Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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   2017| October-December  | Volume 20 | Issue 4  
    Online since October 9, 2017

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Ischemic mitral regurgitation
Praveen Kerala Varma, Neethu Krishna, Reshmi Liza Jose, Ashish Narayan Madkaiker
October-December 2017, 20(4):432-439
Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.
  4,624 10,082 9
The use of intravenous hydroxocobalamin as a rescue in methylene blue-resistant vasoplegic syndrome in cardiac surgery
Yi Cai, Anwar Mack, Beth L Ladlie, Archer Kilbourne Martin
October-December 2017, 20(4):462-464
Vasoplegic syndrome is a well-recognized complication during cardiopulmonary bypass (CPB) and is associated with increased morbidity and mortality, especially when refractory to conventional vasoconstrictor therapy. This is the first reported case of vasoplegia on CPB unresponsive to methylene blue whereas responsive to hydroxocobalamin, which indicates that the effect of hydroxocobalamin outside of the nitric oxide system is significant or that the two drugs have a synergistic effect in one or multiple mechanisms.
  4,103 200 9
Two episodes of cardiac tamponade in the same patient from removing pacing wires and a pericardial drain: A case report
Rekha Suthar, Osman Nawazish Salaria, Carolina De La Cuesta, Omar Viswanath
October-December 2017, 20(4):459-461
A patient presented for an elective transcatheter aortic valve replacement with temporary transvenous pacing (TVP) wires placement per protocol. On postoperative day 1, the patient remained stable, so the wires were subsequently removed, after which the patient acutely decompensated, with transthoracic echocardiography revealing pericardial effusion. Emergent pericardiocentesis was performed, and a pericardial drain was placed. Three days later, the drain was removed; again, the patient acutely decompensated, requiring another emergent pericardiocentesis. Despite the relatively benign nature of TVP wires and pericardial drains, the possibility of cardiac tamponade should be kept in mind as a potential complication when they are being removed.
  2,899 85 2
Think beyond right bundle branch block in atrial septal defect
Monish S Raut, Arvind Verma, Arun Maheshwari, Ganesh Shivnani
October-December 2017, 20(4):475-476
  2,770 113 -
Low-dose intravenous ketamine for postcardiac surgery pain: Effect on opioid consumption and the incidence of chronic pain
Jennifer Cogan, Geneviève Lalumière, Grisell Vargas-Schaffer, Alain Deschamps, Zeynep Yegin
October-December 2017, 20(4):395-398
Background: Recent meta-analyses have concluded that low-dose intravenous ketamine infusions (LDKIs) during the postoperative period may help to decrease acute and chronic postoperative pain after major surgery. Aims: This study aims to evaluate the level of pain at least 3 months after surgery for patients treated with a postoperative LDKI versus patients who were not treated with a postoperative LDKI. Methods: Administrative and Ethics Board approval were obtained for this study. We performed a retrospective chart review for all patients receiving LDKI, and equal number of age-, sex-, and surgery-matched patients who did not receive LDKI. Low-dose ketamine was prepared using 100 mg of ketamine in 100 ml of normal saline and run between 50 and 200 mcg/kg/h. Results: We reviewed 115 patients with LDKI and 115 without LDKI. The average age was 63.1 years, 73% of the patients were men and sex was evenly distributed between LDKI and non-LDKI. The average duration of the ketamine infusions was 26.8 h with the average dose being 169.9 mg. At an average of 9 months after surgery, 42% of the ketamine group and 38% of the nonketamine group stated that they had had pain on discharge. Of these patients, 30% of the ketamine group and 26% of the nonketamine group still had pain at the time of the phone call. Women in both groups had more acute and chronic pain than men. Conclusion: These results show that LDKI does not promote a decrease in long-term postoperative pain.
  2,632 235 2
Congenital syndromes affecting heart and airway alike
Rajinder Singh Rawat
October-December 2017, 20(4):393-394
  2,441 162 3
Perioperative management of a patient with glanzmann's thrombasthenia for mitral valve repair under cardiopulmonary bypass
Parimala Prasanna Simha, Prasanna Simha Mohan Rao, Deepak Arakalgud, Rakesh Rajashekharappa, Manjunath Narasimhaih
October-December 2017, 20(4):468-471
A 30-year-old male patient presented with Glanzmann's thrombasthenia and mitral valve prolapse. He was in acute decompensated congestive heart failure due to severe mitral and tricuspid regurgitation. After his cardiac failure had been stabilized, the patient was subjected to mitral and tricuspid valve repair. His transfusion requirements were guided by thrombelastography and his bleeding disorder was managed by infusing single donor plasmapheresed platelet transfusions in the perioperative period. The patient underwent surgery uneventfully.
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Does bilevel positive airway pressure improve outcome of acute respiratory failure after open-heart surgery?
Ahmed Said Elgebaly
October-December 2017, 20(4):416-421
Background: Respiratory failure is of concern in the postoperative period after cardiac surgeries. Invasive ventilation (intermittent positive pressure ventilation [IPPV]) carries the risks and complications of intubation and mechanical ventilation (MV). Aims: Noninvasive positive pressure ventilation (NIPPV) is an alternative method and as effective as IPPV in treating insufficiency of respiration with less complications and minimal effects on respiratory and hemodynamic parameters next to open-heart surgery. Design: This is a prospective, randomized and controlled study. Materials and Methods: Forty-four patients scheduled for cardiac surgery were divided into two equal groups: Group I (IPPV) and Group II (NIPPV). Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), oxygen saturation (SpO2), arterial blood gas, weaning time, reintubation, tracheotomy rate, MV time, postoperative hospital stay, and ventilator-associated pneumonia during the period of hospital stay were recorded. Results: There was statistically significant difference in HR between groups with higher in Group I at 30 and 60 min and at 12 and 24 h. According to MAP, it started to increase significantly at hypoxemia, 15 min, 30 min, 4 h, 12 h, and at 24 h which was higher in Group I also. RR, PaO2, and PaCO2showed significant higher in Group II at 15, 30, and 60 min and 4 h. According to pH, there was a significant difference between groups at 15, 30, and 60 min and at 4, 12, and 24 h postoperatively. SpO2showed higher significant values in Group I at 15 and 30 min and at 12 h postoperatively. Duration of postoperative supportive ventilation was higher in Group I than that of Group II with statistically significant difference. Complications were statistically insignificant between Group I and Group II. Conclusion: Our study showed superiority of invasive over noninvasive mode of ventilator support. However, NIPPV (bilevel positive airway pressure) was proved to be a safe method.
  2,144 190 1
Comparison of dexmedetomidine and ketamine versus propofol and ketamine for procedural sedation in children undergoing minor cardiac procedures in cardiac catheterization laboratory
Vidya Sagar Joshi, Sandeep S Kollu, Ram Murti Sharma
October-December 2017, 20(4):422-426
DOI:10.4103/aca.ACA_16_17  PMID:28994677
Background: The ideal anaesthetic technique for management of paediatric patients scheduled to undergo cardiac catheterisation is still not standardised. Aim: To compare the effects of ketamine-propofol and ketamine-dexmedetomidine combinations on hemodynamic parameters and recovery time in paediatric patients undergoing minor procedures and cardiac catheterisation under sedation for various congenital heart diseases. Material and Methods: 60 children of either sex undergoing cardiac catheterisation were randomly assigned into two groups Dexmedetomidine-ketamine group (DK) and Propofol-ketamine (PK) of 30 patients each. All patients were premedicated with glycopyrrolate and midazolam (0.05mg/kg) intravenously 5-10 min before anaesthetic induction. Group 'DK'received dexmedetomidineiv infusion 1 μg/kg over 10 min + ketamine1mg/kg bolus, followed by iv infusion of dexmedetomidine 0.5μg/kg/hr and of ketamine1 mg/kg/hr. Group 'PK' received propofol 1mg/kg and ketamine 1mg/kg/hr for induction followed by iv infusion of propofol 100 μg/kg/hr and ketamine 1 mg/kg/hr for maintenance. Haemodynamic parameters and recovery time was recorded postoperatively. Statistical Analysis: Independent sample t test was used to compare the statistical significance of continuous variables of both the groups.Chi square test was used for numerical data like gender.Fischer exact test was applied for non parametric data like ketamine consumption. Results: We observed that heart rate in dexmedetomidine (DK) group was significantly lower during the initial 25 mins after induction compared to the propofol (PK) group. Recovery was prolonged in the DK group compared to the PK group (40.88 vs. 22.28 min). Even ketamine boluses consumption was higher in DK group. Conclusion: Use of dexmedetomidine-ketamine combination is a safe alternative, without any hemodynamic orrespiratory effects during the cardiac catheterization procedure but with some delayed recovery.
  2,035 280 7
Comparison of the renoprotective effect of dexmedetomidine and dopamine in high-risk renal patients undergoing cardiac surgery: A double-blind randomized study
Rabie Soliman, Mohamed Hussien
October-December 2017, 20(4):408-415
DOI:10.4103/aca.ACA_57_17  PMID:28994675
Objective: The purpose of the current study was to compare the renoprotective effects of continuous infusion of dexmedetomidine and dopamine in high-risk renal patients undergoing cardiac surgery. Design: A double-blind randomized study. Setting: Cardiac Centers. Patients: One hundred and fifty patients with baseline serum creatinine level ≥1.4 mg/dl were scheduled for cardiac surgery with cardiopulmonary bypass. Intervention: The patients were classified into two groups (each = 75): Group Dex – the patients received a continuous infusion of dexmedetomidine 0.4 μg/kg/h without loading dose during the procedure and the first 24 postoperative hours and Group Dopa – the patients received a continuous infusion of dopamine 3 μg/kg/min during the procedure and the first 24 postoperative hours. Measurements: The monitors included serum creatinine, creatinine clearance, blood urea nitrogen, and urine output. Main Results: The creatinine levels and blood urea nitrogen decreased at days 1, 2, 3, 4, and 5 in Dex group and increased in patients of Dopa group (P < 0.05). The creatinine clearance increased at days 1, 2, 3, 4, and 5 in Dex group and decreased in patients of Dopa group (P < 0.05). The amount of urine output was too much higher in the Dex group than the Dopa group (P < 0.05). Conclusions: The continuous infusion of dexmedetomidine during cardiac surgery has a renoprotective effect and decreased the deterioration in the renal function in high-risk renal patients compared to the continuous infusion of dopamine.
  1,882 235 5
An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit
Francesco De Simone, Luigi Cassarà, Salvatore Sardo, Elena Scarparo, Omar Saleh, Caetano Nigro Neto, Alberto Zangrillo, Giovanni Landoni
October-December 2017, 20(4):399-402
Context: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. Aims: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. Settings and Design: Tertiary teaching hospital. Subjects and Methods: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. Results: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase. Conclusions: Widespread implementation of scavenging system like the one we designed may facilitate the perfusionist and the anesthesiologist in delivering these cardioprotective drugs with beneficial impact on patients' outcome without compromising on safety.
  1,792 157 4
Rising Central venous pressure: Impending right-sided failure?
Monish S Raut, Arun Maheshwari, Vinayak Desurkar, Rajesh Bhavsar
October-December 2017, 20(4):440-441
Central venous pressure generally indicates right sided cardiac filling pressure. Although it is a static hemodynamic parameter, however trend of CVP gives important information regarding the patient's management. Patient with left ventricular assist device is prone to develop right ventricular dysfunction which can easily be suspected by trend of CVP. However rising CVP does not always imply right heart dysfunction.
  1,809 131 1
Accidental placement of central venous catheter into internal mammary vein: A rare catheter malposition
Manish Kela, Haridas Munde, Sushil Raut
October-December 2017, 20(4):477-478
  1,840 100 1
Atmospheric pollution in cardiac operating rooms
Mukul Chandra Kapoor
October-December 2017, 20(4):391-392
  1,778 151 1
Evaluation of the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients
Kamran Ghods, Hossein Davari, Abbasali Ebrahimian
October-December 2017, 20(4):427-431
Introduction: Insulin therapy is the most commonly used treatment for controlling hyperglycemia after coronary artery bypass surgery in both diabetic and nondiabetic patients. Metformin has been indicated for critically ill patients as an alternate for the treatment of hyperglycemia. This study evaluated the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients. Settings and Design: This study was a clinical trial comprising nondiabetic patients who had undergone coronary artery bypass surgery. Patients were randomly divided into the insulin group and the metformin group. Methods: Patients in the insulin group received continuous infusion of insulin while those in the metformin group received 500 mg metformin tablets twice daily. All the patients were followed up for 3 days after stabilization of blood glucose levels. Statistical Analysis: Data were analyzed using Chi-square test and Mann–Whitney U-test. Results: This study included a total of 56 patients. During the study period, the mean blood glucose levels decreased from 225.24 to 112.36 mg/dl (↓112.88 mg/dl) in the insulin group and from 221.80 to 121.92 mg/dl in the metformin group (↓99.88 mg/dl). There was no significant difference in the blood glucose levels of the patients between the two groups at any measurement times (P > 0.05). Conclusion: Using 500 mg metformin twice daily is similar to using insulin in nondiabetic patients undergoing coronary artery bypass graft. Therefore, the use of metformin can be considered as a treatment strategy for controlling hyperglycemia in this group of patients.
  1,755 128 1
Atrial myxomas causing severe left and right ventricular dysfunction
Aanchal Dixit, Prabhat Tewari, Rashmi Soori, Surendra Kumar Agarwal
October-December 2017, 20(4):450-452
Myxomas are the most common cardiac tumors, accounting for about 50% of benign primary cardiac tumors, with the majority located in the left atrium, and 80% of which originate in the interatrial septum. We report two cases with severe cachexia, neurological sequelae, and severe biventricle dysfunction secondary to atrial myxomas with marked early improvement after tumor excision.
  1,736 146 -
Relationship between perioperative left atrial appendage doppler velocity estimates and new-onset atrial fibrillation in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass
Kunal Sarin, Sandeep Chauhan, Akshay K Bisoi, Poonam Malhotra Kapoor, Parag Gharde, Arindam Choudhury
October-December 2017, 20(4):403-407
Background: Literature search reveals that postoperative atrial fibrillation (POAF) occurs in 15%–40% of coronary artery bypass graft (CABG) patients. Although several risk models exist for predicting the development of POAF, few have studied left atrial appendage (LAA) velocity. We hypothesize that an association between LAA velocity and development of POAF exists. Design and Methods: Single institution university hospital prospective observational clinical study performed between May 2016 and November 2016 in 96 adult patients undergoing CABG surgery utilizing cardiopulmonary bypass (CPB). Transesophageal echocardiography was performed perioperatively to measure LAA velocity and left atrial (LA) size after anesthetic induction, post-CPB and during the postoperative period before extubation. Student's t-test was used for inter-group comparisons. Data are expressed as mean ± (standard deviation). The value of P < 0.05 was considered statistically significant. Results: A total of 95 patients (69 males and 26 females) completed the study and were included in the final analysis. Of these, 21 (22%) (15 males and 5 females) developed POAF. The patient group which developed POAF was compared with the group that did not develop POAF. On comparing mean age of patients in each group (59 years in patients with no POAF and 63.71 years in patients with POAF, P = 0.04). LA volume indexed in POAF group (34.13 ml/m2) compared with that in group with no POAF (34.82 ml/m2) resulted in P = 0.04. Mean LAA velocities (pre-CPB, post-CPB, postoperative Intensive Care Unit) in group with no POAF were 41.06, 56.33, and 60.44 cm/s, respectively, whereas in the other group with POAF the values were 39.68, 55.04, and 58.09 cm/s, respectively. No statistical significance was noted (P > 0.05). Comparison of comorbidities also did not yield any significant results (P > 0.05). Conclusions: Decreasing LAA velocity does not appear to independently predict the development of POAF in patients undergoing CABG surgery with the use of CPB. There is, however, a positive correlation of POAF with age and LA volume.
  1,609 127 -
Inadvertent diversion of inferior vena cava to left atrium after repair of atrial septal defect – Early diagnosis and correction of error: role of intraoperative transesophageal echocardiography
Mangesh Sudhakar Choudhari, Nameirakpam Charan, Manish Ishwar Sonkusale, Rashmi Arun Deshpande
October-December 2017, 20(4):481-482
  1,612 95 1
Bifid epiglottis: What perioperative physician should know about it?
Rupesh Yadav, Sohan Lal Solanki, Jeson R Doctor
October-December 2017, 20(4):479-480
  1,503 93 -
An uncommon intraoperative implantable cardiac device complication and subsequent troubleshooting
Rekha Suthar, Omar Viswanath, S Howard Wittels, Gerald P Rosen
October-December 2017, 20(4):483-484
  1,490 70 -
Lutembacher syndrome: Dilemma of doing a tricuspid annuloplasty
AV Varsha, Gladdy George, Raj Sahajanandan
October-December 2017, 20(4):456-458
We discuss the case of a 24-year-old woman with Lutembacher syndrome and severe tricuspid regurgitation (TR) who underwent surgical closure of atrial septal defect and mitral valve replacement without tricuspid annuloplasty despite a severe TR and a large tricuspid annulus on preoperative echo. The pathophysiology of Lutembacher syndrome is discussed below. The utility of perioperative echocardiography in assessing the annular diameter, tenting area and coaptation depth and thus providing insights into the functioning of the tricuspid valve will also be emphasized.
  1,269 120 5
Distortion of aortic valve from mechanical traction imposed by the mitral valve prosthesis: The three-dimensional transesophageal echocardiographic perception
Saravana Babu, P Unnikrishnan Koniparambil, Muthu Kumar, K Bineesh Radhakrishnan, Neelam Aggarwal, Saurabh Nanda
October-December 2017, 20(4):472-474
Iatrogenic injury to the aortic valve is a rare but frequently reported complication during mitral valve surgeries. Intraoperative 2-dimensional transesophageal echocardiography (2D TEE) has a major impact in diagnosing these injuries, so that timely intervention is possible. However, 2D TEE has lot of limitations during the perioperative period, which can be overcome by the three dimensional echocardiography (3D-TEE). We report a case where 3D TEE has undoubtedly delineated the cause for distortion of aortic sinus after mitral valve replacement and helped in the successful outcome.
  1,292 76 1
Rhabdomyolysis and compartment syndrome in a bodybuilder undergoing minimally invasive cardiac surgery
Sebastian John Baxter, Madhusudan Rao Puchakayala, Vinayak N Bapat
October-December 2017, 20(4):453-455
Rhabdomyolysis is the result of skeletal muscle tissue injury and is characterized by elevated creatine kinase levels, muscle pain, and myoglobinuria. It is caused by crush injuries, hyperthermia, drugs, toxins, and abnormal metabolic states. This is often difficult to diagnose perioperatively and can result in renal failure and compartment syndrome if not promptly treated. We report a rare case of inadvertent rhabdomyolysis and compartment syndrome in a bodybuilder undergoing minimally invasive cardiac surgery. The presentation, differential diagnoses, and management are discussed. Hyperkalemia may be the first presenting sign. Early recognition and management are essential to prevent life-threatening complications.
  1,267 81 -
Successful surgical osteoplasty of the left main coronary artery with concomitant mitral valve replacement and tricuspid annuloplasty
Ujjwal Kumar Chowdhury, Abhinav Singh Chauhan, Poonam Malhotra Kapoor, Suruchi Hasija, Priya Jagia, Pradeep Ramakrishnan
October-December 2017, 20(4):444-446
A 50-year-old woman with rheumatic heart disease, mitral stenosis, and critical isolated left main ostial stenosis was successfully treated by mitral valve replacement, tricuspid annuloplasty, and surgery of left main osteoplasty and is reported for its rarity. Notable clinical findings included an intermittently irregular pulse, blood pressure of 100/70 mmHg, cardiomegaly, a diastolic precordial thrill, a mid-diastolic murmur without presystolic accentuation that was loudest at the mitral area. Chest radiograph revealed cardiomegaly with a cardiothoracic ratio of 0.7 due to enlarged right atrium, right ventricle with a straightened left heart border and evidence of pulmonary hypertension. The investigation shows that surgical reconstruction of the left main coronary artery is safe and effective for the treatment.
  1,239 89 -
A case report of combined radical pericardiectomy and beating heart coronary artery bypass grafting in a patient with tubercular chronic constrictive pericarditis with coronary artery disease
Gauranga Majumdar, Surendra Kumar Agarwal, Shantanu Pande, Bipin Chandra, Prabhat Tewari
October-December 2017, 20(4):465-467
We here report a successful midterm outcome following combined off-pump radical pericardiectomy and coronary artery bypass surgery (CABG) in a 65-year-old male patient who was suffering from chronic constrictive calcified tubercular pericarditis with coronary artery disease. Simultaneous off-pump CABG and radical pericardiectomy for nonsurgical constrictive pericarditis is reported very rarely in English literature.
  1,211 89 -
Sutureless aortic valve implantation in patient with porcelain aorta via unclamped aorta and deep hypothermic circulatory arrest
Vagelis Boultadakis, Nikolaos G Baikoussis, Victoras Panagiotakopoulos, Nikolaos A Papakonstantinou, Polyxeni Xelidoni, Stratos Anagnostou, Christos Charitos
October-December 2017, 20(4):447-449
Severe atherosclerotic calcification of the ascending aorta, the so-called porcelain aorta, precludes cardiac surgeons from placing an aortic cross-clamp and direct aortic cannulation due to the increased risk of systemic embolism and stroke. In the present report, we support the option of sutureless valve implantation in a case of a porcelain ascending aorta, with deep hypothermic circulatory arrest and also without aortic cross-clamp.
  1,114 71 -
Pulmonary valve reconstruction during conduit revision: Technique and transesophageal echocardiography imaging
Sachin Talwar, Poonam Malhotra Kapoor, Sukhjeet Singh, Deepanwita Das, Kamal Prakash Sharma, Balram Airam
October-December 2017, 20(4):442-443
DOI:10.4103/aca.ACA_55_17  PMID:28994681
Transesophageal echocardiography can be a useful adjunct in assessing the quality of repair in patients undergoing novel methods of reconstruction of the right ventricular outflow. We present one such patient here.
  957 74 -
Hypertrophic obstructive cardiomyopathy, yamaguchi syndrome and kounis syndrome: Clinical challenges
Nicholas G Kounis, Ioanna Koniari, George Soufras, Nicholas Patsouras, George Hahalis
October-December 2017, 20(4):485-485
  917 76 -