Introduction: Ventricular dysfunction requiring inotropic support frequently occurs after cardiac surgery, and the associated low cardiac output syndrome largely contributes to postoperative death. We aimed to study the incidence and potential risk factors of postcardiotomy ventricular dysfunction (PCVD) in moderate-to-high risk patients scheduled for open-heart surgery. Methods: Over a 5-year period, we prospectively enrolled 295 consecutive patients undergoing valve replacement for severe aortic stenosis or coronary artery bypass surgery who presented with Bernstein-Parsonnet scores >7. The primary outcome was the occurrence of PCVD as defined by the need for sustained inotropic drug support and by transesophageal echography. The secondary outcomes included in-hospital mortality and the incidence of any major adverse events as well as Intensive Care Unit (ICU) and hospital length of stay. Results: The incidence of PCVD was 28.4%. Patients with PCVD experienced higher in-hospital mortality (12.6% vs. 0.6% in patients without PCVD) with a higher incidence of cardiopulmonary and renal complications as well as a prolonged stay in ICU (median + 2 days). Myocardial infarct occurred more frequently in patients with PCVD than in those without PCVD (19 [30.2%] vs. 12 [7.6%]). By logistic regression analysis, we identified four independent predictors of PCVD: left ventricular ejection fraction <40% (odds ratio [OR] = 6.36; 95% confidence interval [CI], 2.59–15.60), age older than 75 years (OR = 3.35; 95% CI, 1.64–6.81), prolonged aortic clamping time (OR = 3.72; 95% CI, 1.66–8.36), and perioperative bleeding (OR = 2.33; 95% CI, 1.01–5.41). The infusion of glucose-insulin-potassium was associated with lower risk of PCVD (OR = 0.14; 95% CI, 0.06–0.33). Conclusions: This cohort study indicates that age, preoperative ventricular function, myocardial ischemic time, and perioperative bleeding are predictors of PCVD which is associated with poor clinical outcome.

Background: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality, and economic burden. In this study, we assessed the usefulness of estimating serum neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker in predicting AKI in patients with stable chronic kidney disease (CKD) and undergoing off-pump coronary artery bypass grafting (OP-CABG). Patients and Methods: We prospectively studied sixty nondialysis-dependent CKD patients with estimated glomerular filtration rate <60 ml/min/1.73 m² who required elective OP-CABG. Patients were randomized into two groups, Group D received dopamine infusion at 2 μg/kg/min following anesthesia induction till the end of the surgery and Group P did not receive any intervention. Serum creatinine, NGAL, brain natriuretic peptide, and troponin-I were estimated at specified intervals before, during, and after surgery. The results of the study patients were also compared to a simultaneous matched cohort control of thirty patients (Group A) without renal dysfunction who underwent OP-CABG. Results: No patient required renal replacement therapy, and no mortality was observed during perioperative and hospitalization period. Six patients from control group (n = 30), ten patients from placebo group (n = 30), and 12 patients from dopamine group (n = 30) developed stage 1 AKI. However, we did not observe any stage 2 and stage 3 AKI among all the groups. There was a significant increase in serum NGAL levels at the end of surgery and 24 h postoperatively in placebo and dopamine groups as compared to the control. Conclusion: The measurement of NGAL appears to predict the occurrence of AKI after OP-CAB surgery. However, large multicentric studies may be required to confirm the findings of this study.

Background: Patients' beliefs about the cause of cardiac disease (perceived risk factors) as part of the global psychological presentation are influenced by patients' health knowledge. Hence, the present study aimed to assess the relationship between actual and perceived risk factors, identification of underestimated risk factors, and indication of underestimation of every risk factor. Materials and Methods: In this cross-sectional study, data of 313 coronary artery bypass graft (CABG) patients admitted to one hospital in the west of Iran were collected through a demographic interview, actual risk factors' checklist, open single item of perceived risk factors, and a life stressful events scale. Data were analyzed by means of Spearman's correlation coefficients and one-sample Z-test for proportions. Results: Although there are significant relations between actual and perceived risk factors related to hypertension, family history, diabetes, smoking, and substance abuse (P < 0.05), there is no relation between the actual and perceived risk factors, and patients underestimate the role of actual risk factors in disease (P < 0.001). The patients underestimated the role of aging (98.8%), substance abuse (95.2%), overweight and obesity (94.9%), hyperlipidemia (93.1%), family history (90.3%), and hypertension (90%) more than diabetes (86.1%), smoking (72.5%), and stress (54.7%). Conclusion: Cardiac patients seem to underestimate the role of aging, substance abuse, obesity and overweight, hyperlipidemia, family history, and hypertension more than other actual risk factors. Therefore, these factors should be highlighted to patients to help them to (i) increase the awareness of actual risk factors and (ii) promote an appropriate lifestyle after CABG surgery.

Background: Arytenoid cartilage dislocation/subluxation is one of the rare complications following tracheal intubation, and there have been no reports about risk factors leading this complication. From our clinical experience, we have an impression that patients undergoing cardiovascular operations tend to be associated with this complication. Aims: We designed a large retrospective study to reveal the incidence and risk factors predicting the occurrence and to examine whether our impression is true. Settings and Designs: This was a retrospective study. Methods: We retrospectively studied 19,437 adult patients who were intubated by an anesthesiologist in our operation theater from 2002 to 2008. The tracheal intubation was performed by a resident anesthesiologist managing the patients. Only patients whose postoperative voice was disturbed more than 7 days were referred to the Department of Otorhinolaryngology-Head and Neck Surgery and examined using laryngostroboscopy by a laryngologist to diagnose arytenoid cartilage dislocation/subluxation. We evaluated age, sex, weight, height, duration of intubation, difficult intubation, and major cardiovascular operation as risk factors to lead this complication. Statistical Analysis: The data were analyzed by logistic regression analysis to assess factors for arytenoid cartilage dislocation/subluxation after univariate analyses using logistic regression analysis. Results: Our analysis indicated that difficult intubation (odds ratio: 12.1, P = 0.018) and cardiovascular operation (odds ratio: 9.9, P < 0.001) were significant risk factors of arytenoid cartilage dislocation/subluxation. Conclusion: The present study demonstrated that major cardiovascular operation is one of the significant risk factors leading this complication.

Objective: The study was done to compare propofol and ketofol for sedation of pediatric patients scheduled for elective pulmonary valve implantation in a catheterization laboratory. Design: This was a double-blind randomized study. Setting: This study was conducted in Prince Sultan Cardiac Centre, Saudi Arabia. Patients and Methods: The study included 60 pediatric patients with pulmonary regurge undergoing pulmonary valve implantation. Intervention: The study included sixty patients, classified into two groups (n = 30). Group A: Propofol was administered as a bolus dose (1–2 mg/kg) and then a continuous infusion of 50–100 μg/kg/min titrated as needed. Group B: Ketofol was administered 1–2 mg/kg and then infusion of 20–60 μg/kg/min. The medication was prepared by the nursing staff and given to anesthetist blindly. Measurements: The monitors included heart rate, mean arterial blood pressure, respiratory rate, temperature, SPO₂and PaCO₂, Michigan Sedation Score, fentanyl dose, antiemetic medications, and Aldrete score. Main Results: The comparison of heart rate, mean arterial pressure, respiratory rate, temperature, SPO₂and PaCO₂, Michigan Sedation Score, and Aldrete score were insignificant (P > 0.05). The total fentanyl increased in Group A more than Group B (P = 0.045). The required antiemetic drugs increased in Group A patients more than Group B (P = 0.020). The durations of full recovery and in the postanesthesia care unit were longer in Group A than Group B (P = 0.013, P < 0.001, respectively). Conclusion: The use of propofol and ketofol is safe and effective for sedation of pediatric patients undergoing pulmonary valve implantation in a catheterization laboratory. However, ketofol has many advantages more than the propofol. Ketofol has a rapid onset of sedation, a rapid recovery time, decreased incidence of nausea and vomiting and leads to rapid discharge of patients from the postanesthesia care unit.

Background: Pulmonary hypertension secondary to congenital heart disease is a common problem in pediatric patients presenting for open heart surgery. Milrinone has been shown to reduce pulmonary vascular resistance and pulmonary artery pressure in pediatric patients and neonates postcardiac surgery. We aimed to evaluate the postoperative outcome in such patients with three different fixed maintenance doses of milrinone. Methodology: Patients were randomized into three groups. All patients received fixed bolus dose of milrinone 50 μg/kg on pump during rewarming. Following this, patients in low-dose group received infusion of milrinone at the rate of 0.375 μg/kg/min, medium-dose group received 0.5 μg/kg/min, and high-dose group received 0.75 μg/kg/min over 24 h. Heart rate, mean arterial pressure (MAP), mean airway pressure (MaP), oxygenation index (OI), and central venous pressure (CVP) were compared at baseline and 24 h postoperatively. Dose of inotropic requirement, duration of ventilatory support and Intensive Care Unit (ICU) stay were noted. Results: MAP, MaP, OI, and CVP were comparable in all three groups postoperatively. All patients in the low-dose group required low inotropic support while 70% of patients in the high-dose group needed high inotropic support to manage episodes of hypotension (P = 0.000). Duration of ventilatory support and ICU stay in all three groups was comparable (P = 0.412, P = 0.165). Conclusion: Low-dose infusions while having a clinical impact were more beneficial in avoiding adverse events and decreasing inotropic requirement without affecting duration of ventilatory support and duration of ICU stay.

The systemic to pulmonary artery shunts are done as palliative procedures for cyanotic congenital heart diseases ranging from simple tetralogy of Fallots (TOFs)/pulmonary atresia (PA) to complex univentricular hearts. They allow growth of pulmonary arteries and maintain regulated blood flow to the lungs till a proper age and body weight suitable for definitive corrective repair is reached. We have reviewed the BT shunt with its anaesthtic considerations and management of associated complications.

We present the case of a 65-year-old male who presented with stable angina and dyspnea on exertion. His initial workup yielded a positive treadmill stress test for reversible apical ischemia, and transthoracic echocardiogram demonstrated impaired systolic function. Cardiac catheterization was then performed, revealing severe atherosclerotic disease including multiple coronary artery aneurysms. As a result, the patient was advised to and subsequently underwent a coronary artery bypass graft. This case highlights the presence of multiple coronary artery aneurysms and the ability to appreciate these pathologic findings on multiple imaging modalities, including coronary angiogram, transesophageal echocardiography, and direct visualization through the surgical field.

Malposition of venous cannula can cause inadequate venous drainage during cardiopulmonary bypass. It would be good clinical practice to use TEE to check the position of inferior venous cannula to avoid this problem at the earliest.

Congenital high airway obstruction (CHAOS) is a rare lethal fetal malformation characterised by obstruction to the fetal upper airway, which can be partial or complete. Antenatal diagnosis of CHAOS is important due to recent management options. Diagnosis is made with secondary changes such as hyperechoic enlarged lungs resulting in mediastinal compression, ascites, hydrops, flattened or everted diaphragms and dilated distal airways. We reported a case of CHAOS, antenatally on ultrasonography (USG) at 20 weeks of gestation.

Introduction: Propofol may lead to patient recall and discomfort when used for sedation in elective cardioversion. The aim of the present study was to evaluate dexmedetomidine as an additive to propofol for sedation in elective cardioversion. Materials and Methods: A total of 500 patients undergoing elective cardioversion were randomized into Group 1 (n = 250) and Group 2 (n = 250) on the basis of computer-generated randomization table. Patients in Group 1 were given dexmedetomidine (1 mcg/kg) over 10 min before giving propofol (1 mg/kg), while patients in Group 2 were given only propofol (1 mg/kg). One or two additional doses of 0.5 mg/kg propofol were given if modified Ramsay Sedation Score (mRSS) was <5. Number of patients requiring additional doses were noted. Any hemodynamic or respiratory complication along with the mean time to recovery (mRSS = 1) was recorded. Patient recall, patient discomfort, and further requirement of cardioversion in the next 24 h were also noted. Results: About 10% patients in Group 1 and 64% patients in Group 2 required the first additional dose of propofol. While no patient in Group 1 required second dose, 16% patients in Group 2 required second dose of propofol. The mean time to recovery in Group 1 was 8.36 ± 3.08 min and 8.22 ± 2.38 min in Group 2 (P = 0.569). Sixty-seven patients (26.8%) in Group 1 and 129 patients (51.6%) in Group 2 reported remembering something (P < 0.0001), i.e., recall. Thirty-five patients (14%) in Group 1 and 79 patients (31.6%) in Group 2 reported dreaming during the procedure (P < 0.0001). Visual analog scale score was higher in Group 1 as compared to Group 2. Six patients in Group 1 and 24 patients in Group 2 had a requirement of repeat cardioversion in 24-h follow-up (P = 0.001). Conclusions: Dexmedetomidine is a useful adjunct to propofol for elective cardioversion.

We are reporting two cases of neck and arm major venous thrombosis in patients of posttubercular chronic constrictive pericarditis posted for pericardectomy. There was unanticipated difficulty in placement of Internal Jugular vein catheter and subsequent ultrasound revealed thrombosis in the major veins. It was not diagnosed in the preoperative period. This report raises this major complication and highlights the use of ultrasound in such scenarios.

Congenital coronary artery fistula is an uncommon anomaly. Transcatheter coil embolization or Amplatzer vascular plug device closure of fistula is often done in symptomatic patients with safe accessibility to the feeding coronary artery. Embolization of Amplatzer vascular plug device is rare. We report an 11-year-old male child who presented to us with increasing shortness of breath for 7 years. He had a history of Amplatzer vascular plug device closure of right coronary–cameral fistula 8 years back. Echocardiography demonstrated a dilated aneurysmal right coronary artery with turbulent jet entering into the right ventricle (RV) and device embolized into the left pulmonary artery (LPA). Cardiac catheterization eventually confirmed the diagnosis. Surgical closure of fistula and retrieval of device was done using cardiopulmonary bypass. Intraoperatively transesophageal echocardiogram helped in localizing fistula opening in the RV below the anterior leaflet of tricuspid valve, continuous monitoring to prevent further distal embolization of the device during surgical handling, and assessment of completeness of repair of the fistula and LPA following retrieval of the device.

Silicone tracheobronchial stents are being increasingly used in a large number of patients for the treatment of tracheal stenosis. One very rare complication due to tracheobronchial stenting is bronchoesophageal fistula (BEF), which has been associated with the use of metallic stents. We report intraoperative management of a patient undergoing repair of a BEF, following previous insertion of a silicone Y-stent that is soft in texture and has not been implicated for this complication till date. In addition, misalignment of this silicone tracheobronchial Y-stent resulted in a tracheal mucosal bulge proximal to the stent that vanished after its removal.

Large posterior mediastinal masses may lead threatening complications such as critical tracheobronchial compression. Airway management in these individuals is a challenge and being a lower airway obstruction; rescue strategies are limited. We encountered one such case of a large esophageal mucocele causing extrinsic tracheobronchial compression. We have described the anesthetic management of this case using awake fiber-optic assessment followed by intubation. Close communication with the surgical team, meticulous planning of airway management, and early drainage of the mucocele are the cornerstones of management in such patients.

Tracheal stenosis in association with the double aortic arch (DAA) is uncommon; however, it carries a high risk of morbidity, mortality, and restenosis. Although surgery is the mainstay of managing a case of the DAA with tracheal stenosis, management of tracheal restenosis requires a multidisciplinary approach. In this case report, we present our successful experience in managing a child of DAA with tracheal stenosis who developed tracheal restenosis after sliding tracheoplasty of trachea.

We report a case of 18-year-old female patient with large patent ductus arteriosus (PDA)-preductal coarctation of descending thoracic aorta. She underwent large PDA closure with a prosthetic graft from ascending aorta to descending thoracic aorta by mid-sternotomy on cardiopulmonary bypass machine under total hypothermic circulatory arrest.

Idarucizumab before cardiopulmonary bypass was used for the reversal of dabigatran during an emergent frozen elephant trunk repair of a transverse arch aneurysm. Reversal was successful and minimal not massive transfusion was required with no abnormal sequelae seen with use before cardiopulmonary bypass.

Congenital coronary artery anomalies as a whole are uncommon. Abnormal origin of the left coronary artery from the pulmonary artery (ALCAPA) is probably the most common congenital coronary defect. An overwhelming majority of the patients with untreated ALCAPA do not survive to adulthood. As yet, there is no consensus on the management of adults with ALCAPA. We describe a patient with breast malignancy and incidentally detected ALCAPA; primacy was given to treatment of the oncologic condition as a first step. Anesthesia management was focused on maintaining adequate collateral coronary perfusion and avoidance of excessive loading of the left ventricle. This was achieved using a simplified transthoracic echocardiography (TTE) protocol at the time of induction of anesthesia; TTE was also used to reconfirm the absence of disturbances in myocardial function at the end of surgery. We sugggest the routine use of tte in managing perioperative care in low resource settings when the underlying cardiac disease is rare and the evidence base if often insufficient.

Sugammadex is a novel agent for the reversal of neuromuscular blockade. The speed and efficacy of reversal with sugammadex are significantly faster than acetylcholinesterase inhibitors, such as neostigmine. Sugammadex also has a limited adverse profile when compared with acetylcholinesterase inhibitors, specifically in regard to the incidence of bradycardia. This adverse effect may be particularly relevant in the setting of a heart transplant recipient with a denervated heart. The authors present a case of an 8-year-old child, status postcardiac transplantation, who required anesthetic care for laparoscopy and lysis of intra-abdominal adhesions. Sugammadex was used to reverse neuromuscular blockade and avoid the potential adverse effects of neostigmine. The unique mechanism of action of sugammadex is discussed, previous reports of its use in this unique patient population are reviewed, and its potential benefits compared to traditional acetylcholinesterase inhibitors are presented.

Pulmonary Artery banding (PAB) is limited to selected patients who cannot undergo primary repair due to complex anatomy, associated co-morbidities, as a part of staged univentricular palliation, and for preparing the left ventricle prior to an arterial switch operation. We report a catastrophic iatrogenic complication in which the pulmonary artery was injured during the PAB. We discuss its multi-pronged management.