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   2013| January-March  | Volume 16 | Issue 1  
    Online since January 2, 2013

 
 
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REVIEW ARTICLE
Anesthesia for off-pump coronary artery bypass surgery
Thomas M Hemmerling, Gianmarco Romano, Nora Terrasini, Nicolas Noiseux
January-March 2013, 16(1):28-39
DOI:10.4103/0971-9784.105367  PMID:23287083
The evolution of techniques and knowledge of beating heart surgery has led anesthesia toward the development of new procedures and innovations to promote patient safety and ensure high standards of care. Off-pump coronary artery bypass (OPCAB) surgery has shown to have some advantages compared to on-pump cardiac surgery, particularly the reduction of postoperative complications including systemic inflammation, myocardial injury, and cerebral injury. Minimally invasive surgery for single vessel OPCAB through a limited thoracotomy incision can offer the advantage of further reduction of complications. The anesthesiologist has to deal with different issues, including hemodynamic instability and myocardial ischemia during aorto-coronary bypass grafting. The anesthesiologist and surgeon should collaborate and plan the best perioperative strategy to provide optimal care and ensure a rapid and complete recovery. The use of high thoracic epidural analgesia and fast-track anesthesia offers particular benefits in beating heart surgery. The excellent analgesia, the ability to reduce myocardial oxygen consumption, and the good hemodynamic stability make high thoracic epidural analgesia an interesting technique. New scenarios are entering in cardiac anesthesia: ultra-fast-track anesthesia with extubation in the operating room and awake surgery tend to be less invasive, but can only be performed on selected patients.
  25,199 2,771 4
CASE REPORTS
Magnets and implantable cardioverter defibrillators: What's the problem?
Yiliam F Rodriguez-Blanco, Fouad Souki, Evelyn Tamayo, Keith Candiotti
January-March 2013, 16(1):54-57
DOI:10.4103/0971-9784.105372  PMID:23287088
A growing number of surgical patients present to the operating room with implantable cardioverter defibrillators (ICD). Peri-operative care of these patients dictates that ICD function be suspended for many surgical procedures to avoid inappropriate, and possibly harmful, ICD therapy triggered by electromagnetic interference (EMI). An alternative to reprogramming the ICD is the use of a magnet to temporarily suspend its function. However, this approach is not without complications. We report a case where magnet use failed to inhibit ICD sensing of EMI, and a shock was delivered to the patient. Measures to decrease EMI, controversies regarding magnet use, and expert recommendations are discussed.
  10,231 267 1
ORIGINAL ARTICLE
The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery
Deepak K Tempe, Sanjula Virmani, Jyotsna Agarwal, Manisha Hemrajani, Subodh Satyarthy, Harpreet Singh Minhas
January-March 2013, 16(1):16-20
DOI:10.4103/0971-9784.105364  PMID:23287081
Aims and objectives: Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. Materials and Methods: The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. Results: The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. Conclusion: IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations.
  7,297 595 4
JANAK MEHTA AWARDS
Myocardial protection during off pump coronary artery bypass surgery: A comparison of inhalational anesthesia with sevoflurane or desflurane and total intravenous anesthesia
Sharadaprasad Suryaprakash, Murali Chakravarthy, Geetha Muniraju, Swapnil Pandey, Sona Mitra, Benak Shivalingappa, Stany Chittiappa, Jayaprakash Krishnamoorthy
January-March 2013, 16(1):4-8
DOI:10.4103/0971-9784.105361  PMID:23287079
Aims and Objectives: The objective of the study was to evaluate the myocardial protective effect of volatile agents-sevoflurane and desflurane versus total intravenous anesthesia (TIVA) with propofol in offpump coronary artery bypass surgery (OPCAB) by measuring cardiac troponin-T (cTnT) as a marker of myocardial cell death. Materials and Methods: The study was conducted on 139 patients scheduled to undergo elective OPCAB surgery. The patients were randomly allocated to receive anesthesia with sevoflurane, desflurane or TIVA with propofol. The cTnT levels were measured preoperatively, at arrival in postoperative intensive care unit, at 8, 24, 48 and 96 hours thereafter. Results: The changes in cTnT levels at all time intervals were comparable in the three groups. Conclusion: The study did not reveal any difference in myocardial protection after OPCAB with either sevoflurane or desflurane or TIVA using propofol as assessed by measuring serial cTnT values.
  6,509 806 8
A comparison of hemodynamic effects of levosimendan and dobutamine in patients undergoing mitral valve repair / replacement for severe mitral stenosis
Ravikumar Gandham, Ayya Syamasundar, Harish Ravulapalli, Ranjith B Karthekeyan, Mahesh Vakamudi, Rajeshkumar Kodalli, Sushma Nandipati
January-March 2013, 16(1):11-15
DOI:10.4103/0971-9784.105363  PMID:23287080
Aims and Objectives: We aimed to compare the hemodynamic effects of levosimendan and dobutamine in patients undergoing mitral valve surgery on cardiopulmonary bypass (CPB). Materials and Methods: Sixty patients were divided into 2 groups of 30 each. Group-L patients received levosimendan 0.1 μg/kg/min and Group-D patients received dobutamine 5 μg/kg/min while weaning off CPB. Additional inotrope and/or vasoconstrictor were started based on hemodynamic parameters. Hemodynamic data were collected at the end and at 30 minutes after CPB, thereafter at 6, 12, 24, and 36 hours post-CPB. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI), and lactate levels were measured. Results: Group-L showed increased requirement of inotropes and vasoconstrictors. The SVRI, CVP, and MAP were reduced more in Group-L. The CI was low in Group-L in the initial period when compared to Group-D. Later Group-L patients showed a statistically significant increase in CI even after 12 hrs of discontinuation of levosimendan infusion. The HR was increased more in Group-D. Lactate levels, intensive care unit stay, and duration of ventilation were similar in both groups. Conclusions: Levosimendan 0.1 μg/kg/min compared to dobutamine 5 μg/kg/min showed more vasodilation and lesser inotropic activity in patients undergoing mitral valve surgery for mitral stenosis. Levosimendan compared to dobutamine showed a statistically significant increase in CI even after 12 hrs of discontinuation. The requirement of another inotrope or vasopressor was frequent in levosimendan group.
  5,136 593 6
CASE REPORTS
Management of patients with hematological malignancies undergoing coronary artery bypass grafting
Deepak Borde, Uday Gandhe, Neha Hargave, Kaushal Pandey
January-March 2013, 16(1):47-50
DOI:10.4103/0971-9784.105370  PMID:23287086
The number of patients with a previously diagnosed malignancy who need cardiac surgery is increasing. Patients with hematological malignancies represent only 0.38% of all patients undergoing cardiac surgery. The literature in this subset of patients is limited to only a few retrospective case series, with limited number of patients undergoing emergency cardiac surgery. We describe three cases with hematological malignancies namely chronic myelogenous leukemia, acute promyelocytic leukemia and chronic lymphocytic leukemia presenting for coronary artery bypass grafting (CABG). Two patients were taken up for emergency CABG in view of ongoing ischemia, one of them was on preoperative intra-aortic balloon pump support. No mortality was observed. Two patients needed transfusion of blood products which was guided by thromboelastography. One patient developed superficial sternal wound infection requiring antibiotic therapy.
  4,892 349 1
Transesophageal echocardiography in surgical management of pseudoaneurysm of mitral-aortic intervalvular fibrosa with aneurysms of right sinus of Valsalva and left main coronary artery
Shreedhar S Joshi, Arkalgud Marigowda Jagadeesh, Arul Furtado, Seetharam Bhat
January-March 2013, 16(1):40-43
DOI:10.4103/0971-9784.105368  PMID:23287084
Pseudoaneurysm of mitral-aortic intervalvular fibrosa (MAIVF) is a rare complication associated with aortic and/or mitral valve surgery complicated by infective endocarditis. We report pseudoaneurysm of MAIVF in a young adult without overt cardiac disease or previous cardiac surgery. The patient had a rare combination of pseudoaneurysm of MAIVF impinging on anterior mitral leaflet causing moderate mitral regurgitation, right sinus of Valsalva aneurysm extending into interventricular septum, and left main coronary artery aneurysm. Transesophageal echocardiography helped in confirming the lesions, delineating the anatomy of all the lesions, and assessing the adequacy of surgical repair.
  3,778 233 5
BOOK REVIEW
Clinical practice of cardiac anaesthesia: Third Edition
K Muralidhar
January-March 2013, 16(1):72-72
  3,389 596 -
EDITORIAL
The saddle shape of the mitral valve: More than just a shape
Praveen Kumar Neema
January-March 2013, 16(1):1-3
DOI:10.4103/0971-9784.105360  PMID:23287078
  3,329 275 -
LETTERS TO EDITOR
Ventricular extrasystole during peri-operative intravenous dexmedetomidine infusion
Divya Srivastava, Sohan L Solanki, Krishna Pradhan, Prabhat K Singh
January-March 2013, 16(1):69-71
DOI:10.4103/0971-9784.105379  PMID:23287095
  2,756 198 1
CASE REPORTS
Utility of pulmonary venous flow diastolic deceleration time in an adult patient undergoing surgical closure of atrial septal defect and coronary artery bypass grafting
Dharmesh R Agrawal, Mohammed Rehan Sayeed, Murali R Chakravarthy, TA Patil
January-March 2013, 16(1):44-46
DOI:10.4103/0971-9784.105369  PMID:23287085
Acute left ventricular (LV) failure has been reported after surgical closure of atrial septal defect (ASD) in adult patients. We report acute LV failure in a 56 year old gentleman following coronary artery bypass grafting (CABG) and surgical closure of ASD. Transesophageal echocardiography examination of the patient following closure of ASD and CABG showed a residual ASD and a shunt (Qp :Qs = 1.5). The residual ASD was closed after re-institution of cardiopulmonary bypass (CPB) under cardioplegic cardiac arrest. However, the patient did not tolerate closure of the residual ASD. The CPB was re-established and under cardioplegic cardiac arrest residual ASD was reopened to create a fenestration. This time patient was weaned easily from CPB. Postoperatively, 16 hours after extubation, patient became hemodynamically unstable, the patient was electively put on ventilator and intra-aortic balloon pump. Later the patient was weaned off successfully from ventilator. Retrospective analysis of pulmonary venous flow diastolic deceleration time (PVDT D ) recorded during prebypass period measured 102 msec suggestive of high left atrial pressure which indicate possibility of LV failure after ASD closure.
  2,672 142 -
INTERESTING IMAGES
Megaesophagus: A challenge for anesthesiologists
Prabhat Tewari, Devendra Gupta
January-March 2013, 16(1):61-62
DOI:10.4103/0971-9784.105374  PMID:23287090
  2,597 193 1
CASE REPORTS
Anesthetic management for reentry sternotomy in a patient with a full stomach and pericardial tamponade from left ventricular rupture
Bryan G Maxwell, Katherine B Harrington, Nate E Kelly
January-March 2013, 16(1):51-53
DOI:10.4103/0971-9784.105371  PMID:23287087
A 57-year-old man presented with chest pain and shortness of breath 1 month after left ventricular aneurysmectomy and ventricular septal defect closure for post-infarct left ventricular aneurysm and ventricular septal defect. Echocardiography revealed a large recurrent ruptured inferior left ventricular aneurysm with high-velocity flow into a 5 cm posterolateral pericardial effusion. Thirty minutes earlier, the patient had eaten a full meal. Rapid sequence induction was performed with midazolam, ketamine, and succinylcholine. Moderate hypotension was treated effectively and the patient tolerated controlled transition to cardiopulmonary bypass. The ventricular defect was oversewn and reinforced with bovine pericardium. The patient had a difficult but ultimately successful recovery. Options for anesthetic management in the setting of tamponade and a full stomach are discussed, with a brief review of the evidence relating to this clinical problem.
  2,529 182 -
LETTERS TO EDITOR
Solid ovoid left atrial myxoma
Sarvesh Pal Singh, Sandeep Chauhan, Richa Chauhan
January-March 2013, 16(1):66-67
DOI:10.4103/0971-9784.105376  PMID:23287092
  2,456 173 -
ORIGINAL ARTICLE
Echocardiographic quantification of mitral valvular response to myocardial revascularization
Sapna Govindan, Geoffrey Hayward, Feroze Mahmood, Balachundhar Subramaniam
January-March 2013, 16(1):23-27
DOI:10.4103/0971-9784.105366  PMID:23287082
Aims and Objectives: Mild and/or moderate ischemic mitral regurgitation (IMR) may resolve after isolated coronary artery bypass grafting (CABG). It has been shown that the loss of saddle shape of the mitral valve is associated with IMR and is determined by an increase in the nonplanarity angle (NPA). The aim of this prospective, observational study was to test the hypothesis that NPA might decrease immediately after CABG alone in patients with mild to moderate IMR. Materials and Methods: This prospective, observational study was conducted in an academic, tertiary care hospital. Twenty patients underwent 2D and 3D transoesophageal echocardiography (TEE) and mitral valve assessment before and immediately after the CABG. NPA, circularity index, and other geometric variables were obtained. They were compared using paired t test. The SPSS (Version 15.0, Chicago, IL, USA) was used for statistical analysis. P <0.05 was considered significant. Results: The NPA was similar in the pre- and post-bypass periods (148° ± 15°, 148° ± 19°, P = 0.88). Circularity index (0.93 ± 0.13, 0.97 ± 0.11, P = 0.41) also was similar. Conclusions: There was no change in the mitral valve NPA with revascularization alone in patients with mild or moderate IMR. Mitral valve does not change its planarity (NPA) with revascularization alone in patients with IMR.
  2,352 268 4
CASE REPORTS
Extradural hematoma following double valve replacement under cardiopulmonary bypass: A rare complication
Bhupesh Kumar, Hemant Bhagat, Ravi Raj, Aveek Jayant
January-March 2013, 16(1):58-60
DOI:10.4103/0971-9784.105373  PMID:23287089
The primary mechanisms responsible for acute neurological deterioration following cardiopulmonary bypass (CPB) include cerebral embolism, cerebral hypoperfusion and/or inflammatory process triggered by CPB. Extradural hematoma (EDH) following CPB is rare but associated with significant mortality and morbidity. We present a case of EDH following double valve replacement in an adolescent boy.
  2,331 146 -
BRIEF COMMUNICATION
When blood is thinner than water
Dilip Gude, Aslam Abbas, Hina Mohiuddin
January-March 2013, 16(1):63-65
DOI:10.4103/0971-9784.105375  PMID:23287091
Antagonists of vitamin K dependant clotting factors are commonly used as treatment/prophylaxis for anticoagulation. Due to their narrow therapeutic window, a wide range of complications including death may occur. International normalized ratio (INR) is monitored to measure adequacy/excess of anticoagulation. There is a plethora of risk factors that may contribute to the uncontrollably high INR values. We describe our experience of a case of deep venous thrombosis wherein the patient had an overshoot of INR during anticoagulation therapy. We review the literature and discuss management in such scenarios.
  2,050 168 1
LETTERS TO EDITOR
Patient controlled analgesia using ketorolac prevented respiratory failure in a child after cardiac surgery
Amit Rai, Usha Kiran
January-March 2013, 16(1):68-69
DOI:10.4103/0971-9784.105378  PMID:23287094
  1,963 174 -
INVITED COMMENTARY
Invited Commentary
Giovanni Landoni, Marta Mucchetti
January-March 2013, 16(1):9-10
  1,684 140 -
LETTERS TO EDITOR
Successful conversion to tracheal intubation during cardiopulmonary bypass after emergency airway rescue with ProSeal TM laryngeal mask airway in cardiac surgery
Joanna Ooi
January-March 2013, 16(1):67-68
DOI:10.4103/0971-9784.105377  PMID:23287093
  1,581 157 -
INVITED COMMENTARY
Invited Commentary
Alexander Mittnacht
January-March 2013, 16(1):21-22
  1,042 95 -