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   2021| January-March  | Volume 24 | Issue 1  
    Online since January 22, 2021

 
 
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REVIEW ARTICLE
PRO: The pulmonary artery catheter has a paramount role in current clinical practice
Christian Szabo, Maria Betances-Fernandez, Jose R Navas-Blanco, Raj K Modak
January-March 2021, 24(1):4-7
DOI:10.4103/aca.ACA_125_19  PMID:33938823
Ever since its clinical introduction, the utilization of the pulmonary artery catheter (PAC) has been surrounded by multiple controversies, mostly related to imprecise clinical indications and the complications derived from its placement. Currently, one of the most important criticisms of the PAC is the ambiguity in the interpretation of its hemodynamic measurements and therefore, in the translation of this data into specific therapeutic interventions. The popularity of the PAC stems from the fact that it provides hemodynamic data that cannot be obtained from clinical examination. The assumption is that this information would allow better understanding of the individual's hemodynamic profile which would trigger therapeutic interventions that improve patient outcomes. Nevertheless, even with the current diversity of hemodynamic devices available, the PAC remains a valuable tool in a wide variety of clinical settings. The authors present a review exposing the benefits of the PAC, current clinical recommendations for its use, mortality and survival profile, its role in goal-directed therapy, and other applications of the PAC beyond cardiac surgery and the intensive care unit.
  4,670 175 -
ORIGINAL ARTICLES
The synergistic effect of tranexamic acid and ethamsylate combination on blood loss in pediatric cardiac surgery
Ibrahim I. Abd El Baser, Hanaa M ElBendary, Ahmad ElDerie
January-March 2021, 24(1):17-23
DOI:10.4103/aca.ACA_84_19  PMID:33938826
Background: Pediatric patients are at risk for bleeding after cardiac surgery. Administration of antifibrinolytic agents reduces postoperative blood loss. Objective: Evaluation of the efficacy of combined administration of tranexamic acid (TXA) and ethamsylate in the reduction of postoperative blood loss in pediatric cardiac surgery. Methods: This prospective randomized study included 126 children submitted for cardiac surgery, and they were allocated into three groups: control group (n = 42); TXA group (n = 42):- received only TXA; and combined ethamsylate TXA group (n = 42):- received a combination of TXA and ethamsylate. The main collected data included sternal closure time, the needs for intraoperative transfusion of blood and its products, the total amount of blood loss, and the amount of the whole blood and its products transfused to the patients in the first 24 postoperative hours. Results: Blood loss volume in the first 24 postoperative hours was significantly smaller in combined group than the TXA and control groups and was significantly smaller in the TXA group than the control group. The sternal closure time was significantly shorter in the combined group than the other 2 groups and significantly shorter in TXA than the control group. The amount of whole blood transfused to patients in the combined group during surgery and in the first postoperative 24 h was significantly smaller than the other 2 groups and smaller in TXA group than the control group during surgery. Conclusion: Combined administration of ethamsylate and TXA in pediatric cardiac surgery was more effective in reducing postoperative blood loss and whole blood transfusion requirements than the administration of TXA alone.
  3,903 130 -
EDITORIAL
Pulmonary artery catheter – Dilemma is still on?
Manjula Sarkar, Sanjeeta Umbarkar
January-March 2021, 24(1):1-3
DOI:10.4103/aca.ACA_185_19  PMID:33938822
  3,346 131 -
REVIEW ARTICLE
CON: Pulmonary artery catheter use should be forgone in modern clinical practice
Jose R Navas-Blanco, Ashwin Vaidyanathan, Paula Trigo Blanco, Raj K Modak
January-March 2021, 24(1):8-11
DOI:10.4103/aca.ACA_126_19  PMID:33938824
The pulmonary artery catheter (PAC) and its role in the practice of modern medicine remains to be questioned and has experienced a substantial decline in its use in the most recent decades. The complications associated to its use, the lack of consistency of the interpretation provided by the PAC among clinicians, the development of new hemodynamic methods, and the deleterious cost profile associated to the PAC are some of the reasons behind the decrease in its use. Since its introduction into clinical practice, the PAC and the data obtained from its use became paramount in the management of critically ill patients as well as for the high-risk/invasive procedures. Initially, many clinicians were under the impression that regardless the clinical setting, acquiring the information provided by the PAC justified its use, until a growing body of evidence demonstrated its lack of mortality and morbidity improvement, as well as several reports of the presence of difficulties—some of them fatal—during its insertion. The authors present an updated review discussing the futility of the PAC in current clinical practice, the complications associated to its insertion, the lack of mortality benefit in critically ill patients and cardiac surgery, as well as present alternative hemodynamic methods to the PAC.
  3,256 121 -
ORIGINAL ARTICLES
Comparison of thromboelastography with routine laboratory coagulation parameters to assess the hemostatic profile and prognosticate postoperative critically ill patients
Amrita Bhattacharyya, Prabhat Tewari, Devendra Gupta
January-March 2021, 24(1):12-16
DOI:10.4103/aca.ACA_162_19  PMID:33938825
Background: Patients undergoing surgery often demonstrate coagulopathy. Usually, this derangement in coagulation is assessed by the laboratory based evaluation of blood samples. However, collection of samples, their transportation to the lab, and the analyses can result in several errors and as such these tests may not be representative of the complete coagulation process. In our study, we compared the lab coagulation parameters with the point of care TEG indices and attempted to compare the outcome prediction of our patients based on the TEG indices and the various practiced ICU scores. Methods: A prospective, observational study was conducted between May 2014 and May 2015. Fifty adult patients who had undergone noncardiac surgery and had developed new onset 2 or more than 2 system involvement in the postoperative period were enrolled in the study. They were sampled simultaneously for lab coagulation parameters (PT, APTT, INR, fibrinogen, and platelet count) and TEG on days 1, 3, and 5 post admission. Results: There were significant differences between TEG and lab coagulation parameters on day 1 of the study 1 (P = 0.004) but not on days 3 and 5. On days 1 and 3 of our study, the ICU scores (SOFA and APACHE II) were significantly higher in the group with deranged TEG parameters (P = 0.003, 0.02). The patient subpopulation with deranged TEG parameters had significantly higher mortality at median survival time (P = 0.014). Such a difference was not found in patients with higher ICU scores or deranged lab coagulation times. We constructed a ROC curve and arrived at a cutoff value of the reaction time to predict the median survival day mortality. Conclusions: The agreement between TEG and conventional lab parameters remains poor but the TEG parameters seem to be more deranged in sicker patients. As the relationship between the overall severity of illness and derangement in the hemostatic system has been well explored in medical literature, TEG may be a more appropriate modality in such patients.
  3,072 125 -
Comparison of ringer's lactate and plasmalyt-a as cardiopulmonary bypass prime for bypass associated acidosis in valve replacement surgeries
Sandill Surabhi, Meenakshi Kumar
January-March 2021, 24(1):36-41
DOI:10.4103/aca.ACA_104_19  PMID:33938829
Introduction: A wide range of acid base fluctuations are seen during Cardiopulmonary bypass (CPB) and the development of metabolic acidosis is well recognized. We conducted a study tocompare the metabolic effects of Ringer lactate and Plasmalyte-A as CPB prime in causing bypass associated acidosis in valve replacement surgeries. Methods: We performed a prospective, randomized controlled study on a total of 80 adult patients undergoing CPB for valvular heart surgeries. The patients were randomized into two groups: Group I (Ringer Lactate) and Group II (Plasmalyte-A). Arterial blood samples were taken before initiating CPB, 30 minutes after starting CPB, then every half hourly till termination of CPB and after half an hour stay in the ICU post operatively to analyze primarily H+ ions, bicarbonates, lactate and strong ion difference. Results and Discussion: The results were analyzed in a quantitative manner. In Ringer Lactate group, during CPB, there was reduction in pH from 7.428 ± 0.029 at T1 to 7.335 ± 0.06 (P < 0.01) and 7.358 ± 0.06 (P < 0.01) at T2 and T3 respectively. Mean bicarbonates decreased in Ringer Lactate group during CPB from 24.28 ± 1.65 mEq/L at T1 to 20.98 ± 2.97 mEq/L at T2 (P < 0.01). In Plasmalyte-A group, mean pH, bicarbonate, strong ion difference (SID) were comparable at all time intervals (P > 0.05). In Ringer Lactate group, maximum surge in mean blood lactate levels was seen from 0.85 ± 0.35 mmol/l at T1 to 4.29 ± 1.78 mmol/L (P < 0.01) and 4.17 ± 1.28 mmol/L (P < 0.01) at T2 and T3, respectively. Such surge was not seen in Plasmalyte-A group. The mean SID decreased during the CPB in Ringer Lactate group from 41.102 mEq/L at T1 to 35.66 mEq/L (P = 0.033) at T2 implying metabolic acidosis. Numbered patients having hypotension and arrhythmias were also higher in Ringer Lactate group again indicating higher acidosis. Conclusion: The different composition of Plasmalyte-A and Ringer Lactate have different metabolic implications for patients undergoing cardiac surgery. Patients who received Plasmalyte-A as cardiopulmonary bypass prime developed less metabolic acidosis. Hence we conclude that Plasmalyte-A is the preferred cardiopulmonary bypass prime in adult patients undergoing valve replacement surgeries.
  1,677 118 -
The Glenn procedure: Clinical outcomes in patients with congenital heart disease in pakistan
Muhammad Tariq, Ibrahim Zahid, Shiraz Hashmi, Muneer Amanullah, Syed Shahabuddin
January-March 2021, 24(1):30-35
DOI:10.4103/aca.ACA_85_19  PMID:33938828
Objectives: Congenital heart defects (CHDs) affect more than 40,000 children annually in Pakistan. Approximately 80' of patients require at least one surgical intervention to achieve a complete or palliative cardiac repair. The Glenn shunt, a palliative procedure is established between superior vena cava (SVC) and the right pulmonary artery to provide an anastomosis offering minimal risk to patients with univentricular heart disease. The aim of this study was to assess the clinical outcomes of the Glenn shunt procedure in patients with complex congenital heart diseases in a developing country like Pakistan. Materials and Methods: A retrospective chart review was conducted on patients who underwent a bidirectional Glenn shunt procedure from July 2006 to June 2017. Data were collected on a structured questionnaire and analyses performed on SPSS version 22. Frequencies and percentages were computed for categorical variables while mean and standard deviation for continuous variables where appropriate. Results: A total of 79 patients underwent the Glenn shunt procedures. The median age was 1.9 years and 54.5' were male. Tricuspid atresia was the primary diagnosis in 30.4' of the patients. Common morbidities included arrhythmias (6.3'), pleural effusion (8.9'), wound infection (3.8'), pneumonia (2.5'), and seizures (3.8'); reopening was required in 2.5' of the patients and 8.8' were readmitted within 30 days of index operation. There were three (3.8') deaths in total. Conclusions: Bidirectional Glenn shunt procedure can be performed safely in patients with ideal characteristics as the first stage palliation and has favorable results with acceptable rate of complications.
  1,470 104 -
Efficacy of paravertebral block in “Fast-tracking” pediatric cardiac surgery - Experiences from a tertiary care center
Raj Sahajanandan, AV Varsha, D Sathish Kumar, Balaji Kuppusamy, Sathappan Karuppiah, Vinayak Shukla, Roy Thankachen
January-March 2021, 24(1):24-29
DOI:10.4103/aca.ACA_83_19  PMID:33938827
Introduction: Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery. Methods: We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB. Results: The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*). Conclusion: PVB provides an effective and safe anaesthetic approach which can form an important component of “fast-track” care in paediatric cardiac surgery.
  1,216 127 -
CASE REPORTS
External tracheal manipulation for bronchial blocker placement in children undergoing thoracic surgery requiring one lung ventilation: A case report
Ravish Kapoor, Pascal Owusu- Agyemang, Dilip R Thakar, Jagtar Singh Heir
January-March 2021, 24(1):105-107
DOI:10.4103/aca.ACA_56_19  PMID:33938846
Limited options exist for pediatric one lung ventilation (OLV). Compared to adults, pediatric OLV can be more challenging due to physiological/anatomical differences, various pathologies, and size limitations of lung isolation devices. Fiberoptic bronchoscopy can be harder due to the restricted tube sizes through which bronchial blockers (BB) and scopes can appropriately fit, while providing adequate oxygenation and ventilation. Recent literature is sparse concerning facilitation of BB placement in children. A 2-, 8-, and 10-year-old presented for thoracic surgeries requiring OLV. External tracheal manipulation (ETM) facilitated BB placement in each case and can potentially offer unique advantages in pediatric OLV.
  988 58 -
ORIGINAL ARTICLES
Smoking behavior after coronary artery bypass surgery: Quit, relapse, continuing
Fotini Ampatzidou, Rafail Ioannidis, Odysseas Drosos, Charisios Mavromanolis, Athanasia Vlahou, George Drossos
January-March 2021, 24(1):56-61
DOI:10.4103/aca.ACA_63_19  PMID:33938833
Objective: Tobacco smoking represents a major risk factor for coronary artery disease. Our study aimed to investigate whether Coronary Artery Bypass Graft (CABG) surgery could act as a motivating factor to enforce smoking cessation. Specifically, we observed the success rate in individuals who quitted smoking, along with the number and reasons of relapse(s) at least one year after the operation. Methods: The pre-operative characteristics, pre-operative tobacco exposure, socioeconomic factors and perioperative complications in patients who underwent isolated Coronary Artery Bypass Graft surgery in our Department from June 2012 to September 2016 were reviewed. Our survey was conducted via phone interview and using a standardized questionnaire. Only patients who were current smokers at the time of surgery were interviewed. Results: Our study group consisted of a total of 120 patients, 91 (75.8') reported initially quitting tobacco smoking. Because of relapse(s), one year after the procedure the number of patients who were still non-smokers dropped to 69 (57.5'). Smoking cessation attempts were not supported by professional assistance. Conclusions: Our findings demonstrate that there is a desire from CABG patients to quit smoking, as indicated by the high percentage of initial attempts in early postoperative period. However, a year after the procedure, only 57.5' of CABG patients were able to achieve or maintain smoking cessation. Patients who were retired or who were unemployed at the time of the surgery, found it easier to stop smoking than patients who were active employees. Patients who lived alone at the time of surgery also found it harder to stop smoking. Finally, patients with COPD also found quitting smoking harder in the post-operative period.
  914 63 -
Comparative evaluation of propofol and combination of propofol-dexmedetomidine in adjunct with topical airway anesthesia for rigid bronchoscopy: A randomized double-blinded prospective study
Mekhla Paul, Amit Rastogi, Arindam Chatterje, Aarti Agarwal, Prabhaker Mishra, Ajmal Khan
January-March 2021, 24(1):49-55
DOI:10.4103/aca.ACA_45_19  PMID:33938832
Context: Rigid bronchoscopy (RB) procedures require continuous vigilance and monitoring. Such procedures warrant proper ventilation strategy and titration of potent short-acting anesthetics. Aims: To compare propofol with the propofol-dexmedetomidine in conjunction with topical airway anesthesia in two groups during spontaneous assisted ventilation on peri-procedural hemodynamic stability. Settings and Design: This prospective, randomized, double-blinded study was done on 40 patients who were randomized in two groups, 20 patients in each group; PS (Propofol+ Normal saline) and PD (Propofol+ Dexmedetomidine) group. All patients in both groups were induced with 1' IV propofol (1–3 mg/kg), IV midazolam (0.05 mg/kg), and IV fentanyl (2 μ/kg). PS group received propofol infusion for maintenance along with saline infusion 10 min before induction, whereas PD group also received propofol infusion for maintenance along with Injection dexmedetomidine infusion 10 min before induction. Outcome measured were heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO2), and post-procedure awakening using Modified Observer's Assessment of Alertness/Sedation (MOAAS) scale and complications. Results: In both the groups, MBP decreased significantly from baseline, however, when MBP were compared at the same time points between the groups there were no significant differences. In PD group, HR remained significantly lower when compared with baseline and at 6, 12, 18, and 24 min time points when compared with PS group. Number of patients who developed hypotension requiring vasoactive drugs, their mean dose and duration of hypotension were more in PD group, and they awoke with significant delay. Conclusions: Propofol is better than combination of propofol and dexmedetomidine when given in adjunct with topical airway anesthesia for RB in view of early awakening, lesser duration of intra-procedural hypotension, and lesser requirement of vasoactive agents.
  866 63 -
Comparison of different size left-sided double-lumen tubes for thoracic surgery
Raisa D Nguyen, Lakshmi N Kurnutala, Michelle A Tucci, Bryan J Hierlmeier
January-March 2021, 24(1):42-46
DOI:10.4103/aca.ACA_93_19  PMID:33938830
Study Objective: The aim of this study is to see if there are any clinical differences between using 35 F DLT for all patients versus using patient height regardless of gender to estimate appropriate DLT size. Design: Prospective randomized study. Setting: University Hospital. Patients: 50 patients age ≤18 years, undergoing lung or esophageal surgery requiring OLV. Interventions: Patients randomized to two groups (group-35F, group –DLT based on height). Measurements and Main Results: Data collected include demographics, ASA status, airway assessment, number of intubation attempts, Cormack-Lehane grade, number of times DLT repositioned, incidence of sore throat, oxygen saturation at induction and oxygen saturation at 5 minutes and 10 minutes after OLV. There was no statistically significant difference in demographics, ASA classification, Mallampati score, number of intubation attempts, Cormack-Lehane grade, number of times DLT was repositioned, and incidence of sore throat. In height based DLT group the odds were higher for the incidence of sore throat in 37-41 F group. Oxygen saturation at induction, 5 minutes and 10 minutes after OLV are not statistically significant between the two groups. Conclusion: Our findings suggest that the majority of patients receive unnecessarily large DLTs for thoracic surgery, which not only makes intubation inherently more difficult but also increases their risk of postoperative sore throat.
  843 78 -
CASE REPORTS
Intestinal mucormycosis in an adult with H1N1 pneumonia on extracorporeal membrane oxygenation
GJ Himaal Dev, Pradeep M Venkategowda, Anand R Sutar, V Shankar
January-March 2021, 24(1):92-94
DOI:10.4103/aca.ACA_1_20  PMID:33938842
Gastrointestinal mucormycosis involving ileum is a very rare phenomenon. We present a case of 52-year-old male, known case of diabetes mellitus requiring extracorporeal membrane oxygenation (ECMO) for H1N1 pneumonia with severe acute respiratory distress syndrome (ARDS). The patient had small bowel obstruction with impending perforation requiring emergency bowel resection and ileostomy. The resected bowel segment histopathology showed mucormycosis. He was treated with conventional Amphotericin-B and later changed to Posaconazole. The patient responded very well and was gradually weaned from ventilator and successfully discharged home. This case report highlights rare site of mucormycosis. Early diagnosis and timely intervention can reduce mortality.
  760 93 -
Diagnostic challenges with transesophageal echocardiography for intraoperative iatrogenic aortic dissection: Role of epiaortic ultrasound
Daniel Rhoades, Sudhakar Subramani
January-March 2021, 24(1):83-86
DOI:10.4103/aca.ACA_4_19  PMID:33938839
Iatrogenic aortic dissection is a rare and serious complication of cardiac surgery with an incidence between 0.12' and 0.16'. Dissections involving an intimal flap can be detected using trans-esophageal echocardiography (TEE) with a sensitivity of 94'–100' and specificity of 77'–100'. Rarely, dissections can occur that are not detectable by TEE. There have been reports of iatrogenic dissection in the ascending aortic cannulation site; however, a dissection at the antegrade cardioplegia cannulation site is very rare. It also presents challenges associated with early diagnosis and appropriate intervention. We are describing a rare case of aortic dissection at the antegrade cardioplegia cannulation site in the proximal ascending aorta. The dissection was unable to be visualized with TEE initially, and required epi-aortic ultrasound to diagnose dissection in timely manner.
  738 79 -
INTERESTING IMAGES
Windsock deformity of submitral left ventricular aneurysm communicating into left atrium – role of transesophageal echocardiography
Subash Sundar Singh, Vijay Thomas Cherian, Shaji Palangadan
January-March 2021, 24(1):72-74
DOI:10.4103/aca.ACA_81_19  PMID:33938835
Submitral left ventricular aneurysm (SMLA) is a rare condition. We report here a 38-year-old male patient, presented with mitral regurgitation and features of congestive cardiac failure (CCF) with New York Heart Association (NYHA) function class III, diagnosed to have SMLA. We discuss here the etiology, types, clinical presentation, and management of SMLA and also the role of transesophageal echocardiography in diagnosis.
  702 70 -
CASE REPORTS
Successful medical management of fungal infective endocarditis post VSD closure
Kalla Krishna Prasad Gourav, Banashree Mandal, Anand Kumar Mishra, V Krishna Narayanan Nayanar
January-March 2021, 24(1):95-98
DOI:10.4103/aca.ACA_33_19  PMID:33938843
Fungal infective endocarditis (IE) is uncommon in postoperative cardiac surgical patients. The fungal IE accounts for 1.3'–6.8' of all IE cases and is considered the most severe form with a mortality rate as high as 45'–50'. There are various predisposing factors for fungal IE which include congenital heart defects, cardiac interventions like pacemaker insertion, degenerative valvular heart diseases, long-term use of broad-spectrum antimicrobial therapy, and long-term use of central venous. Mortality can reach up to 100' without specific treatment. Definitive therapy necessitates surgical debridement of vegetations/mass/abscess followed by long-term treatment with antifungal agents in patients who have symptoms of heart failure despite optimum medical management. We, hereby, report a case of fungal IE which occurred after the closure of a ventricular septal defect and was treated successfully with liposomal amphotericin B.
  694 75 -
Left atrial thrombus in a case of severe aortic stenosis with severe left ventricular dysfunction: An Incidental finding on transesophageal echocardiography
Aanchal Dixit, Prabhat Tewari, Bipin Chandra
January-March 2021, 24(1):87-89
DOI:10.4103/aca.ACA_98_19  PMID:33938840
Left atrial thrombus in a patient with aortic stenosis and aortic regurgitation in sinus rhythm is an infrequent finding and is most commonly associated with cases of mitral stenosis. This case report emphasizes upon the importance of suspecting the presence of left atrial thrombus in other valvular lesions when additional risk factors such as dilated left ventricle are present. The undeniable role of comprehensive perioperative transesophageal echocardiography is also depicted in this case report.
  676 44 -
Right ventricular injury and pulmonary embolism: The perils of deep intramyocardial left anterior descending artery dissection in off-pump coronary artery bypass grafting
Biswarup Purkayastha, Lalit Kapoor, Vikash Toshniwal, Devraj Kumar
January-March 2021, 24(1):99-101
DOI:10.4103/aca.ACA_49_19  PMID:33938844
An inadvertent vent in the right ventricle (RV) resulted during dissection of a deep intramyocardial left anterior descending coronary artery (LAD), during off-pump coronary artery bypass grafting (OPCAB), led to pulmonary artery air embolism and hemodynamic instability, requiring conversion to cardiopulmonary bypass (CPB) prior to repair. This required a special maneuver in positioning the patient to identify the RV injury and prevent the pulmonary air embolism.
  658 56 -
INTERESTING IMAGES
Parachute mitral valve
Nicholas Suraci, Howard Goldman, Diego Baruqui, Orlando Santana
January-March 2021, 24(1):75-76
DOI:10.4103/aca.ACA_82_19  PMID:33938836
An asymptomatic 30-year-old male was referred for a transthoracic echocardiogram because of a systolic murmur that was noted on a pre-employment physical exam. Transthoracic imaging demonstrated a single papillary muscle from which the chordae of both mitral valve leaflets were attached. The mitral valve was seen to have a parachute-like configuration. Given the benign nature of the presentation, the patient did not seek further investigation.
  614 47 -
ORIGINAL ARTICLES
Preexisting right ventricular systolic dysfunction in high-risk patients undergoing non.emergent open abdominal surgery: A retrospective cohort study
Jody Chou, Michael Ma, Maryte Gylys, Nicolas Salvatierra, Robert Kim, Barseghian Ailin, Joseph Rinehart
January-March 2021, 24(1):62-71
DOI:10.4103/aca.ACA_46_19  PMID:33938834
Background: The prognostic value of right ventricular systolic dysfunction in high-risk patients undergoing non-emergent open abdominal surgery is unknown. Here, we aim to evaluate whether presence of preexisting right ventricular systolic dysfunction in this surgical cohort is independently associated with higher incidence of postoperative major adverse cardiac events and all-cause in-hospital mortality. Methods: This is a single-centered retrospective study. Patients identified as American Society Anesthesiology Classification III and IV who had a preoperative echocardiogram within 1 year of undergoing non-emergent open abdominal surgery between January 2010 and May 2017 were included in the study. Incidence of postoperative major cardiac adverse events and all-cause in-hospital mortality were collected. Multivariable logistic regression was performed in a step-wise manner to identify independent association between preexisting right ventricular systolic dysfunction with outcomes of interest. Results: Preexisting right ventricular systolic dysfunction was not associated with postoperative major adverse cardiac events (P = 0.26). However, there was a strong association between preexisting right ventricular systolic dysfunction and all-cause in-hospital mortality (P = 0.00094). After multivariate analysis, preexisting right ventricular systolic dysfunction continued to be an independent risk factor for all-cause in-hospital mortality with an odds ratio of 18.9 (95' CI: 1.8-201.7; P = 0.015). Conclusion: In this retrospective study of high-risk patients undergoing non-emergent open abdominal surgery, preexisting right ventricular systolic dysfunction was found to have a strong association with all-cause in-hospital mortality.
  612 48 -
CASE REPORTS
Surgical retrieval of broken, inflated angioplasty balloon catheter within intracoronary stent: A real emergency
Hemant Digambar Waikar, Rajitha Desilva, Wasanthi Rathnayake, Chandrika Ponnamperuma, Anthonpillai Ravikiran
January-March 2021, 24(1):111-113
DOI:10.4103/aca.ACA_2_20  PMID:33938848
A 54-year old, hypertensive female patient underwent percutaneous coronary angioplasty (PTCA) followed by stenting of calcified chronic totally occluded right coronary artery. The post dilation balloon catheter got stuck and snapped during manipulations in inflated position within the stent, which could not be retrieved by nonsurgical interventions. Emergency surgery was performed to retrieve the stent along with an inflated balloon, followed by vein patch closure of arteriotomy and reversed saphenous vein graft anastomosis to right coronary artery and left anterior descending artery on cardiopulmonary bypass.
  600 59 -
INTERESTING IMAGES
Incidentally found guidewire during bacterial endocarditis workup
Nicholas Suraci, Sofia A Horvath, Heather Barkin, Orlando Santana
January-March 2021, 24(1):77-78
DOI:10.4103/aca.ACA_88_19  PMID:33938837
A 67-year-old female with recent hospitalization for pneumonia was transferred to our facility for high fevers and positive blood cultures for staph aureus. During her treatment for pneumonia, central venous catheter was placed. A systolic murmur was found in conjunction with fever and notable premature ventricular contractions on telemetry monitoring. Chest x-ray and transesophageal echocardiography were then performed, and a free guidewire was identified which was later successfully removed under interventional radiology.
  592 43 -
CASE REPORTS
Anaesthetic challenges in pulmonary alveolar microlithiasis – a rare disease treated with bilateral lung transplantation, first case from India
Pradeep Kumar, Apar Jindal, Prabhat Dutta, Sandeep Attawar, Vijil Rahulan
January-March 2021, 24(1):79-82
DOI:10.4103/aca.ACA_165_19  PMID:33938838
Pulmonary Alveolar Microlithiasis (PAM) is a rare autosomal recessive end stage lung condition characterized by widespread alveolar deposition of calcium microliths. It is worth emphasis india has reported 80 cases out of 1022 cases worldwide but there is no report on lung transplant and and anaesthetic management in this category of patient. This report present the anaesthetic challenge in management of first indian patient with the diagnosis of PAM, who underwent bilateral lung transplantation. Bilateral lung transplantation is one of the most challenging surgeries that require the care of a cardiothoracic anesthesiologist. Utilization of extracorporeal circulation has allowed a safer performance of this procedure in patients with severe cardiopulmonary compromise. Intraoperative management is a pivotal part of the patient's care, as it contributes to the patient's overall outcome.
  575 59 -
Mitral kissing lesion with anterior mitral leaflet aneurysm in a child
Javid Raja, Srawanthi Ponnuru, Baiju S Dharan, PR Suneel
January-March 2021, 24(1):108-110
DOI:10.4103/aca.ACA_123_19  PMID:33938847
Aortic valve endocarditis can lead to secondary involvement of aorto mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected diastolic jet of aortic regurgitation hitting the ventricular surface of the anterior mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called “kissing lesion”. We describe a case of infective endocarditis of aortic valve in a 13-year-old child causing secondary mitral valve involvement with AML perforation and aneurysm formation.
  570 51 -
Right ventricular undifferentiated pleomorphic sarcoma: A case report
Sadra Yadsar, Mahnaz Abavisani, Rasool Lakziyan, Zohreh Sarchahi
January-March 2021, 24(1):102-104
DOI:10.4103/aca.ACA_53_19  PMID:33938845
In this paper, a case of undifferentiated pleomorphic sarcoma in a patient with right-sided heart failure has been explored. A 61-year-old woman complaining from cough and dyspnea for a week following indistinctive surgery on right buttock area with reported pathology of malignant undifferentiated tumor presented to the hospital. Laboratory results indicated negative TPi enzyme and D.dimer of 4127.81 mg/L. In transthoracic echocardiography, a mass filling the entire right ventricular space was observed. A resection surgery was performed and the pathology was reported as primary cardiac sarcoma.
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COMMENTARIES
In response to “Left atrial thrombus in a case of severe aortic stenosis with severe left ventricular dysfunction: An incidental finding on transesophageal echocardiography”
Prateek Arora, Praveen K Neema
January-March 2021, 24(1):90-91
DOI:10.4103/aca.ACA_150_19  PMID:33938841
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LETTERS TO THE EDITORS
Bronchoscopy examination of a patient with tracheobronchial injury having intractable cough: Role of sevoflurane sedation and paraoxygenation
Chinmaya K Panda, Habib M R Karim, Praveen K Neema
January-March 2021, 24(1):121-123
DOI:10.4103/aca.ACA_182_19  PMID:33938855
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CASE REPORTS
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient with a history of bentall operation
Ali Hosseinsabet, Kyomars Abbasi
January-March 2021, 24(1):120-121
DOI:10.4103/aca.ACA_186_19  PMID:33938854
  516 59 -
LETTERS TO THE EDITORS
Lessons from the frank-starling curve
Summit D Bloria
January-March 2021, 24(1):118-119
DOI:10.4103/aca.ACA_29_20  PMID:33938853
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Impact of simulator.based training on acquisition of transthoracic echocardiography skills in medical students- Medical students' perspective
Benjamin Patterson, Edward Antram
January-March 2021, 24(1):116-117
DOI:10.4103/aca.ACA_194_20  PMID:33938851
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Can central venous oxygen saturation replace arterial blood gas sampling in patients with end.stage renal failure having arteriovenous fistula?
Rajinder Singh Rawat, Chandrashekhar Laxmanrao Mankar, Said Musallam Al Maashani
January-March 2021, 24(1):123-124
DOI:10.4103/aca.ACA_40_19  PMID:33938856
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COMMENTARIES
Practice patterns of left-sided double-lumen tube: Does It match recommendation from literature
Amit Rastogi
January-March 2021, 24(1):47-48
DOI:10.4103/aca.ACA_165_18  PMID:33938831
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LETTERS TO THE EDITORS
Velcro fastener to hold heavy cables and cords across the ether screen
Pallavi Horo
January-March 2021, 24(1):114-115
DOI:10.4103/aca.ACA_173_19  PMID:33938849
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In the Internal thoracic artery, more diameter does not always mean more flow
Yoandy López de la Cruz
January-March 2021, 24(1):125-126
DOI:10.4103/aca.ACA_118_20  PMID:33938857
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In reply
Roshith Chandran, Rupa Sreedhar, Shrinivas Gadhinglajkar, Prashat Kumar Dash, Jayakumar Karunakaran, Vivek Pillai
January-March 2021, 24(1):126-127
DOI:10.4103/aca.ACA_171_20  PMID:33938858
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In Reply
Conrad Hempel, Edwin Turton, Elham Hasheminejad, Carmine Bevilacqua, Gunther Hempel, Jörg Ender, Daisy Rotzoll
January-March 2021, 24(1):117-118
DOI:10.4103/aca.ACA_204_20  PMID:33938852
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Therapeutic occlusion of the internal mammary arteries to relieve refractory angina
Marco Picichè
January-March 2021, 24(1):115-116
DOI:10.4103/aca.ACA_124_19  PMID:33938850
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