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   2009| July-December  | Volume 12 | Issue 2  
    Online since July 21, 2009

 
 
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E-ACA: ECHO TUTORIALS
Trans-esophageal echocardiography for tricuspid and pulmonary valves
Mahesh R Prabhu
July-December 2009, 12(2):174-174
DOI:10.4103/0971-9784.53439  PMID:19602749
Transesophageal echocardiography has been shown to provide unique information about cardiac anatomy, function, hemodynamics and blood flow and is relatively easy to perform with a low risk of complications. Echocardiographic evaluation of the tricuspid and pulmonary valves can be achieved with two-dimensional and Doppler imaging. Transesophageal echocardiography of these valves is more challenging because of their complex structure and their relative distance from the esophagus. Two-dimensional echocardiography allows an accurate visualization of the cardiac chambers and valves and their motion during the cardiac cycle. Doppler echocardiography is the most commonly used diagnostic technique for detecting and evaluating valvular regurgitation. The lack of good quality evidence makes it difficult to recommend a validated quantitative approach but expert consensus recommends a clinically useful qualitative approach. This review ennumerates probe placement, recommended cross-sectional views, flow patterns, quantitative equations including the clinical approach to the noninvasive quantification of both stenotic and regurgitant lesions.
  10,660 1,192 1
ORIGINAL ARTICLES
A comparison of the effects of desflurane, sevoflurane and propofol on QT, QTc, and P dispersion on ECG
Dilek Kazanci, Suheyla Unver, Umit Karadeniz, Dondu Iyican, Senem Koruk, M Birhan Yilmaz, Ozcan Erdemli
July-December 2009, 12(2):107-112
DOI:10.4103/0971-9784.51361  PMID:19602734
The aim of this prospective, randomized, and double-blinded study was to compare the effects of desflurane, sevoflurane, propofol on both atrial and ventricular wall function by measurement of QT dispersion (QTd), corrected QT dispersion (QTcd), and P dispersion (Pd) on electrocardiogram (ECG). Forty-six patients from the American Society of Anesthesiologists class I−II undergoing noncardiac surgery, were enrolled in this study. Patients were randomly allocated to receive desflurane, sevoflurane or propofol anesthesia. ECG recordings were taken before and after 5 minutes of drug administration. Induction with desflurane significantly increased the QTd compared to baseline (38 2 ms vs. 62 6 ms, P < 0.05). Sevoflurane and propofol anesthesia was not associated with any changes in QTd. QTcd was increased with desflurane induction and decreased with sevoflurane and propofol induction, but this decrease was only significant in the propofol group (67 5 ms vs. 45 3 ms, P < 0.05). Pd was significantly increased after induction with desflurane (34 3 vs. 63 6 ms, P < 0.05). There was a significant increase in QTd and Pd in desflurane group, but this increment did not cause any dangerous arrhythmias. QTcd significantly decreased in propofol group. We believe that further investigations are required for using desflurane as safe as sevoflurane and propofol in noncardiac surgery patients who have high cardiac arrhythmia and ischemia risk.
  8,211 1,414 22
E-ACA: ECHO TUTORIALS
Intra-operative trans-esophageal echocardiography in congenital heart disease
Rajnish Garg, Keshava Murthy, Shekhar Rao, Kanchi Muralidhar
July-December 2009, 12(2):173-173
DOI:10.4103/0971-9784.53436  PMID:19602747
Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.
  8,185 1,178 2
TUTORIAL
Adult cardiac transplantation: A review of perioperative management (Part - II)
Harish Ramakrishna, Dawn E Jaroszewski, Francisco A Arabia
July-December 2009, 12(2):155-165
DOI:10.4103/0971-9784.53441  PMID:19602745
Heart transplant is the definitive therapy for end-stage heart failure. This two part review article focussed first on the perioperative management of patients for heart transplantation. This part II will be a comprehensive review of the current status of mechanical assist device therapy for surgical management of the patient with refractory end-stage heart failure.
  7,595 1,612 6
LETTERS TO EDITOR
Intravenous ondansetron causing severe bradycardia: Two cases
Nisha Afonso, Amit Dang, Viraj Namshikar, Sahish Kamat, Padmanabh V Rataboli
July-December 2009, 12(2):170-171
DOI:10.4103/0971-9784.53433  PMID:19602754
  7,974 639 5
EDITORIALS
Therapeutic hypothermia after cardiac arrest in cardiac surgery: A meaningful pursuit?
Murali Chakravarthy
July-December 2009, 12(2):101-103
DOI:10.4103/0971-9784.53426  PMID:19602732
  6,980 1,324 2
E-ACA: ECHO TUTORIALS
Trans-esophageal echocardiography in off-pump coronary artery bypass grafting
Poonam Malhotra Kapoor, Ujjwal Chowdhury, Banashree Mandal, Usha Kiran, Rajendra Karnatak
July-December 2009, 12(2):174-174
DOI:10.4103/0971-9784.53438  PMID:19602750
The two features of off-pump coronary artery bypass (OPCAB) grafting that lead to haemodynamic instability are, transient occlusion of the coronary arteries during distal anastomosis construction and displacement of the heart to provide access to the distal coronary arteries. The position of the heart as seen by trans-oesophageal echocardiography (TOE) can often provide an indication as to how much compression of the right or left ventricle has occurred. If either chamber is not filling, repositioning of the heart will be necessary. Close observation of the heart with TOE during periods of coronary occlusion may facilitate detection of worsening cardiac function as evidenced by weakening contraction, ventricular dilatation, or increasing mitral or tricuspid regurgitation. Haemodynamic change are more pronounced with displacement of the heart to access posterior than the anterior coronary arteries. Cardiac manipulations along with transient occlusion of coronary arteries during distal anastomosis may cause transient hypotension with increased filling pressures. TOE is helpful in this scenario as it helps to differentiate between cardiac dysfunction secondary to myocardial ischaemia (in which regional wall motion abnormalities will be present) from a much more common scenario where the increase in filling pressure is secondary to extra-cardiac compression and provides the ability to detect mitral regurgitation with a colour flow Doppler as well as assess the right heart function.
  7,083 964 2
CASE REPORTS
Infrarenal abdominal aortic aneurysm repair in presence of coronary artery disease: Optimization of myocardial stress by controlled phlebotomy
Praveen Kumar Neema, Arun Vijayakumar, S Manikandan, Ramesh Chandra Rathod
July-December 2009, 12(2):133-135
DOI:10.4103/0971-9784.53445  PMID:19602738
The repair of abdominal aortic aneurysm (AAA) in the presence of significant coronary artery disease (CAD) carries a high-risk of adverse peri-operative cardiac event. The options to reduce cardiac risk include perioperative β-blockade, preoperative optimization by myocardial revascularization and simultaneous (combined) coronary artery bypass grafting and aneurysm repair. We describe intra-operative controlled phlebotomy to optimize myocardial stress during repair of infrarenal AAA in a patient with significant stable CAD.
  7,339 502 4
ST elevation - An indication of reversible neurogenic myocardial dysfunction in patients with head injury
Hemant Bhagat, Rajiv Narang, Deepak Sharma, Hari Hara Dash, Himanshu Chauhan
July-December 2009, 12(2):149-151
DOI:10.4103/0971-9784.53446  PMID:19602742
This report describes a patient who presented with signs of meningitis four days after head injury. The patient had ST elevation on electrocardiography along with hypotension and positive tropinin T test, mimicking inferior wall infarction. The ST changes resolved within 48 hours of intensive care management. Subsequent investigations failed to document any myocardial infarction.
  6,663 512 11
EDITORIALS
Brain, cardiopulmonary bypass and temperature: What should we be doing?
Sandeep Chauhan
July-December 2009, 12(2):104-106
DOI:10.4103/0971-9784.53427  PMID:19602733
  5,695 1,096 2
E-ACA: ECHO TUTORIALS
Quantification of AS and AR
Yatin Mehta, Rajni Singh
July-December 2009, 12(2):173-173
DOI:10.4103/0971-9784.53437  PMID:19602746
Trans-esophageal echocardiography (TEE) is routinely used in valvular surgery in most institutions. The popularity of TEE stems from the fact that it can supplement or confirm information gained from other methods of evaluation or make completely independant diagnoses. Quantitative and qualitative assessment permits informed decisions regarding surgical intervention, type of intervention, correction of inadequate surgical repair and re-operation for complications. This review summarizes the various methods for quantification of aortic regurgitation and stenosis on TEE. The application of Doppler echo (pulsed wave, continuous wave and color) with two-dimensional echo allows the complete evaluation of AV lesions.
  5,776 946 1
ORIGINAL ARTICLES
Pre-operative high sensitive C-reactive protein predicts cardiovascular events after coronary artery bypass grafting surgery: A prospective observational study
Mindaugas Balciunas, Loreta Bagdonaite, Robertas Samalavicius, Laimonas Griskevicius, Alain Vuylsteke
July-December 2009, 12(2):127-132
DOI:10.4103/0971-9784.53442  PMID:19602737
C-reactive protein is a powerful independent predictor of cardiovascular events in patients with coronary artery disease. The relation between C-reactive protein (CRP) concentration and in-hospital outcome, after coronary artery bypass grafting (CABG), has not yet been established. The study aims to evaluate the predictive value of pre-operative CRP for in-hospital cardiovascular events after CABG surgery. High-sensitivity CRP (hs-CRP) levels were measured pre-operatively on the day of surgery in 66 patients scheduled for elective on pump CABG surgery. Post-operative cardiovascular events such as death from cardiovascular causes, ischemic stroke, myocardial damage, myocardial infarction and low output heart failure were recorded. During the first 30 days after surgery, 54 patients were free from observed events and 14 developed the following cardiovascular events: 10 (15%) had myocardial damage, four (6%) had low output heart failure and two (3%) suffered stroke. No patients died during the follow-up period. Serum concentration of hs-CRP ≥ 3.3 mg/l (cut-off point obtained by ROC analysis) was related to higher risk of post-operative cardiovascular events (36% vs 6%, P = 0.01), myocardial damage (24% vs 6%, P = 0.04) and low output heart failure (12% vs 0%, P = 0.04). Multivariate logistic regression analysis showed that hs-CRP ≥ 3.3 mg/l ( P = 0.002, O.R.: 19.3 (95% confidence interval (CI) 2.9-128.0)), intra-operative transfusion of red blood cells ( P = 0.04, O.R.: 9.9 (95% C.I. 1.1-85.5)) and absence of diuretics in daily antihypertensive treatment ( P = 0.02, O.R.: 15.1 (95% C.I. 1.4-160.6) were independent predictors of combined cardiovascular event. Patients having hs-CRP value greater or equal to 3.3 mg/l pre-operatively have an increased risk of post-operative cardiovascular events after on pump coronary artery bypass grafting surgery.
  5,735 761 18
Delay in onset of metabolic alkalosis during regional citrate anti-coagulation in continous renal replacement therapy with calcium-free replacement solution
Kay Choong See, Margaret Lee, Amartya Mukhopadhyay
July-December 2009, 12(2):122-126
DOI:10.4103/0971-9784.53440  PMID:19602736
Regional citrate anti-coagulation for continuous renal replacement therapy chelates calcium to produce the anti- coagulation effect. We hypothesise that a calcium-free replacement solution will require less citrate and produce fewer metabolic side effects. Fifty patients, in a Medical Intensive Care Unit of a tertiary teaching hospital (25 in each group), received continuous venovenous hemofiltration using either calcium-containing or calcium-free replacement solutions. Both groups had no significant differences in filter life, metabolic alkalosis, hypernatremia, hypocalcemia, and hypercalcemia. However, patients using calcium-containing solution developed metabolic alkalosis earlier, compared to patients using calcium-free solution (mean 24.6 hours,CI 0.8-48.4 vs. 37.2 hours, CI 9.4-65, P = 0.020). When calcium-containing replacement solution was used, more citrate was required (mean 280ml/h, CI 227.2-332.8 vs. 265ml/h, CI 203.4-326.6, P = 0.069), but less calcium was infused (mean 21.2 ml/h, CI 1.2-21.2 vs 51.6ml/h, CI 26.8-76.4, P ≤ 0.0001).
  5,608 850 1
LETTERS TO EDITOR
A practical tip: Rings of blood for successful radial artery cannulation
Virendra Kumar Arya, Rajeev Subramanyam
July-December 2009, 12(2):169-170
DOI:10.4103/0971-9784.53432  PMID:19602753
  4,716 388 -
ORIGINAL ARTICLES
Treating myocardial stunning randomly, with either propofol or isoflurane following transient coronary occlusion and reperfusion in pigs
Felipe Urdaneta, Emilio B Lobato, David S Kirby, Avner Sidi
July-December 2009, 12(2):113-121
DOI:10.4103/0971-9784.51362  PMID:19602735
  4,185 652 6
CASE REPORTS
Decompression of superior vena cava during bidirectional Glenn shunt
Venugopal Kulkarni, Ravikiran Mudunuri, Krishnaprasad Mulavisala, R Jagannath Byalal
July-December 2009, 12(2):146-148
DOI:10.4103/0971-9784.53447  PMID:19602741
Patients undergoing bi-directional Glenn shunt for various congenital anomalies of the heart will have their superior vena cava (SVC) clamped during the procedure. The duration of the procedure is variable, ranging from five to 30 minutes. This can affect the cerebral perfusion due to raised venous pressure [Cerebral blood flow = Mean arterial pressure − (Intracranial pressure + Central venous pressure)]. Shunting away the SVC blood is a well known technique to counter this problem, but we describe two cases where a novel technique was successfully used to decompress the SVC.
  4,371 373 2
LETTERS TO EDITOR
ABO blood groups and myocardial infarction among Palestinians
Younis AM Skaik
July-December 2009, 12(2):171-172
DOI:10.4103/0971-9784.53434  PMID:19602755
  3,932 400 3
E-ACA: ECHO TUTORIALS
How do I get an optimal image?
HR Anil Kumar
July-December 2009, 12(2):173-173
DOI:10.4103/0971-9784.53435  PMID:19602748
Trans-esophageal echocardiography (TEE) is fast becoming an indispensable monitoring and diagnostic modality in cardiac operation rooms. Its convenience and dependability in making important and crucial decisions intra-operatively, during cardiac operative procedures, makes it one of the most useful weapons in a cardiac anesthesiologist's armory. But to make reliable inferences based on intra-operative TEE, creation and development of a proper image is one of the fundamental requirements. The image quality can be affected by factors like patient anatomy, quality of the ultrasound system, and skill of the echocardiographer. Since the first two cannot be changed, in most of cases, we will have to work on the third factor to optimize image quality. A working knowledge of the physics of ultrasound imaging and a sufficient familiarity with the various knobs and controls on the machine will go a long way in helping one acquire an optimum image.
  3,552 566 1
CASE REPORTS
Intra-operative assessment of biventricular function using trans-esophageal echocardiography pre/post-pulmonary thromboembolectomy in patient with chronic thromboembolic pulmonary hypertension
Shrinivas Gadhinglajkar, Rupa Sreedhar, K Jayakumar, Manoranjan Misra, S Ganesh, Varghese Panicker
July-December 2009, 12(2):140-145
DOI:10.4103/0971-9784.53449  PMID:19602740
Postoperative studies in patients with chronic thromboembolic pulmonary hypertension (CTPH) have shown that pulmonary thromboembolectomy (PTE) results in a rapid decrease of right ventricular (RV) size, improvement in the RV systolic function and left ventricular (LV) diastolic function. However, the extent to which the biventricular function recovers immediately after embolectomy in post-cardiopulmonary bypass period is not clear. A 45-year-old male patient was operated for retrieval of thrombus from pulmonary trunk and right pulmonary artery. Intraoperative transesophageal echocardiography (TOE) before surgery revealed signs of RV dysfunction and enlargement. The interventricular septum was seen moving paradoxically during end-systole and early-diastole. E/A ratio on transmitral Doppler flow velocity profile was about 0.63 and S/D ratio on pulmonary venous Doppler profile was 2.25, indicative of LV diastolic dysfunction. After weaning the patient from bypass, navigation on TOE showed marginal recovery of the RV systolic function and abatement of septal paradox to some extent. However, significant improvement was observed in the LV diastolic parameter (normal E/A ratio, S/D ratio of 1.08). We conclude that the geometrically altered LV recovers more than the hypertrophied and hypokinetic RV in a patient with CTPH in the post-bypass period
  3,094 441 1
Delayed presentation of right and left ventricle perforation due to suicidal nail gun injury
Sampurna Tuladhar, Abdalla Eltayeb, Suresh Lakshmanan, Patrick Yiu
July-December 2009, 12(2):136-139
DOI:10.4103/0971-9784.53448  PMID:19602739
We describe a case of delayed presentation of attempted suicide with a nail gun that penetrated both the right and left ventricle. Nearly invisible entry point of the nail did not reflect the gravity of the injury. A prompt and accurate history along with chest X-ray and bedside transthoracic echocardiography facilitated localization of the nails and helped assess the damage. Despite cardiac arrest after induction of general anesthesia, the patient had a successful outcome. Issues related to the injury site, modalities of investigation and management strategies in a patient with cardiac tamponade are discussed.
  3,177 282 7
LETTERS TO EDITOR
High thoracic epidural analgesia for cardiac surgery: Time to move from morbidity to quality of recovery indicators
Colin F Royse
July-December 2009, 12(2):166-167
DOI:10.4103/0971-9784.53429  PMID:19602751
  2,984 451 4
Thoracic epidural anesthesia in cardiac surgery - Current standing
Poonam Malhotra Kapoor, Minati Choudhury, Madhava Kakani
July-December 2009, 12(2):167-168
DOI:10.4103/0971-9784.53430  PMID:19602752
  2,840 535 4
INTERESTING IMAGES
Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication
Satyajeet Misra, Thomas Koshy, Satya N Patro, Prasanta K Dash
July-December 2009, 12(2):152-153
DOI:10.4103/0971-9784.53444  PMID:19602743
  2,942 363 1
Endothoracic hemopoiesis: Imaging of a rare clinical entity
Nikolaos G Baikoussis, John P Beis, Michael Siafakas, Stavros N Siminelakis
July-December 2009, 12(2):154-154
DOI:10.4103/0971-9784.53443  PMID:19602744
  1,894 197 1
LETTERS TO EDITOR
Author's response
Mark A Chaney
July-December 2009, 12(2):168-169
DOI:10.4103/0971-9784.53431  
  1,487 191 -
MEDICOLEGAL CASE
Legal consequences of not making life saving equipments available to patients

July-December 2009, 12(2):175-176
  1,301 209 -