Introduction: The concerns for induction of anaesthesia in patients undergoing cardiac surgery include hemodynamic stability, attenuation of stress response and maintenance of balance between myocardial oxygen demand and supply. Various Intravenous anaesthetic agents like Thiopentone, Etomidate, Propofol, Midazolam, and Ketamine have been used for anesthetizing patients for cardiac surgeries. However, many authors have expressed concerns regarding induction with thiopentone, midazolam and ketamine. Hence, Propofol and Etomidate are preferred for induction in these patients. However, these two drugs have different characteristics. Etomidate is preferred for patients with poor left ventricular (LV) function as it provides stable cardiovascular profile. But there are concerns about reduction in adrenal suppression and serum cortisol levels. Propofol, on the other hand may cause a reduction in systemic vascular resistance and subsequent hypotension. Thus, this study was conducted to compare induction with these two agents in cardiac surgeries. Methods: Baseline categorical and continuous variables were compared using Fisher's exact test and student's t test respectively. Hemodynamic variables were compared using student's t test for independent samples. The primary outcome (serum cortisol and blood sugar) of the study was compared using Wilcoxon Rank Sum test. The P value less than 0.05 was considered significant. Results: Etomidate provides more stable hemodynamic parameters as compared to Propofol. Propofol causes vasodilation and may result in drop of systematic BP. Etomidate can therefore be safely used for induction in patients with good LV function for CABG/MVR/AVR on CPB without serious cortisol suppression lasting more than twenty-four hours.

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Introduction: European system for cardiac operative risk evaluation (EuroSCORE) is a valuable tool in control of the quality of cardiac surgery. However, the validity of the risk score for the individual patient may be questioned. The present study was carried out to investigate whether the continued fall in short-term mortality reflects an actual improvement in late mortality, and subsequently, to investigate EuroSCORE as predictor of 1-year mortality. Methods: A population-based cohort study of 25,602 patients from a 12-year period from three public university hospitals undergoing coronary artery bypass grafting (CABG) or valve surgery. Analysis was carried out based on EuroSCORE, age and co-morbidity factors (residual EuroSCORE). Results: During the period the average age increased from 65.1 ± 10.0 years to 68.9 ± 10.7 years (P < 0.001, one-way ANOVA), and the number of females increased from 26.0% to 28.2% (P = 0.0012, Chi-square test). The total EuroSCORE increased from 4.67 to 5.68 while the residual EuroSCORE decreased from 2.64 to 1.83. Thirty-day mortality decreased from 4.07% in 1999-2000 to 2.44% in 2011-2012 (P = 0.0056; Chi-square test), while 1-year mortality was unchanged (6.50% in 1999-2000 vs. 6.25% in 2011-2012 [P = 0.8086; Chi-square test]). Discussion: The study demonstrates that both co-morbidity and age has a great impact on 30-day mortality. However, with time the impact of co-morbidity seems less. Thus, age is more important than co-morbidity in late mortality. The various developments in short and long-term mortality are not readily explained. Conclusion: Although 30-day mortality of CABG and valve surgery patients has decreased during the 12-year period, the 1-year mortality remains the same.

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Background: Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity and has been found to be as high as 30-56%. Aim: To review the management of such patients in a tertiary center over a 15 year period, as the current literature consists of a few case reports, a few small case series and 2 meta-analyses. Materials and Methods: A review of all patients admitted to our institution for management of PH in pregnancy between 1994 and February 2009 was undertaken. Cases were identified from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records. Severity of PH, type of PH, NYHA functional status at presentation and delivery, mode of delivery, peripartum monitoring and APGAR scores were noted. Patients were reviewed by a multidisciplinary team and management planned accordingly. Results: 19 eligible patients were identified. Patients who were significantly sick due to their PH were aggressively managed during pregnancy. Overall there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operatively delivery seem to be the ideal choice. Conclusion: Multidisciplinary approach is a key to the successful management of these patients. Secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality.

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Ketamine is a unique anesthetic drug that provides analgesia, hypnosis, and amnesia with minimal respiratory and cardiovascular depression. Because of its sympathomimetic properties it would seem to be an excellent choice for patients with depressed ventricular function in cardiac surgery. However, its use has not gained widespread acceptance in adult cardiac surgery patients, perhaps due to its perceived negative psychotropic effects. Despite this limitation, it is receiving renewed interest in the United States as a sedative and analgesic drug for critically ill-patients. In this manuscript, the authors provide an evidence-based clinical review of ketamine use in cardiac surgery patients for intensive care physicians, cardio-thoracic anesthesiologists, and cardio-thoracic surgeons. All MEDLINE indexed clinical trials performed during the last 20 years in adult cardiac surgery patients were included in the review.

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Background: Extracorporeal membrane oxygenation (ECMO) is a complex treatment. Despite this, there are a lack of training programs designed to develop relevant clinical and nonclinical skills required for ECMO specialists. The aim of the current study was to describe the design, implementation and evaluation of a 1-day simulation course for delivering training in ECMO. Methods: A 1-day simulation course was developed with educational and intensive care experts. First, the delegates received a lecture on the principles of simulation training and the importance of human factors. This was, followed by a practical demonstration and discussion of the ECMO circuit, console components, circuit interactions effects and potential complications. There were then five ECMO simulation scenarios with debriefing that covered technical and nontechnical issues. The course culminated in a knowledge-based assessment. Course outcomes were assessed using purpose-designed questionnaires. Results: We held 3 courses with a total of 14 delegates (9 intensive care nurses, 3 adult intensive care consultants and 2 ECMO technicians). Following the course, 8 (57%) gained familiarity in troubleshooting an ECMO circuit, 6 (43%) increased their familiarity with the ECMO pump and circuit, 8 (57%) perceived an improvement in their communication skills and 7 (50%) perceived an improvement in their leadership skills. At the end of the course, 13 (93%) delegates agreed that they felt more confident in dealing with ECMO. Conclusions: Simulation-training courses may increase knowledge and confidence in dealing with ECMO emergencies. Further studies are indicated to determine whether simulation training improves clinical outcomes and translates to reduced complication rates in patients receiving ECMO.

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Increasing numbers of adult patients with complex congenital heart conditions are presenting for noncardiac surgery later in life. These disorders can present challenges for surgical and anesthesia providers. Specifically, single ventricle lesions offer anatomic and physiologic concerns during the perioperative period. Single ventricle physiology represents a delicate balance between systemic and pulmonary blood flow. Any alterations in blood flow through these systems can produce undesirable hemodynamic changes, especially during the perioperative period. We present a case of an adult patient with a single left ventricle who presented for laparoscopic total colectomy due to inflammatory bowel disease. His abnormal anatomy coupled with the hemodynamic disruptions caused by laparoscopy presented significant anesthetic challenges. We highlight the anesthetic concerns of single ventricle physiology, specifically pertaining to laparoscopic surgery. We provide recommendations for safely managing these patients perioperatively. With detailed preoperative evaluation and close hemodynamic monitoring during the perioperative period, these patients can experience successful surgical and anesthetic outcomes.

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Fast-track extubation is an established safe practice in pediatric congenital heart disease (CHD) surgical patients. On table extubation (OTE) in acyanotic CHD surgical patients is well established with validated safety profile. This practice is not yet reported in tetralogy of Fallot (TOF) cardiac surgical repair patients in developing countries. Evidence suggests that TOF total correction patients should be extubated early, as positive pressure ventilation has a negative impact on right ventricular function and the overall increase in post-TOF repair complications such as low cardiac output state and arrhythmias. The objective of the case series was to determine the safety and feasibility of OTE in elective TOF total correction cardiac surgical patients with an integrated team approach. To the best of our knowledge, this is the first reported case series. A total of 8 elective male and female TOF patients were included. Standard anesthetic, surgical and perfusion techniques were used in these procedures. All patients were extubated in the operating room safely without any complications with the exception of one patient who continued to bleed for 3 h of postextubation at 2-3 ml/kg/h which was managed with transfusion of fresh frozen plasma at 15 mL/kg, packed red blood cells 10 mL/kg and bolus of transamine at 20 mg/kg. Apart from better surgical and bypass techniques, the most important factor leading to successful OTE was an excellent analgesia. On the basis of the case series, it is suggested to extubate selected TOF cardiac surgery repair patients on table safely with integrated multidisciplinary approach.

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Background: Transapical off-pump mitral valve intervention with neochord implantation for degenerative mitral valve disease have been recently introduced in the surgical practice. The procedure is performed under 2D-3D transesophageal echocardiography guidance. Methods: The use of 3D real-time transesophageal echocardiography provides more accurate information than 2D echocardiography only in all the steps of the procedure. In particular 3D echocardiography is mandatory for preoperative assessment of the morphology of the valve, for correct positioning of the neochord on the diseased segment , for the final tensioning of the chordae and for the final evaluation of the surgical result. Result and Conclusion: This article is to outline the technical aspects of the transesophageal echocardiography guidance of the NeoChord procedure showing that the procedure can be performed only with a close and continuous interaction between the anesthesiologist and the cardiac surgeon.

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Anaphylactic shock is a life-threatening condition which needs detailed and mediculous clinical assessment and thoughtful treatment. Several causes can join forces in order to degranulate mast cells. Amiodarone which is an iodine-containing highly lipophilic benzofuran can induce allergic reactions and anaphylactic shock in sensitized patients. Epinephrine is a life saving drug, but in sulfite allergic patients it should be given with caution due its metabisulfite preservative. Metals covering cardiac defibrillators and pacemakers can act as antigens attached to serum proteins and induce allergic reactions. In anaphylactic shock, myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Clinically, combined treatment targeting the primary cause of anaphylaxis together with protection of cardiac tissue seems to be of paramount importance.

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Intimo-intimal intussusception is a very rare and unusual complication of type A dissections, typically noted on  TEE exam. It has been reported in a few cases in the cardiothoracic surgical and radiology literature, and even more rarely in the cardiac anesthesia/TEE literature. This uncommon variation occurs in severe, acute, type A dissections when the ascending aortic intima circumferentially strips and detaches from the media and forms a tube-like structure which may either prolapse antegrade into the ascending aortic lumen or retrograde into the left ventricular (LV) outflow tract and LV cavity. Antegrade intussusceptions may be severe enough to partially or completely occlude the ostia of the innominate, left common carotid, and left subclavian arteries producing acute neurologic symptoms. Retrograde intussusceptions may severely impair LV filling in diastole, can worsen aortic insufficiency, mitral regurgitation, as well as produce occlusion of the coronary ostia and acute coronary ischemia. Here, we describe the incidental finding of a retrograde intussusception that was not visualized on computed tomography scan but by intraoperative TEE examination, in a patient with a severe, extensive type A dissection.

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We are presenting the case of a 76-year-old female scheduled for major abdominal surgery. Her past medical history was remarkable for a three-vessel coronary artery disease, with a severely impaired left ventricular function. She had already undergone complex coronary artery bypass surgery. Currently, she presented with the rare constellation of a hemodynamic relevant and interventionally intractable stenosis of the left subclavian artery proximal to a crucial coronary bypass from left internal mammary artery to the left anterior descending. To protect this patient from perioperative myocardial infarction, an intra-aortic balloon pump was successfully used.

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Current technique of airway management for impaled knife in the back includes putting the patient in lateral position and intubation. We present here a novel technique of anesthesia induction (intubation and central line insertion) in a patient with impaled knife in the back which is simple and easily reproducible. This technique can be used for single lung ventilation using double lumen tube or bronchial blocker also if desired.

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Background: Identifying infections early, commencing appropriate empiric antibiotic not only helps gain control early, but also reduces mortality and morbidity. Conventional cultures take about 5 days to identify infections. To identify the infections early biomarker like serum procalcitonin (SPC). Aims: We studied the correlation of an elevated level of SPC and positive culture in elective adult patients undergoing cardiac surgery. Methods: This prospective study was conducted from January to December 2013. SPC was checked in patients showing evidence of sepsis. Simultaneously, relevant culture was also undertaken. Correlation, specificity, and sensitivity of elevated SPC were checked. Results: A total of 819 adult patients were included in the study. 43 of them had signs of infection and SPC levels were checked. Based on the level of SPC criteria, 10 patients were diagnosed as "nil", out of them, 4 had culture-positive infections, 17 were suggested to have "mild infection," 3 out those had culture positivity. None among the eleven patients suggested to have "moderate infection," had a positive culture, and one among the five suggested to have a severe infection had a positive culture. The sensitivity was 50% and the specificity 17%. The positive predictive value was 12% and the negative predictive value 60%. Conclusions: We failed to elicit positive correlation between elevated SPC levels and postoperative infection in cardio surgical patients.

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Aims and Objectives: To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario. Materials and Methods: A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the sub-groups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer-Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis. Results: The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer-Lemeshow statistic was <0.05 for the total data and also within the sub-groups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62-0.77) and when tested separately, it was 0.73 (0.64-0.81) for CABG, 0.79 (0.63-0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26-0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR] - 1.7), preoperative intra-aortic balloon pump (OR - 10.7), combined procedures (OR - 5.1), dialysis dependency (OR - 23.4), and re-operation (OR - 9.4). Conclusions: The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.

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Objectives: To compare the effects of propofol and nitroglycerine (NTG) on the efficacy of rewarming, extra volume added during cardiopulmonary bypass and extravascular lung water (EVLW) in patients undergoing on-pump coronary artery bypass grafting. Materials and Methods: A prospective, randomized, blinded trial, twenty adult patients were randomly assigned to receive either NTG infusion (NTG group) or propofol infusion (propofol group) during rewarming. Results: After drop in temperature at the end of surgery and till 24 h were significantly less in propofol group compare to NTG group (P < 0.025). Extra volume added during cardiopulmonary bypass and net crystalloid balance till 24 h was less in the propofol group (P < 0.003). There was no difference in EVLW and postoperative outcome. Conclusions: Propofol use during moderate hypothermic cardiopulmonary bypass is associated with less after drop in temperature and less requirement of extra fluid during the perioperative period.

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Truncus arteriosus (TA) is a rare congenital heart disease defined as a single arterial vessel arising from the heart that gives origin to the systemic, pulmonary and coronary circulations. The truncal valve in majority of the cases is tricuspid though quadricuspid and bicuspid valves have been reported. Patients with TA typically have a large nonrestrictive sub truncal ventricular septal defect. Survival of these infants beyond 1-year is uncommon. Here, we report a unique case of 12-year-old female patient with persistent TA who underwent surgical repair by using transesophageal echocardiography as a monitoring device during the perioperative management.

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Transcatheter valve implantation continues to grow worldwide and has been used principally for the nonsurgical management of native aortic valvular disease-as a potentially less invasive method of valve replacement in high-risk and inoperable patients with severe aortic valve stenosis. Given the burden of valvular heart disease in the general population and the increasing numbers of patients who have had previous valve operations, we are now seeing a growing number of high-risk patients presenting with prosthetic valve stenosis, who are not potential surgical candidates. For this high-risk subset transcatheter valve delivery may be the only option. Here, we present an inoperable patient with severe, prosthetic valve aortic and mitral stenosis who was successfully treated with a trans catheter based approach, with a valve-in-valve implantation procedure of both aortic and mitral valves.

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Thromboembolism continues to be a major concern in patients with mechanical heart valves, especially in those with unsatisfactory anticoagulation levels. The new On-X valve (On-X Life Technologies, Austin, TX, USA) has been reported as having unique structural characteristics that offer lower thrombogenicity to the valve. We report a case where the patient received no or minimal systemic anticoagulation after placement of On-X mitral and aortic valves due to development of severe mucosal arterio-venous malformations yet did not show any evidence of thromboembolism. This case report reinforces the findings of recent studies that lower anticoagulation levels may be acceptable in patients with On-X valves and suggests this valve may be particularly useful in those in whom therapeutic levels of anticoagulation cannot be achieved due to increased risk of bleeding.

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Background: Use of the Tei index has not been described to assess myocardial function before or after surgery in pediatric patients. This study was designed to evaluate the left ventricular (LV) function using the Tei index pre- and post-cardiopulmonary bypass in patients with lesion that result in a volume loaded right ventricle (RV). Methods: Retrospective data on 55 patients who underwent repair of a cardiac defect were analyzed. Patients with volume overload RV (n = 15) were compared to patients without volume overload but with other cardiac defects (n = 40). We reviewed pre- and post-operative LV myocardial performance index (Tei index). Tei index was obtained from transesophageal Doppler echocardiogram. Results: Patients with right heart volume overload, the mean preoperative Tei index was 0.6, with a postoperative mean decrease of 0.207 (P = 0.014). Patients without right heart volume overload, the mean preoperative Tei was 0.48 with no significant postoperative change (P = 0.82). Conclusion: Pre- and post-operative transesophageal echocardiogram assessment provides an easy and quick way of evaluating LV function intra-operatively using LV Tei index. Preoperative LV Tei index was greater in the RV volume overload defects indicating diminished LV global function. This normalized in the immediate postoperative period, implying an immediate improvement in LV function. In patients without right heart volume load, consist of other cardiac defects, demonstrated no changes in the pre- and post-operative LV Tei. This implies that LV function was similar after the surgery.

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Objective: The purpose of our study was to determine the effect of induced apnea on quality of cardiopulmonary structures during computerized tomographic (CT) angiography images in children with congenital heart diseases. Methods: Pediatric patients with congenital heart defects undergoing cardiac CT angiography at our facility in the past 3 years participated in this study. The earlier patients underwent cardiac CT angiography without induced apnea and while, later, apnea was induced in patients, which was followed by electrocardiogram gated cardiac CT angiography. General anesthesia was induced using sleep dose of intravenous propofol. After the initial check CT, on request by the radiologist, apnea was induced by the anesthesiologist by administering 1 mg/kg of intravenous suxamethonium. Soon after apnea ensued, the contrast was injected, and CT angiogram carried out. CT images in the "apnea group" were compared with those in "nonapnea group." After the completion of the procedure, the patients were mask ventilated with 100% oxygen till the spontaneous ventilation was restored. Results: We studied 46 patients, of whom 36 with apnea and yet another 10 without. The quality of the image, visualization of structures such as cardiac wall, outflow tracts, lung field, aortopulmonary shunts, and coronary arteries were analyzed and subjected to statistical analysis (Mann-Whitney U, Fischer's exact test and Pearson's Chi-square test). In the induced apnea group, overall image quality was considered excellent in 89% (n = 33) of the studies, while in the "no apnea group," only 30% of studies were excellent. Absent or minimal motion artifacts were seen in a majority of the studies in apnea group (94%). In the nonapnea group, the respiratory and body motion artifacts were severe in 50%, moderate in 30%, and minimal in 20%, but they were significantly lesser in the apnea group. All the studied parameters were statistically significant in the apnea group in contrast to nonapnea group (P < 0.000). Conclusion: The image quality of cardiac CT angiography greatly improves, and motion artifact significantly decreases with the use of induced apnea in pediatrics patients being evaluated for congenital heart disease. This technique poses no additional morbidity of significance.

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