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EDITORIALS |
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Pediatric cardiac program in India: Changing perspectives |
p. 79 |
Suresh G Nair DOI:10.4103/0971-9784.81559 PMID:21636925 |
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Cardiac tamponade and clinical acumen |
p. 82 |
Shanelle Wijesuriya, Alain Vuylsteke DOI:10.4103/0971-9784.81560 PMID:21636926 |
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ORIGINAL ARTICLES |
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Validation of a decision-making strategy for systolic anterior motion following mitral valve repair |
p. 85 |
Giovanni Landoni, Giuseppe Crescenzi, Alberto Zangrillo, Davide Nicolotti, Elena Bignami, Giuseppe Iaci, Ottavio Alfieri, Fabio Guarracino DOI:10.4103/0971-9784.81561 PMID:21636927Low cardiac output syndrome and hypotension are dreadful consequences of systolic anterior motion (SAM) after a mitral valve (MV) repair. The management of SAM in the operating room remains controversial. We validate a recently suggested two-step management method and classification of this complication. This was a teaching hospital-based observational study. We validated a novel two-step conservative management method, consisting in intravascular volume expansion and discontinuation of inotropic drugs (step 1), and increasing the afterload by ascending aorta manual compression while administering esmolol e.v. (step 2). We also validate a novel classification of SAM: easy-to-revert (responding to step 1), difficult-to-revert (responding to step 2), or persistent. Fifty patients had an easy-to-revert while 26 had a difficult-to-revert SAM; 4 patients had a persistent condition (promptly diagnosed through our decisional algorithm) and underwent an immediate second pump run to repeat the mitral repair surgery. We confirmed that SAM after a repair of a degenerative MV is common and validated a simple two-step conservative management method that allows to clearly identify those few patients who require immediate surgical revision. |
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Real-time three-dimensional echocardiographic assessment of mitral valve: Is it really superior to 2D transesophageal echocardiography? |
p. 91 |
Chirojit Mukherjee, Heinz Tschernich, Udo X Kaisers, Sarah Eibel, Joerg Seeburger, Joerg Ender DOI:10.4103/0971-9784.81562 PMID:21636928Aim of our study was to investigate the feasibility of use and possible additional value of real-time 3D transesophageal echocardiography (RT-3D-TEE) compared to conventional 2D-TEE in patients undergoing elective mitral valve repair. After ethical committee approval, patients were included in this prospective study. After induction of anesthesia, a comprehensive 2D-TEE examination was performed, followed with RT-3D-TEE. The intraoperative surgical finding was used as the gold standard for segmental analysis. Only such segments which were surgically corrected either by resection or insertion of artificial chords were judged pathologic. A total of 50 patients were included in this study; usable data were available from 42 of these patients . Based on the Carpentier classification, the pathology found was type I in 2 (5%) patients, type II in 39 (93%) patients and type IIIb in 1 (2%) patient. We found that 3D imaging of complex mitral disease involving multiple segments, when compared to 2D-TEE did not show any statistically significant difference.RT-3D-TEE did not show any major advantage when compared to conventional 2D-TEE for assessing mitral valve pathology, although further study in a larger population is required to establish the validity of this study. |
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Anesthetic management of patients undergoing extra-anatomic renal bypass surgery for renovascular hypertension |
p. 97 |
Bhupesh Kumar, Prabhat Kumar Sinha, M Unnikrishnan DOI:10.4103/0971-9784.81563 PMID:21636929Renal artery disease is the most common cause for surgically curable form of hypertension. In a small subset of patients with severe aortic disease where the aorta is not suitable for endovascular technique and to provide an arterial inflow, an extra-anatomic renal bypass surgery (EARBS) is an option. Anesthetic management of such procedures has not been described so far in the literature. We retrospectively analyzed the anesthetic techniques used in all patients who underwent EARBS between February 1998 and June 2008 at this institute. We also further analyzed data concerning blood pressure (BP) control and renal function response following surgery as outcome variable measures. A total of 11 patients underwent EARBS during this period. Five received oral clonidine with premedication. During laryngoscopy, esmolol was used in 4 patients, while lignocaine was used in remaining 7 patients. Of 11 patients, 7 showed significant hemodynamic response to laryngoscopy and intubation; among these, one had oral clonidine with premedicant, and 6 received lignocaine just before laryngoscopy. Intravenous vasodilators were used to maintain target BP within 20% of baseline during perioperative period. All patients received renal protective measures. During follow-up, 10% were considered cured, 70% had improved BP response, while 20% failed to show improvement in BP response. Renal functions improved in 54.5%, remain unchanged in 36.5%, and worsened in 9% of patients. Use of clonidine during premedication and esmolol before laryngoscopy were beneficial in attenuating hemodynamic response to laryngoscopy, while use of vasodilators to maintain target BP within 20% of baseline, and routine use of renal protective measures appear to be promising in patients undergoing EARBS. |
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Comparison of transthoracic electrical bioimpedance cardiac output measurement with thermodilution method in post coronary artery bypass graft patients |
p. 104 |
Vikas Sharma, Ajmer Singh, Bhuvnesh Kansara, Anil Karlekar DOI:10.4103/0971-9784.81564 PMID:21636930Transthoracic electrical bioimpedance (TEB) has been proposed as a non-invasive, continuous, and cost-effective method of cardiac output (CO) measurement. In this prospective, non-randomized, clinical study, we measured CO with NICOMON (Larsen and Toubro Ltd., Mysore, India) and compared it with thermodilution (TD) method in patients after off-pump coronary artery bypass (OPCAB) graft surgery. We also evaluated the effect of ventilation (mechanical and spontaneous) on the measurement of CO by the two methods. Forty-six post-OPCAB patients were studied at five predefined time points during controlled ventilation and at five time points when breathing spontaneously. A total of 230 data pairs of CO were obtained. During controlled ventilation, TD CO values ranged from 2.29 to 6.74 L/min (mean 4.45 ± 0.85 L/min), while TEB CO values ranged from 1.70 to 6.90 L/min (mean 4.43 ± 0.94 L/min). The average correlation (r) was 0.548 (P = 0.0002), accompanied by a bias of 0.015 L/min and precision of 0.859 L/min. In spontaneously breathing patients, TD CO values ranged from 2.66 to 6.92 L/min (mean 4.66 ± 0.76 L/min), while TEB CO values ranged from 3.08 to 6.90 L/min (mean 4.72 ± 0.82 L/min). Their average correlation was relatively poor (r = 0.469, P= 0.002), accompanied by a bias of −0.059 L/min and precision of 0.818 L/min. The overall percent errors between TD CO and TEB CO were 19.3% (during controlled ventilation) and 17.4% (during spontaneous breathing), respectively. To conclude, a fair correlation was found between TD CO and TEB CO measurements among post-OPCAB patients during controlled ventilation. However, the correlation was weak in spontaneously breathing patients. |
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CASE REPORTS |
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Pericardial tamponade after left posterolateral thoracotomy for left upper lobectomy for pulmonary aspergilloma |
p. 111 |
Praveen Kumar Neema, Hetal Shah, Manikandan Sethuraman, Ramesh Chandra Rathod DOI:10.4103/0971-9784.81565 PMID:21636931Pericardial tamponade limits diastolic filling of the heart; therefore, a high venous pressure is required to fill the ventricle. In presence of cardiac tamponade, therapeutic agents and manoeuvres that results in venodilation or vasodilation can severely compromise diastolic filling of the heart and might result in rapid cardiac decompensation. Equalization of central venous pressure and pulmonary artery diastolic pressure or equalization of pressures in all four chambers during diastole confirms cardiac tamponade. Transthoracic echocardiography can detect the site of tamponade and assist in pericardiocentesis. We describe acute pericardial tamponade in a young man who underwent left posterolateral thoracotomy for left upper lobectomy. Intraoperatively, mobilization of the left upper lobe was frequently associated with hypotension. Postoperatively, the patient suffered two more episodes of hypotension. The episodes of hypotension were attributed to surgical manipulation and epidural blockade. Hemodynamics normalized after discontinuing epidural infusion, volume resuscitation and lobectomy. On third postoperative day, the patient developed cardiovascular collapse; arterial blood pressure and central venous pressure were 70/50 and 12 mmHg. Investigations showed haziness of left lung, and severe respiratory acidosis. On opening of the left thoracotomy wound, pericardial tamponade was diagnosed. A pericardial window was created and tamponade was released with that the hemodynamics normalized. Episodes of unexplained hypotension after left upper lobectomy suggest a cardiac etiology and acute pericardial tamponade is a possibility which should be released immediately otherwise it can result in fatal outcome. |
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Anesthetic management for combined mitral valve replacement and aortic valve repair in a patient with osteogenesis imperfecta |
p. 115 |
Jiapeng Huang, Michelle Dinh, Nicholas Kuchle, Jing Zhou DOI:10.4103/0971-9784.81566 PMID:21636932Osteogenesis imperfecta is a rare disorder of connective tissues and presents multiple challenges, including difficult airway, hyperthermia, coagulopathy and respiratory dysfunction, for anesthesiologists, especially during cardiac surgery. We present anesthetic management of a patient with osteogenesis impertecta during double valve surgery. Dexmedetomidine infusion minimized the risks of malignant hyperthermia. Glidescope and in-line stabilization facilitated endotracheal intubation and protected his oral structures and cervical spine. Transesophageal echocardiography (TEE) diagnosed a flail A3 segment and redundant left coronary cusp causing mitral and aortic regurgitation. The mitral valve was replaced and the aortic valve repaired. Coagulopathy was corrected according to comprehensive coagulation analysis. Glidescope, dexmedetomidine, coagulation analysis and TEE could facilitate anesthetic management in these patients. |
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An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device |
p. 119 |
M Parikh, M Wong, J Farrimond DOI:10.4103/0971-9784.81567 PMID:21636933We report an unknown complication of peripherally inserted central venous catheter in a patient with Ventricular Assist Device. This rare complication led to the failure of the right ventricular assist device, which could be detrimental in patients with dilated cardiomyopathy. |
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Placement of an implantable cardioverter-defibrillator in an infant with congenital long QT syndrome: Anesthetic considerations |
p. 122 |
Bhuvnesh Kansara, Ajmer Singh, Sunil Kaushal, Anil Saxena DOI:10.4103/0971-9784.81568 PMID:21636934Sudden cardiac arrest (SCA) in children is a rare, but catastrophic event. Children with cardiac pathology at particular risk include those with congenital long QT syndrome (CLQTS) and hypertrophic cardiomyopathy. CLQTS is a genetic disorder of the cardiac ion channels and is associated with significant risk of malignant ventricular arrhythmias and SCA. For symptomatic, untreated patients, the mortality rate is approximately 20% for the first year and 50% at ten years. Use of an implantable cardioverter-defibrillator (ICD) is recommended for the prevention of SCA in this patient population. We report a case of CLQTS, who after successful resuscitation from SCA, underwent ICD placement at our center. |
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TUTORIALS |
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Perioperative hypotension and myocardial ischemia: Diagnostic and therapeutic approaches  |
p. 127 |
Amrik Singh, Joseph F Antognini DOI:10.4103/0971-9784.81569 PMID:21636935Although perioperative hypotension is a common problem, its true incidence is largely unknown. There is evidence that postoperative outcome, including the incidence of myocardial adverse events, may be linked to the prolonged episodes of perioperative hypotension. Despite this, there are very few comprehensive resources available in the literature regarding diagnosis and management of these not so uncommon clinical occurrences, especially during non-cardiac surgery. Most anesthesia providers consider intraoperative hypotension to be caused by systemic vasodilatation and relative hypovolemia and so treat it empirically. The introduction of new monitoring devices including transesophageal echocardiography and arterial pressure waveform based stroke volume measurement have provided additional tools to narrow the differential diagnoses and initiate optimal treatment measures. Understanding the basic pathophysiology of hypotension and myocardial ischemia can further assist in providing goal directed management. This article serves as a comprehensive guide for anesthesiologists to diagnose and treat hypotension and myocardial ischemia. A summary of available techniques to monitor perioperative myocardial ischemia and their limitations are also discussed. |
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Role of multimodality cardiac imaging in preoperative cardiovascular evaluation before noncardiac surgery |
p. 134 |
Ahmed Fathala, Walid Hassan DOI:10.4103/0971-9784.81570 PMID:21636936The preoperative cardiac assessment of patients undergoing noncardiac surgery is common in the daily practice of medical consultants, anesthesiologists, and surgeons. The number of patients undergoing noncardiac surgery worldwide is increasing. Currently, there are several noninvasive diagnostic tests available for preoperative evaluation. Both nuclear cardiology with myocardial perfusion single photon emission computed tomography (SPECT) and stress echocardiography are well-established techniques for preoperative cardiac evaluation. Recently, some studies demonstrated that both coronary angiography by gated multidetector computed tomography and stress cardiac magnetic resonance might potentially play a role in preoperative evaluation as well, but more studies are needed to assess the role of these new modalities in preoperative risk stratification. A common question that arises in preoperative evaluation is if further preoperative testing is needed, which preoperative test should be used. The preferred stress test is the exercise electrocardiogram (ECG). Stress imaging with exercise or pharmacologic stress agents is to be considered in patients with abnormal rest ECG or patients who are unable to exercise. After reviewing this article, the reader should develop an understanding of the following: (1) the magnitude of the cardiac preoperative morbidity and mortality, (2) how to select a patient for further preoperative testing, (3) currently available noninvasive cardiac testing for the detection of coronary artery disease and assessment of left ventricular function, and (4) an approach to select the most appropriate noninvasive cardiac test, if needed. |
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BRIEF COMMUNICATION |
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Antiphospholipid syndrome, cardiac surgery and cardiopulmonary bypass  |
p. 146 |
Vipul Krishen Sharma, Ravindra Chaturvedi, VSM Manoj Luthra DOI:10.4103/0971-9784.81571 PMID:21636937 |
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INTERESTING IMAGES |
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Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images |
p. 150 |
Mridu P Nath, Neeti Makhija, Usha Kiran, Naresh Dhawan, Devagourou Velayoudam DOI:10.4103/0971-9784.81572 PMID:21636938 |
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Unmasking of patent ductus arteriosus on cardiopulmonary bypass: Role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum |
p. 152 |
Suman Kandachar, Murali Chakravarthy, Jayaprakash Krishnamoorthy, Sharadaprasad Suryaprakash, Geetha Muniappa, Sourabh Pandey, Vivek Jawali, Joseph Xavier DOI:10.4103/0971-9784.81573 PMID:21636939 |
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LETTERS TO EDITOR |
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A simple method of electrocardiogram: Controlled central venous catheterization |
p. 154 |
R Raviraj, Grace Korula, Kandasamy Subramani, S Shalinicynthia DOI:10.4103/0971-9784.81574 PMID:21636940 |
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Dengue fever in a patient recovering from coronary artery bypass grafting |
p. 155 |
SKS Rawat, Yatin Mehta, Rajiv Juneja, Naresh Trehan DOI:10.4103/0971-9784.81575 PMID:21636941 |
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Post-extubation pulmonary edema after open cholecystectomy: Significance of diastolic cardiac dysfunction |
p. 156 |
Sameer Sethi, Virender Kumar Arya, Shelly Chauhan DOI:10.4103/0971-9784.81576 PMID:21636942 |
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Bipolar hip arthroplasty in an adult patient with uncorrected tetralogy of fallot: Anesthetic management |
p. 158 |
Ajmer Singh, Deepa Sarkar, Bhuvnesh Kansara, KK Sharma DOI:10.4103/0971-9784.81577 PMID:21636943 |
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Heart and ECMO: Are we ready? |
p. 161 |
Dilip Gude DOI:10.4103/0971-9784.81578 PMID:21636944 |
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Comparison of cardiac output estimation by FloTrac/Vigileo TM and intermittent pulmonary artery thermodilution in patient with Takayasu arteritis |
p. 163 |
Tanvir Samra, VK Arya DOI:10.4103/0971-9784.81579 PMID:21636945 |
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Artifactual ST segment depression induced by electrocautery |
p. 164 |
Amit Jain, Sohan L Solanki, Neeru Sahni, Arun Sharma DOI:10.4103/0971-9784.81580 PMID:21636946 |
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Pulsus alternans after aortic valve replacement: A preventable yet a possible risk of cardiac manipulation - Fact or Fiction? |
p. 165 |
Amit Jain DOI:10.4103/0971-9784.81581 PMID:21636947 |
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Authors' reply |
p. 166 |
Shrinivas Gadhinglajkar, Rupa Sreedhar, Aveek Jayant |
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To evaluate the heart or not in emergency neurosurgical head-injured patients with ST elevation: Authors' reply |
p. 167 |
Hemant Bhagat, Himanshu Chauhan, Hari H Dash DOI:10.4103/0971-9784.81585 PMID:21636948 |
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OBITUARY |
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Dr. Rajaratinam Karnan Kalyan Singh |
p. 169 |
Lailu Mathews |
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