictors of the primary and secondary endpoints. Results: Overall, 25.8% of the patients were female. Diseased vessels were not statistically different in the two groups – men and women. There was no significant difference in postoperative outcomes between males and females in the CABG and CABG + CE groups. There was no significant difference in hospital mortality in the two groups between males and females. Kaplan–Meier curves show that there was no significant difference in the 5-year cardiac mortality between males and females belonging to the CABG and CABG + CE groups. Conclusion: The results of this study show that there was no significant difference in the short- and long-term outcomes of off-pump CABG and CE in both genders although women tend to carry a greater risk.
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Comparison of flow-independent parameters for grading severity of aortic stenosis using intraoperative transesophageal echocardiography – A prospective observational study p. 425
S Nanditha, Vishwas Malik
Introduction: Discrepancies have been reported in grading of severity of aortic stenosis. We propose to compare Aortic valve area by continuity equation, Dimensionless Index and Acceleration time/Ejection time in patients with documented severe aortic stenosis with normal left ventricular function by TEE after induction of anesthesia. This might give use insight about the best parameter we can rely on intra-operatively for decision making. Methodology: 60 patients with severe AS undergoing elective cardiac surgery were enrolled in our study. Post intubation trans-thoracic echocardiography (TEE) was performed and above mentioned parameters was noted. Results: 96.7 % of patients continued in severe AS category when AS was measured using AVA as echo parameter. So there is 3.3 % disparity. There was disparity in 13.3% of cases when DI was considered. And there was 43.3% disparity when AT/ET was considered. Conclusion: Perioperative grading of aortic stenosis continues to be a challenge for cardiac anesthesiologists. Multiple echocardiographic parameters have to be considered. We have found AVA and DI to have less disparity compared to AT/ET.
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Monitoring of limb perfusion after vascular surgery in critical limb ischemia using near-infrared spectroscopy: A prospective observational study p. 429
Tanveer Singh Kundra, Ashwini Thimmarayappa, Sunder Singh Subash, Parminder Kaur
Background: Intra and postoperative perfusion monitoring should be used in critical limb ischemia patients undergoing vascular surgery to improve outcomes and reduce costs. While a pulse oximeter can be applied on the affected limb to monitor the arterial saturation of the limb, thus reflecting flow in that limb, we need to focus on other important parameters like muscle oxygen consumption and regional blood flow for a good outcome. Near-infrared spectroscopy (NIRS) can be used in such patients to monitor regional and tissue oxygenation. Methodology: In this prospective observational study, 30 adult patients undergoing infra-inguinal bypass were recruited. All these patients were given combined spinal-epidural anesthesia. In addition to routine monitoring, a pulse oximeter and NIRS electrodes were applied on the affected limb. rsO2, limb spO2, and Doppler signals were noted before the induction of anesthesia (baseline) and postoperatively at 0, 6, and 12 h. Improvement in rsO2 and limb spO2 values after surgery was noted and fall in these values was evaluated. Pearson correlation between rsO2 and limb spO2 was assessed. The data was analyzed using repeated-measures ANOVA. Results: Pearson correlation between rsO2 and limb spO2 was r > 0.8. Two patients had a fall in rsO2 in postoperative period, which co-related with a fall in limb spO2 and decreased/absent Doppler signals. Conclusion: NIRS represents a noninvasive and reliable means to monitor limb perfusion in patients undergoing vascular surgery for rest pain.
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Tracheal extubation of anesthetized pediatric patients with heart disease decreases the incidence of emergence agitation: A retrospective study p. 433
Tatsuya Kunigo, Yuko Nawa, Yusuke Yoshikawa, Michiaki Yamakage
Background: Emergence agitation for pediatric patients after general anesthesia is one of the postoperative complications. The relationship between consciousness at tracheal extubation and emergence agitation is not clear. Aim: The aim of the present study was to determine whether tracheal extubation of anesthetized pediatric patients with heart disease by propofol decreases the incidence of emergence agitation. Settings and Design: This was a retrospective case-control study conducted at a children's hospital. Materials and Methods: Pediatric patients with heart disease aged 0-14 years who underwent cardiac catheterization under general anesthesia by propofol between October 2014 and September 2018 were enrolled. The incidence of emergence agitation by anesthetized extubation was compared with that by awake extubation. Statistical Analysis Used: Logistic regression analysis was performed. Results: Anesthetized extubation was performed in 202 patients and awake extubation was performed in 56 patients. The incidence of emergence agitation was significantly lower in patients who underwent anesthetized extubation than in patients who underwent awake extubation (25.2% vs. 69.6%, P = 0.000). In logistic regression analysis, anesthetized extubation [odds ratio (OR): 0.075, 95% confidence interval (CI): 0.034-0.165, P = 0.000] and older age (OR: 0.808, 95% CI: 0.728-0.897, P = 0.000) were associated with a decreased incidence of emergence agitation, and preoperative anxiety (OR: 2.220, 95% CI: 1.060-4.660, P = 0.03) was associated with an increased incidence of emergence agitation. Conclusions: Tracheal extubation under anesthesia by propofol decreases the incidence of emergence agitation in pediatric patients with heart disease.
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Fluid responsiveness to passive leg raising in patients with and without coronary artery disease: A prospective observational study p. 439
Varun Suresh, Manikandan Sethuraman, Jayakumar Karunakaran, Thomas Koshy
Introduction: Hemodynamic stability and fluid responsiveness (FR) assume importance in perioperative management of patients undergoing major surgery. Passive leg raising (PLR) is validated in assessing FR in intensive care unit patients. Very few studies have examined FR to PLR in intraoperative scenario. We prospectively studied FR to PLR using transesophageal echocardiography (TEE), in patients with no coronary artery disease (CAD) undergoing major neurosurgery and those with CAD undergoing coronary artery bypass grafting (CABG). Methods: We enrolled 29 adult consenting patients undergoing major neurosurgery with TEE monitoring and 25 patients undergoing CABG. After induction of anesthesia, baseline hemodynamic parameters were obtained which was followed by PLR using automated adjustment of the operating table. Clinical and TEE-derived hemodynamic parameters were recorded at 1 and 10 min after PLR following which patients were returned to supine position. Results: A total of 162 TEE and clinical examinations were done across baseline, 1 and 10 min after PLR; and paired comparison was done at data intervals of baseline versus 1 min PLR, baseline versus 10 min PLR, and 1 min versus 10 min PLR. There was no significant change in hemodynamic variables at any of the paired comparison intervals in patients undergoing neurosurgery. CABG cases had significant hemodynamic improvement 1 min after PLR, partially sustained at 10 min. Conclusion: Patients undergoing CABG had significant hemodynamic response to PLR, whereas non-CAD patients undergoing neurosurgery did not. A blood pressure–left ventricular end-diastolic volume combination represented strong correlation in response prediction (Pearson's coefficient 0.641; P < 0.01).
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Transesophageal probe placement increases endotracheal tube cuff pressure but is not associated with postoperative extubation failure after congenital cardiac surgery p. 447
Stephanie J Pan, Stephen Z Frabitore, Angela R Ingram, Khoa N Nguyen, Phillip S Adams
Context: The concomitant use of cuffed endotracheal tubes (ETT) and transesophageal echocardiography (TEE) probes increases ETT cuff pressures (CP), which may contribute to mucosal ischemia and perioperative complications such as failed extubation. Aims: To assess changes in ETT CP after TEE insertion in patients of different age groups undergoing congenital heart surgery and examine the relationship between ETT CP and postoperative extubation failure. Settings and Design: Single-center quality improvement project. Subjects and Methods: ETT CP was measured with a manometer following intubation and again after TEE insertion. Tracheal perfusion pressure was then calculated and postoperative extubation failures were recorded. Statistical Analysis: Chi-square testing, Fisher's-exact testing, one-way analysis of variance testing or Kruskal–Wallis testing with Dunn's pairwise, and student's t-test or Wilcoxon rank-sum testing were used to analyze the data. Results: Median ETT CP increased significantly after TEE insertion in each age group, with infants showing a smaller magnitude of increase (+2 [1-6] cm H2O, P < 0.001) than adults (+12 [8-14] cm H2O, P = 0.008) (intergroup comparison P = 0.002). Five patients (9%) failed extubation, all of which were infants. Within the infant subgroup, no significant difference existed between failed vs successful extubation regarding ETT CP during bypass (15 ± 1 vs 16 ± 2 mmHg, P = 0.206) or tracheal perfusion pressure pre-bypass (34 ± 9 vs 38 ± 11 mmHg, P = 0.518), during bypass (20 ± 9 vs 22 ± 6 mmHg, P = 0.697), or post-bypass (42 ± 9 vs 41 ± 9 mmHg, P = 0.923). There was a significant difference in cardiopulmonary bypass duration (151 ± 29 vs 85 ± 32 min, P < 0.001). Conclusion: Factors beyond intraoperative ETT CP likely play a larger role in postoperative extubation failure.
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Relationship between transesophageal echocardiography-derived pulmonary artery systolic pressure measurements and early morbidity in patients undergoing coronary artery bypass grafting p. 453
Hariharan Subramanian, Satyen Parida, Chitra Rajeswari Thangaswamy, Ashok Shankar Badhe, BV Sai Chandran, Sandeep Kumar Mishra
Context: We studied the relationship between intraoperative transesophageal echocardiography-derived (TEE-derived) pulmonary artery systolic pressure (PASP) measurements with early morbidity in on-pump coronary artery bypass grafting (CABG) surgery. Aims: The objective of the study was to assess whether TEE-derived elevated PASP is independently predictive of significant morbidity. Settings and Design: Prospective observational study in a university hospital. Materials and Methods: Around 54 patients who underwent CABG under cardiopulmonary bypass (CPB) were divided into two groups; with PASP ≥35 mmHg and PASP <35 mmHg, assessed by intraoperative TEE. Outcomes studied were poor coronary revascularization, postoperative arrhythmias, myocardial infarction, respiratory failure, intra-aortic balloon pump use, pacemaker dependence, significant inotrope use, prolonged intensive care unit stay, and the total length of stay in the hospital. Mortality analysis was not a part of this study since expected sample sizes were low. Results: Patients with PASP ≥35 mmHg had a higher risk of respiratory failure, increased inotrope use and prolonged hospital stay, although multivariate analysis failed to demonstrate an independent association of PASP with these outcomes. Diabetes mellitus (DM), peripheral vascular disease, low cardiac output and elevated mitral annular E/e' ratio were significantly associated with higher pulmonary arterial pressures. Multivariate analysis showed that PASP was independently associated with higher mitral annular E/e' ratio. Conclusions: Our study, therefore, suggests that higher PASP may predict higher left ventricular filling pressures, and although elevated PASP ≥35 mmHg may be associated with DM; peripheral vascular disease, lower intraoperative cardiac output, postoperative respiratory failure, higher inotrope use, and delayed hospital discharge, it is not an independent predictor of any of these variables.
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Does the endotracheal tube cuff pressure increases with transesophageal probe insertion? p. 460
Deepak Prakash Borde, Swati Pande, Balaji Asegaonkar, Sujit Khade, Antony George, Shreedhar Joshi
Context: The cuff pressure (CP) of the endotracheal tube (ETT) exceeding 30 cm of H2O results in reduced perfusion of lateral mucosa of trachea leading to complications. As the posterior tracheal wall is in contact with the esophagus, there is a possibility that the insertion of transesophageal echo (TEE) probe may compress the tracheal wall and increase CP. Aims: This study was aimed to assess the impact of TEE probe insertion on CP in adults undergoing cardiac surgery. Settings and Design: Prospective observational study of 65 patients at tertiary care level hospital. Subjects and Methods: After balanced general anesthesia, patients were intubated with high volume low-pressure ET.TEE probe was then inserted with gentle jaw thrust. CP was measured by standard invasive pressure monitoring device at four points: T1 at baseline before TEE probe insertion; T2 maximum CP noted at TEE probe insertion; T3 at 5 min post TEE probe insertion; and T4 at post-TEE exam. Statistical Analysis Used: CP was compared between pairs of time points (T1 vs. T2; T1 vs. T3; and T1 vs. T4) using Mann-Whitney U test. Factors predicting CP >30 cm of H2O at T4 were assessed by backward stepwise regression. Results: CP (mean ± S.D.) at T1, T2, T3, and T4 was 22 ± 3, 38 ± 10, 30 ± 6, and 30 ± 7, respectively. CP increased significantly from T1 to T2 (P < 0.001), T1 to T3 (P < 0.001), and T1 to T4 (P < 0.001). There were 26 patients (40%) with CP >30 cm of H2O at end of TEE exam (T4). On multivariate analysis baseline, CP (T1) >20 cm of H2O was significantly associated with CP >30 cm of H2O at end of TEE exam with Odd's Ratio (OR) of 8.5 (1.76–41.06, P = 0.008). Conclusions: To conclude, the CP increases significantly with TEE probe insertion in 40% of patients exceeding a safe limit of 30 cm of H2O. The monitoring and optimization of CP is advisable.
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Effect of dexmedetomidine on pulmonary artery pressure in children with congenital heart disease and pulmonary hypertension p. 465
Muralidhar Kanchi, Devdas Thomas Inderbitzin, Kadam Naina Ramesh, Pujar Venkateshauarya Suresh, Shreesha Shankar Mayya, Shanthi Sivanandam, Kumar Belani
Background: This study was undertaken to determine the effects of dexmedetomidine on pulmonary artery pressure (PAP) in children with congenital heart disease (CHD) and pulmonary hypertension (PH) undergoing cardiac catheterization with and without a planned intervention during monitored anesthetic care using midazolam and ketamine. Materials and Methods: Children (<18 years) with known CHD and PH who were scheduled for cardiac catheterization and interventional procedures were included in the study. The procedures were performed under monitored anesthesia. After obtaining baseline PAPs, an intravenous (IV) infusion of dexmedetomidine (1 μg/kg) was given for over 10 min. During infusion, heart rate (HR), blood pressure (BP), respiratory rate (RR), and peripheral arterial oxygen saturation (SPO2) were recorded every 2 min until completion of dexmedetomidine infusion, 15 min later, and when the procedure was completed. In addition, pulmonary artery systolic and diastolic pressures, and mean pulmonary artery pressure (MPAP) were recorded and the pulmonary artery systolic pressure (PASP)/systolic blood pressure (BP) ratio was calculated. Results: All children tolerated the procedure without adverse events. The HR decreased significantly over time during dexmedetomidine infusion. The changes in systemic systolic BP and PAPs were not significantly different from the baseline value at all points of measurement as was the ratio between the systolic pulmonary artery and systolic systemic BPs. Conclusions: Administration of dexmedetomidine in a dose of 1 μg/kg over 10 min did not significantly alter the PAP in children with CHD and PH. There was a decrease in the HR that was not clinically significant. The children tolerated dexmedetomidine without adverse events.
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Decision making, management, and midterm outcomes of postinfarction ventricular septal rupture: Our experience with 21 patients p. 471
Samarjit Bisoyi, Usha Jagannathan, Anjan K Dash, Raghunath Mohapatra, Debashish Nayak, Satyajit Sahu, Pattnaik Satyanarayan
Context: Ventricular septal rupture (VSR) is a dreaded complication following myocardial infarction. Surgical repair of VSR is associated with significant early mortality. Variable outcomes in terms of early mortality and midterm functional status have been reported from different centers. Aims: In our study, we attempt to review the experience of decision making and surgical repair of postinfarction VSR, and to analyze the factors contributing to the early mortality and midterm outcome after repair. Materials and Methods: It is a retrospective study. Data were summarized retrospectively by frequencies and percentages for categorical factors, and means and standard deviations for continuous factors. Multivariate logistic regression, odds ratios, 95% confidence intervals, and P value were calculated for different variables to determine their independent effect on operative mortality. All surviving patients answered the EQ-5D Health Questionnaire. Results: Preoperative renal failure, left ventricular dysfunction (moderate and severe), and Killip class (III and IV) were significantly associated with early mortality after surgery. Small residual ventricular septal defect (VSD) was not found to affect the midterm quality of life. Conclusions: Early surgical repair benefits the patient by preventing early end-organ damage. The renal failure left ventricular dysfunction (moderate and severe) and Killip class (III and IV) adversely affect early outcomes after surgery. Small residual ventricular septal defect (VSD) does not affect the midterm quality of life.
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Myocardial protection in cardiac surgery: Del Nido versus blood cardioplegia p. 477
Gladdy George, AV Varsha, Madhu Andrew Philip, Reshma Vithayathil, Dharini Srinivasan, FX Sneha Princy, Raj Sahajanandan
Objectives: del Nido cardioplegia which was traditionally used for myocardial protection in pediatric congenital heart surgery is now being extensively utilized in adult cardiac surgery. The aim of this study was to compare the safety and efficacy of del Nido cardioplegia (DNC) with blood cardioplegia (BC). Materials and Methods: This is a historical cohort study using secondary data. Two hundred and eighty six patients who underwent coronary artery bypass graft (CABG) or valve surgery were included. They were divided into 2 matched cohorts of which 143 patients received BC and 143 patients received DNC. Results: There was no difference in cardiopulmonary bypass time (P = 0.516) and clamp time (P = 0.650) between the groups. The redosing of cardioplegia was significantly less for DNC (1.13 vs. 2.35, P = <0.001). The post bypass hemoglobin was higher for DNC (9.1 vs. 8.7, P = 0.011). The intraoperative and postoperative blood transfusion was comparable (P = 0.344) (P = 0.40). The incidence of clamp release ventricular fibrillation (P = 0.207) was similar. The creatine kinase-MB isotype levels for the CABG patients were comparable on all 3 days (P = 0.104), (P = 0.106), and (P = 0.158). The postoperative left ventricle ejection fraction was lesser but within normal range in the DNC group (53.4 vs. 56.0, P = <0.001). The duration of ventilation (P = 0.186), ICU days (P = 0.931), and postoperative complications (P = 0.354) were comparable. There was no 30-day mortality or postoperative myocardial infarction in both the groups. Conclusion: DNC provides equivalent myocardial protection, efficacy, and surgical workflow and had comparable clinical outcomes to that of BC. This study shows that DNC is a safe alternate to BC in CABG and valve surgeries.
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Cardiothoracic surgery during COVID-19: Our experience with different strategies p. 485
Sarju Ralhan, Rajesh C Arya, Rama Gupta, Gurpreet S Wander, Rajiv K Gupta, Vivek K Gupta, Suhani Bagga, Bishav Mohan
Background: An acute respiratory disease (COVID-19), caused by a novel coronavirus (SARS-CoV-2,), has been declared a pandemic by WHO. A surgery on COVID-19 patients not only involves a risk of spread of the disease but also there is a serious concern for the patient's surgical outcomes and resources requirement. Aim: The retrospective study is aimed to provide a protocol for pre-operative testing of SARS CoV-2 using RT-PCR in the patient undergoing cardio-thoracic surgeries. Material and Methods: To analyze the impact of pre-operative testing of SARS- CoV-2 using RT-PCR in the patient undergoing elective cardio-thoracic surgeries. The patient who underwent surgical interventions during the COVID-19 lockdown period was divided into two phases. Phase I (without COVID-19 RT-PCR testing) and Phase II (with pre-operative COVID-19 RT-PCR testing). The retrospective comparison between the two study groups was done using Student t-test, Mann–Whitney U, and Chi square (χ2) test depending upon the clinical variable to be analyzed. Results: During the early phase (phase I), 26 patients underwent cardio-thoracic surgery without COVID-19 RT-PCR test. Whereas, during phase II, all patients were tested for COVID-19 using RT-PCR, preoperatively and a total of 64 surgeries were performed during this phase. One patient planned for CABG was positive on RT-PCR for COVID-19 and was sent to the quarantine ward. The difference in the pre-operative hospital stay between two groups was found to be statistically significant and a significant decrease in the number of PPE kits used, during the phase I. Conclusion: All asymptomatic patients should be tested for COVID-19 using RT-PCR prior to cardio-thoracic surgeries not only to contain the disease but to avoid potential implications of COVID-19 on the perioperative course, without added financial implications.
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Anesthetic consideration for patients with micra leadless pacemaker p. 493
Sathappan Karuppiah, Richard Prielipp, Ratan K Banik
MICRA, miniaturized leadless single chamber pacemaker, is inserted directly into the right ventricular myocardium via transcatheter approach. We present a case of a 66-year-old patient with a Micra pacemaker scheduled for kidney-pancreas transplant. The patient is pacemaker dependent. The preoperative cardiology consult did not comment on the need of reprogramming. One hour prior to the surgery, the anesthesia team was unable to locate the pacemaker on the chest wall. The Medtronic hotline was called, and the caregivers learned that the particular pacemaker is buried within the ventricular wall and is not responsive to an external magnet. Thus, the case was delayed and a cardiac electrophysiology team was contacted to reprogram the pacemaker to VOO (fixed ventricular pacing) mode. We suggest that the pacemaker can pose perioperative challenges due to its novelty, paucity of report, and guidelines.
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Coronary cameral fistula and its complications: A case report p. 496
Renu Upadhyay, Aseem Gargava, Vishal Prabhu, Manjula Sarkar, Jitendra Homdas Ramteke
Coronary cameral fistulas (CCFs) are rare arteriovenous malformations that may be congenital or acquired. The presentation of CCFs varies from asymptomatic in early age to symptomatic and start of complications upon aging. Although percutaneous closure with embolization can also be done, surgical closure of CCFs is a gold standard of treatment. We present the case of a 20-year-old patient with a fistula connecting right coronary artery and the right atrium, along with aortic valve endocarditis and congestive cardiac failure.
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Two patterns of the “crossed swords sign” for the accurate diagnosis of diverse mitral valve regurgitations p. 499
Kazuto Miyata, Sayaka Shigematsu
The “crossed swords sign,” demonstrating the divergent jet, is visualized on 2-dimensional color Doppler imaging and indicates complicated mitral regurgitation (MR). We describe the cases of two patients with varying patterns of the crossed swords sign. In the first patient, the crossed swords sign was detected during the holosystolic phase. In the second patient, the direction of the MR jet changed according to the phase of systole: The crossed swords sign was formed by two regurgitation jets during different phases of systole. The crossed swords sign implies two patterns and is useful for the accurate diagnosis of complex MR.
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Iatrogenic intramural hematoma of the ascending aorta complicating inadvertent arterial cannulation during central venous catheter placement. A case report and review of the literature Highly accessed article p. 502
Mafdy Basta
Aortic injury during central venous catheter (CVC) insertion is a rare but serious complication. This presentation describes a case of iatrogenic intramural hematoma of the ascending aorta complicating inadvertent arterial cannulation of the right subclavian artery during attempted Port-A-Cath insertion at the right subclavian vein. Various strategies for the prevention and management of aortic injury during CVC placement are discussed. In this case, the hematoma was managed surgically and replacement of the ascending aorta was undertaken under deep hypothermic circulatory arrest.
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NIRS: So near yet so far (From the brain) p. 505
Suman S Kandachar, Anbarasu Annamalai
Cerebral oximetry is touted as a magic wand to detect cerebral hypoperfusion. Inability to completely exclude extracranial oxygen however is a limitation. Variation in scalp vascularity can magnify the limitations of relatively short emitter–detector distances. The combination of brain ischemia and cutaneous hyperemia, as is the situation during anaphylaxis and anaphylactoid reactions, can be associated with a paradoxical increase in cerebral oximetry values. This could compromise the quality and accuracy of care delivered. We report the association of red man syndrome with exaggerated cerebral oximetry values.
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Post-surgical unilateral left pulmonary edema after mitral valve replacement – A diagnostic challenge p. 508
Saipriya Tharimena, AV R Naidu
Unilateral left pulmonary edema due to inadvertent surgical occlusion of left superior and inferior pulmonary veins is not only an exceedingly rare complication of mitral valve surgeries but also a diagnostic challenge in the postoperative recovery unit. Described here is a case of a 38-year-old male who developed progressively worsening unilateral left pulmonary edema after mitral valve replacement on postoperative day-1. The diagnosis was mostly by the exclusion of multiple possible differentials and was confirmed during reexploration surgery.
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An unusual case of uninterrupted inferior vena cava with accessory hemizygous channel: An incidental finding in a child p. 512
Gaurav Agrawal, Anupam Das, Gaurav Gupta
Azygos or hemizygous continuation of inferior vena cava (IVC) is diagnosed in the presence of intrahepatic interruption of IVC. We report a case of a 4-year-old, male child presenting with a history of poor weight gain. A detailed evaluation of the child revealed a diagnosis of hemizygous continuation of uninterrupted, but severely obstructed, IVC. This incidental finding has rarely been reported in the literature.
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Aortic cannula tip dislodgement: A rare complication p. 515
Aseem Gargava, Manjula Sarkar, Sanjeeta Umbarkar, Amruta Shringarpure
Cardiac surgery involves use of cardiopulmonary bypass which usually requires a circulatory circuit containing numerous cannulae and tubings draining from major vessels (like superior and inferior vena cavae) and returning it back to the systemic circulation (via the aorta, femoral artery, axillary artery etc). Establishment of this circuit not only requires good surgical skills for technical procedures but also requires stringent vigilance and awareness about the working of these disposable items. Surgeons concentrating in the technical aspect might miss out on the minor manufacturing defects in these disposable items and anesthesiologist as well as perfusionist can contribute in this aspect by including systematic precheck of these items to avoid complications in future. In this case report, we would like to discuss a simple case of mitral valve replacement where during aortic decannulation the metallic tip got dislodged and thus got migrated to the abdominal aorta. This is a rare complication which none of us were expecting. By prechecking the various components of the cardiopulmonary bypass circuit, this complication was expected to be avoided.
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Metastasizing leiomyoma obstructing the right ventricular outflow tract p. 518
Miguel Ruben Abalo, John Carey, Oscar Aljure, Yiliam Rodriguez-Blanco
A very loud systolic murmur was identified during a pre-operative evaluation of a 51-year-old woman for an elective hysterectomy. The TTE showed a 4.7 cm intracardiac mass obstructing the RVOT. The patient was scheduled instead for resection of the mass. Before anesthesia induction, the surgical team and perfusionist were prepared to initiate CPB in case of circulatory collapse. After induction of general anesthesia, the patient became hypotensive, requiring vasopressor support. She recovered and was then successfully placed on CPB. The mass was removed without incident, and a TEE confirmed resolution of the RVOT obstruction. The patient did well post-operatively.
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Recurrent unilateral hemorrhagic pleural effusion: A rare manifestation of thoracic endometriosis syndrome p. 521
Neeti Dogra, Ankur Luthra, Rajiv Chauhan, Ritika Bajaj, Kalla Prasad Gourav
Unilateral recurrent pleural effusions are commonly encountered in critical care practice. Relevant clinical history, physical examination, radiology, and diagnostic thoracentesis usually identify the cause of pleural effusion in most cases. Thoracoscopy or video-assisted thoracic surgery may be required in selective cases. We report a case of 32-year-old female with recurrent unilateral hemorrhagic pleural effusion that was the presenting feature of thoracic endometriosis syndrome.
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Intraoperative transesophageal echocardiography: A complement to 18F-fluorodeoxyglucose positron emission tomography-computed tomography in localizing pacemaker lead endocarditis p. 524
Soumya Sarkar, Rajarajan Ganesan, Bhupesh Kumar, Harkant Singh, Rajender Basher, Ashwani Sood
Lead endocarditis (LE) is a serious complication of permanent trans-venous pacing. Localizing LE may be challenging with conventional imaging modalities. 2-deoxy-2-[fluorine-18] fluoro-D-glucose positron emission tomography–computed tomography (FDG PET/CT) has recently emerged as a promising tool in the diagnosis of LE particularly in cases with normal echocardiographic imaging findings and/or negative blood culture. However, this technique is associated with some drawbacks. Knowledge of these drawbacks and correlating its limitations with other imaging modality is essential for the echocardiographer while evaluating such patient. We report a case where transesophageal echocardiography was complementary to FDG PET/CT in the diagnosis and localization of vegetation over pacemaker leads during intraoperative period.
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Left ventricular pacemaker wire through patent foramen ovale p. 528
Nicholas Suraci, Saberio Lo Presti, Gilberto George Concepcion, Orlando Santana
A 53-year-old male status post pacemaker placement three months prior for sinus bradycardia presented with worsening dyspnea, holosystolic murmur, and a ventricular-paced right bundle branch block on electrocardiogram. Transesophageal echocardiography demonstrated a pacer wire in the right atrium coursing into the left atrium and ventricle through an undiagnosed patent foramen ovale. The patient underwent surgical repair and repositioning of the pacemaker lead without complication. Although rare, it should be suspected after recent lead placement.
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Pacemakers-”an infernal machine that interferes with the will of god” p. 530
Praveen Kerala Varma
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Guiding principles for cardiology care in times of the COVID-19 Pandemic: Gazing through the crystal ball p. 532
Ankit Sahu, Aditya Kapoor
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Epicardial lead placement for cardiac resynchronization therapy in dilated cardiomyopathy patient: Fine tuning anaesthetic challenges p. 537
Srinath Damodaran, Komal Gandhi, Banashree Mandal, Anand Kumar Mishra
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A parable of the mask: Stay calm, be a hummingbird p. 538
Hema C Nair
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Preventing intubation with the transverse thoracic muscle plane block p. 540
Johanna B de Haan, Damon Yu, Nadia Hernandez, Sudipta Sen
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Cardioplegic arrest as pharmacological defibrillation; A novel approach for refractory ventricular fibrillation p. 541
Vivek Chowdhry
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Is ECG an aid to differentiate pulmonary embolism from ACS? p. 543
Subramanian Senthilkumaran, Nanjundan Karthikeyan, Ramachandran Meenakshisundaram, Benita Florence, Ponniah Thirumalaikolundusubramanian
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Monitoring of carotid endarterectomy p. 544
Rajinder Singh Rawat, Said Musallam Al Maashani
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Erratum: Intensive care and anesthesia management for HARPOON beating heart mitral valve repair p. 545

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Retraction: The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery p. 546

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