Remifentanil has a unique pharmacokinetic profile, with a rapid onset and offset of action and a plasmatic metabolism. Its use can be recommended even in patients with renal impairment, hepatic dysfunction or poor cardiovascular function. A potential protective cardiac preconditioning effect has been suggested. Drug-related adverse effects seem to be comparable with other opioids. In cardiac surgery, many randomized controlled trials demonstrated that the potential benefits of the use of remifentanil not only include a profound protection against intraoperative stressful stimuli, but also rapid postoperative recovery, early weaning from mechanical ventilation, and extubation. Remifentanil shows ideal properties of sedative agents being often employed for minimally invasive cardiologic techniques, such as transcatheter aortic valve implantation and radio frequency treatment of atrial flutter, or diagnostic procedures such as transesophageal echocardiography. In intensive care units remifentanil is associated with a reduction in the time to tracheal extubation after cessation of the continuous infusion; other advantages could be more evident in patients with organ dysfunction. Effective and safe analgesia can be provided in case of short and painful procedures (i.e. chest drain removal). In conclusion, thanks to its peculiar properties, remifentanil will probably play a major role in critically ill cardiac patients.

Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author's institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.

There has been considerable controversy regarding the use of pulmonary artery catheter (PAC) in clinical practice. Some studies have indicated poor outcome in patients who were monitored with PAC. However, these studies, which have condemned the use of PAC, were conducted on patients in intensive care units, where the clinical scenarios with regard to patients' status are somewhat different as compared to those of a cardiac operating room. This study was designed to identify the indications of PAC use in cardiac operating rooms. A questionnaire was mailed to anasthesiologists in cardiac centers and the response was analyzed.The practicing cardiac anesthesiologists recommended the use of PAC for following indications in cardiac surgery: coronary artery bypass grafting (CABG) with poor left ventricular (LV) function, LV aneurysmectomy, recent myocardial infarction (MI), pulmonary hypertension, diastolic dysfunction, acute ventricular septal rupture and insertion of left ventricular assist device (LVAD).The analysis of responses from practicing anesthesiologists clearly indicates that use of a PAC cannot be recommended as a matter of routine, but a definite role is suggested in selected groups of patients undergoing cardiac surgery.

The prophylactic use of small doses of ephedrine may counter the hypotension response to propofol anesthesia with minimal hemodynamic changes. One hundred-fifty patients scheduled for valve surgery were randomly assigned into five groups (n = 30 for each) to receive saline, 0.07, 0.1, or 0.15 mg/kg of ephedrine, or phenylephrine 1.5 μg/kg before induction of propofol-fentanyl anesthesia. After induction, patient receiving ephedrine had higher mean arterial pressure, systemic vascular resistance (SVRI), cardiac (CI), stroke volume (SVI), and left ventricular stroke work (LVSWI) indices. Patients received 0.15 mg/kg of ephedrine showed additional increased heart rate and frequent ischemic episodes (P < 0.001). However, those who received phenylephrine showed greater rise in SVRI, reduced CI, SVI, and LVSWI and more frequent ischemic episodes. We conclude that the prophylactic use of small doses of ephedrine (0.07−0.1 mg/kg) is safe and effective in the counteracting propofol-induced hypotension during anesthesia for valve surgery.

A patient for double valve replacement developed an unusual complication consequent to extra-vascular displacement of a port of a central venous catheter, placed through the right subclavian vein. The patient had an uneventful surgical course and the trachea extubated after routine mechanical ventilation. Patient developed excessive mediastinal drainage later, which was noticed to be watery in nature. The source of the drainage was found to be a port of the central venous catheter, draining extra-vascular into the subclavian vascular sheath and thereafter through the pericardium into the mediastinal drains.

Branch pulmonary artery obstruction is one of the prime reasons for re-operation in patients who have undergone repair for tetralogy of Fallot. Branch pulmonary artery obstruction may develop over a period of time due to dilation of right ventricular outflow tract or it may be caused by residual stenosis after inadequate repair. This may lead to differential lung perfusion causing morbidity. Intra-operative capnogram monitoring reveals ventilation−perfusion relationship. We report two cases where the capnogram helped the diagnosis and management of branch pulmonary artery obstruction. We found a redundant patch in the first and an extra length of the homograft in second case which led to the obstruction. However, but for the changes in the intraoperative capnogram, this condition may by far remain undiagnosed considering the fact that it does not produce hemodynamic changes but can lead to postoperative morbidity.

Aneurysm of sinus of Valsalva is a rare congenital cardiac defect that can present with myriad signs and symptoms ranging from trivial to catastrophic events like cardiogenic shock and death. As clinical examination is not entirely reliable and the patient can sometimes be so ill as to preclude cardiac catheterization, echocardiography has become the definitive investigative tool not only to define and diagnose the lesion but also to quantify its severity. The following is a case report of multiple aneurysms of the left aortic sinus of Valsalva rupturing into the left ventricle. Diagnosis is made on multi plane transesophageal echocardiography and color Doppler regarding precise identification of structural anomalies and shunt locations for perioperative assessment and definitive treatment is surgical repair.

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a congenital acyanotic heart disease where the left coronary artery (LCA) arises from the pulmonary artery. This results in the LCA receiving blood supply from the low-pressure right ventricle having minimal extractable oxygen. The oxygen delivery to the left ventricle (LV) is severely hampered causing severe hypoxic LV dysfunction early in life. Early surgery prior to serious, irreversible LV dysfunction is the key to survival. Children with ALCAPA usually present in their first few weeks of life, with severe LV dysfunction. After surgical correction of the defect, the myocardium may not recover early from the presurgery myocardial dysfunction. We describe a case where extracorporeal membrane oxygenator was utilized as a means of ventricular support during this critical postoperative period resulting in a favorable outcome.