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2015| July-September | Volume 18 | Issue 3
Online since
July 1, 2015
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ORIGINAL ARTICLES
Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: A prospective randomized controlled study
Shankar V Kadam, Kamlesh B Tailor, Snehal Kulkarni, Smrutiranjan R Mohanty, Preetha V Joshi, Suresh G Rao
July-September 2015, 18(3):323-328
DOI
:10.4103/0971-9784.159801
PMID
:26139736
Introduction:
Incidence of junctional ectopic tachycardia (JET) after repair of tetralogy of Fallot (TOF) is 5.6-14%. Dexmeditomidine is a a-2 adrenoceptor agonist modulates the release of catecholamine, resulting in bradycardia and hypotension. These effects are being explored as a therapeutic option for the prevention of perioperative tachyarrhythmia. We undertook this study to examine possible preventive effects of dexmedetomidine on postoperative JET and its impact on the duration of ventilation time and length of Intensive Care Unit stay.
Methods:
After obtaining approval from the hospitals ethics committee and written informed consent from parents, this quasi-randomized trial was initiated. Of 94 patients, 47 patients received dexmedetomidine (dexmedetomidine group) and 47 patients did not receive the drug (control group).
Results:
Dexmedetomidine group had more number of complex variants like TOF with an absent pulmonary valve or pulmonary atresia (
P
= 0.041). Hematocrit on cardiopulmonary bypass (CPB), heart rate while coming off from CPB and inotrope score was significantly low in the dexmedetomidine group compared to control group. The incidence of JET was significantly low in dexmedetomidine group (
P
= 0.040) compared to control group.
Conclusions:
Dexmedetomidine may have a potential benefit of preventing perioperative JET.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD
Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients
Bhanu Prakash Zawar, Yatin Mehta, Rajiv Juneja, Dheeraj Arora, Arun Raizada, Naresh Trehan
July-September 2015, 18(3):385-391
DOI
:10.4103/0971-9784.159810
PMID
:26139745
Objective:
Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha( TNF ά), interleukin-6 and leucocyte count.
Design:
A prospective randomised non blind study.
Setting:
A clinical study in a multi specialty hospital.
Participants:
Eighty six patients.
Material and Methods/intervention:
The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: - 6, TNF ά, cortisol, Troponin - I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis.
Primary Outcomes:
Postoperative complications, total intensive care unit stay and hospital stay.
Secondary Outcome:
Stress response.
Result:
Study group showed decreased Interlukin - 6 at day 2, TNF ά at day 2 and 5,troponin I at day 5, and decreased total hospital stay ( p < 0.05).
Conclusion:
Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.
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ORIGINAL ARTICLES
Percutaneous tracheostomy in patients on anticoagulants
Laura Pasin, Elena Frati, Luca Cabrini, Landoni Giovanni, Pasquale Nardelli, Tiziana Bove, Maria Grazia Calabro, Anna Mara Scandroglio, Federico Pappalardo, Alberto Zangrillo
July-September 2015, 18(3):329-334
DOI
:10.4103/0971-9784.159802
PMID
:26139737
Aims:
To determine if percutaneous tracheostomy is safe in critically ill patients treated with anticoagulant therapies.
Settings and Design:
Single-center retrospective study including all the patients who underwent percutaneous dilatational tracheostomy (PDT) placement over a 1-year period in a 14-bed, cardiothoracic and vascular Intensive Care Unit (ICU).
Materials and Methods:
Patients demographics and characteristics, anticoagulant and antiplatelet therapies, coagulation profile, performed technique and use of bronchoscopic guidance were retrieved.
Results:
Thirty-six patients (2.7% of the overall ICU population) underwent PDT over the study period. Twenty-six (72%) patients were on anticoagulation therapy, 1 patient was on antiplatelet therapy and 2 further patients received prophylactic doses of low molecular weight heparin. Only 4 patients had normal coagulation profile and were not receiving anticoagulant or antiplatelet therapies. Overall, bleeding of any severity complicated 19% of PDT. No procedure-related deaths occurred.
Conclusions:
PDT was proved to be safe even in critically ill-patients treated with anticoagulant therapies. Larger prospective studies are needed to confirm our findings.
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Do preoperative pulmonary function indices predict morbidity after coronary artery bypass surgery?
Mahdi Najafi, Mehrdad Sheikhvatan, Seyedeh Hamideh Mortazavi
July-September 2015, 18(3):293-298
DOI
:10.4103/0971-9784.159796
PMID
:26139731
Context:
The reported prevalence of chronic obstructive pulmonary disease (COPD) varies among different groups of cardiac surgical patients. Moreover, the prognostic value of preoperative COPD in outcome prediction is controversial.
Aims:
The present study assessed the morbidity in the different levels of COPD severity and the role of pulmonary function indices in predicting morbidity in patients undergoing coronary artery bypass graft (CABG).
Settings
and
Design:
Patients who were candidates for isolated CABG with cardiopulmonary bypass who were recruited for Tehran Heart Center-Coronary Outcome Measurement Study.
Methods:
Based on spirometry findings, diagnosis of COPD was considered based on Global Initiative for Chronic Obstructive Lung Disease category as forced expiratory volume in 1 s [FEV1]/forced vital capacity <0.7 (absolute value, not the percentage of the predicted). Society of Thoracic Surgeons (STS) definition was used for determining COPD severity and the patients were divided into three groups: Control group (FEV1 >75% predicted), mild (FEV1 60-75% predicted), moderate (FEV1 50-59% predicted), severe (FEV1<50% predicted). The preoperative pulmonary function indices were assessed as predictors, and postoperative morbidity was considered the surgical outcome.
Results:
This study included 566 consecutive patients. Patients with and without COPD were similar regarding baseline characteristics and clinical data. Hypertension, recent myocardial infarction, and low ejection fraction were higher in patients with different degrees of COPD than the control group while male gender was more frequent in control patients than the others. Restrictive lung disease and current cigarette smoking did not have any significant impact on postoperative complications. We found a borderline
P
= 0.057 with respect to respiratory failure among different patients of COPD severity so that 14.1% patients in control group, 23.5% in mild, 23.4% in moderate, and 21.9% in severe COPD categories developed respiratory failure after CABG surgery.
Conclusion:
Among post-CABG complications, patients with different levels of COPD based on STS definition, more frequently developed respiratory failure. This finding may imply the prognostic value of preoperative pulmonary function test for determining COPD severity and postoperative morbidities.
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Comparison of tapentadol with tramadol for analgesia after cardiac surgery
Srinivas Kalyanaraman Iyer, Gokulakrishnan Mohan, Sivakumar Ramakrishnan, Sanjay Theodore
July-September 2015, 18(3):352-360
DOI
:10.4103/0971-9784.159805
PMID
:26139740
Background:
Tapentadol is a relatively new analgesic. We decided to compare it with tramadol for their various effects after cardiac surgery.
Setting:
A study in a tertiary care hospital.
Materials and Methods:
Sixty adults undergoing cardiac surgery were divided into 2 groups of 30 each by computerized random allotment (Group X = tapentadol 50 mg oral and Group Y = tramadol 100 mg oral). Informed Consent and Institutional Ethics Committee approval were obtained. The patients were given either drug X or drug Y after extubation in this single blinded study, wherein the data collectors and analyzers were blinded to the study. All patients received oral paracetamol qds and either drug X or drug Y tds. The pain score was noted on a Visual Analog Scale before each drug dose, 3 h later and on coughing. Heart rate, respiratory rate, and blood pressure were recorded before the drug dose and 3 h later. Postoperative nausea or vomiting (PONV), temperature, and modified Glasgow Coma Scale readings were recorded. The above readings were obtained for 6 doses (up to 48 h after extubation).
Statistics:
t
-test, Pearson Chi-square test, Fisher exact test, and Mantel-Haenszel test were used for statistics.
Results:
Tapentadol group patients had significantly better analgesia 3 h after the drug and "on coughing" than tramadol group. The difference in their effects on blood creatinine levels, temperature, hemodynamics, oxygen saturation, and respiratory rate were not clinically significant. Tapentadol produced lesser drowsiness and lesser vomiting than tramadol.
Conclusions:
Tapentadol, due to its norepinephrine reuptake inhibition properties, in addition to mu agonist, is a better analgesic than tramadol and has lesser PONV.
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REVIEW ARTICLES
Inhaled therapy for the management of perioperative pulmonary hypertension
CA Thunberg, ST Morozowich, Harish Ramakrishna
July-September 2015, 18(3):394-402
DOI
:10.4103/0971-9784.159811
PMID
:26139748
Patients with pulmonary hypertension (PH) are at high risk for complications in the perioperative setting and often receive vasodilators to control elevated pulmonary artery pressure (PAP). Administration of vasodilators via inhalation is an effective strategy for reducing PAP while avoiding systemic side effects, chiefly hypotension. The prototypical inhaled pulmonary-specific vasodilator, nitric oxide (NO), has a proven track record but is expensive and cumbersome to implement. Alternatives to NO, including prostanoids (such as epoprostenol, iloprost, and treprostinil), NO-donating drugs (sodium nitroprusside, nitroglycerin, and nitrite), and phosphodiesterase inhibitors (milrinone, sildenafil) may be given via inhalation for the purpose of treating elevated PAP. This review will focus on the perioperative therapy of PH using inhaled vasodilators.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD
Propensity-matched analysis of association between preoperative anemia and in-hospital mortality in cardiac surgical patients undergoing valvular heart surgeries
Shreedhar S Joshi, Antony George, Dhananjaya Manasa, Hemalatha M.R. Savita, Prasad T.H. Krishna, AM Jagadeesh
July-September 2015, 18(3):373-379
DOI
:10.4103/0971-9784.159808
PMID
:26139743
Introduction:
Anaemia is associated with increased post-operative morbidity and mortality. We retrospectively assess the relationship between preoperative anaemia and in-hospital mortality in valvular cardiac surgical population.
Materials and Methods:
Data from consecutive adult patients who underwent valvular repair/ replacement at our institute from January 2010 to April 2014 were collected from hospital records. Anaemia was defined according to WHO criteria (hemoglobin <13g/dl for males and <12g/dl for females). 1:1 matching was done for anemic and non-anemic patients based on propensity for potentially confounding variables. Logistic regression was used to evaluate the relationship between anaemia and in-hospital mortality. MatchIt package for R software was used for propensity matching and SPSS 16.0.0 was used for statistical analysis.
Results:
2449 patients undergoing valvular surgery with or without coronary artery grafting were included. Anaemia was present in 37.1% (33.91% among males & 40.88% among females). Unadjusted OR for mortality was 1.6 in anemic group (95% Confidence Interval [95% CI] - 1.041-2.570; p=0.033). 1:1 matching was done on the basis of propensity score for anaemia (866 pairs). Balancing was confirmed using standardized differences. Anaemia had an OR of 1.8 for mortality (95% CI- 1.042 to 3.094, P=0.035). Hematocrit of < 20 on bypass was associated with higher mortality.
Conclusion:
Preoperative anaemia is an independent risk factor associated with in-hospital mortality in patients undergoing valvular heart surgery.
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ORIGINAL ARTICLES
Mid-term survival after transcatheter aortic valve implantation: Results with respect to the anesthetic management and to the access route (transfemoral versus transapical)
Caroline Gauthier, Parla Astarci, Philippe Baele, Amine Matta, David Kahn, Joëlle Kefer, Mona Momeni
July-September 2015, 18(3):343-351
DOI
:10.4103/0971-9784.159804
PMID
:26139739
Context:
Several studies have analyzed the long-term survival after transcatheter aortic valve implantation (TAVI). However, no previous studies have looked at survival beyond 1-year with respect to the type of anesthesia.
Aims:
The aim was to evaluate the mid-term survival after TAVI with respect to the type of anesthesia (general anesthesia [GA] vs. local anesthesia sedation [LASedation]) or the type of procedure (transfemoral [transfem] vs. transapical TAVI) performed.
Settings and Design:
Retrospective cohort study.
Subjects and Methods:
This retrospective study included TAVI's between January 2009 and June 2013. Patients were divided into three groups: transfem TAVI under GA, transfem TAVI under LASedation and transapical TAVI. A total of 176 patients were eligible. The following clinical outcomes were evaluated: (1) Mortality, (2) Major cardiovascular complications, (3) Conduction abnormalities and arrhythmias, (4) Acute kidney injury, (5) Aortic regurgitation, (6) Neurologic events, (7) Vascular complications, (8) Pulmonary complications, (9) Bleeding, (10) Infectious complications, (11) Delirium.
Statistical Analysis Used:
A Kruskal-Wallis test was performed to test significance between the three groups for quantitative variables. Categorical variables were compared using a Chi-square test. Survival was estimated using Kaplan-Meier method.
Results:
There was no statistically significant difference between the survival of both transfem TAVI's (
P
= 0.46). The short-term outcome of the transfem TAVI groups was better than the transapical arm, but their mid-term survival did not show any significant difference (
P
= 0.69 transapical vs. transfem GA;
P
= 0.07 transapical vs. transfem LASedation).
Conclusions:
Our results demonstrate that the type of anesthesia and the access route do not influence mid-term survival after TAVI.
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Noninvasive estimation of left atrial pressure with transesophageal echocardiography
Brian Cowie, Roman Kluger, Steffen Rex, Carlo Missant
July-September 2015, 18(3):312-316
DOI
:10.4103/0971-9784.159799
PMID
:26139734
Background:
The pulmonary artery catheter (PAC) has historically been used to measure cardiac filling pressures of which pulmonary capillary wedge pressure (PCWP) has been used as a surrogate of left atrial pressure (LAP) and left ventricular end-diastolic pressure. Increasingly, the use of the PAC has been questioned in the perioperative period with multiple large studies unable to clearly demonstrate benefit in any group of patients, resulting in a declining use in the perioperative period. Alternative methods for the noninvasive estimation of left-sided filling pressures are required. Echocardiography has been used to provide noninvasive estimation of PCWP and LAP, based on evaluating mitral inflow velocity with the E and A waves and looking at movement of the mitral annulus with tissue Doppler (e').
Aim:
The aim of our study was to assess the relationship between PCWP and E/e' in cardiac surgical patients with transesophageal echocardiography (TOE).
Design:
A prospective observational study.
Setting:
Cardiac surgical patients in a single quaternary referral university teaching hospital.
Methods:
The ratio of mitral inflow velocity (E wave) to mitral annular tissue velocity (e') (the E/e' ratio) and PCWP of 91 patients undergoing general anesthesia and cardiac surgery were simultaneously recorded, with the use of TOE and a PAC.
Results:
The correlation between E/e' and PCWP was modest with a Spearman rank correlation coefficient of 0.29 (
P
= 0.005). The area under the receiver operating characteristic curve for using E/e' to predict elevated PCWP (≥18 mmHg) was 0.6825 (95% confidence interval: 0.57-0.80), indicating some predictive utility. The optimum threshold value of E/e' was 10 which had 71% sensitivity and 60% specificity to predict a PCWP ≥18 mmHg.
Conclusions:
Noninvasive measurements of E/e' in general cardiac surgical patients have only a modest correlation and does not reliably estimate PCWP.
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LETTERS TO EDITOR
Malpositioning of right internal jugular central venous catheter into right external jugular vein forming "figure of eight"
Sohan Lal Solanki, Raghu S Thota, Vasant P Patil
July-September 2015, 18(3):414-415
DOI
:10.4103/0971-9784.159813
PMID
:26139750
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ORIGINAL ARTICLES
Assessment of feasibility and efficacy of Class IV laser therapy for postoperative pain relief in off-pump coronary artery bypass surgery patients: A pilot study
Anil Karlekar, Saswata Bharati, Ravindra Saxena, Kanchan Mehta
July-September 2015, 18(3):317-322
DOI
:10.4103/0971-9784.159800
PMID
:26139735
Background:
Laser therapy, for its established analgesic properties with minimal side effects, has been used for the treatment of chronic pain. However, it has not been used for the treatment of acute postoperative pain. This pilot study was designed to assess the feasibility and efficacy of Class IV laser on postoperative pain relief following off-pump coronary artery bypass graft (OPCABG) surgery, as a component of multimodal analgesia (MMA) technique.
Methods:
This open observational prospective study comprised of 100 adult patients (84 male, 16 female) who underwent OPCABG through sternotomy. For postoperative analgesia, they were subjected to laser therapy subjected to laser therapy in addition to the standard institutional pain management protocol comprising of IV infusion/bolus of tramadol and paracetamol and fentanyl bolus as rescue analgesic. Pain intensity was measured by Verbal Rating Scale (VRS). The laser therapy was scheduled as once a day regime for three consecutive postoperative days (PODs) starting on POD 1, 30 min following tracheal extubation. The subsequent laser applications were also scheduled at the same time of the day as on day 1 if VRS was ≥5. 10 W Class IV laser was applied over 150 cm
2
sternal wound area for 150 s. VRS was used to assess pain severity and was recorded for statistical analysis using Friedman Test.
Results:
The mean (standard deviation [SD]) VRS of all the 100 patients just before application of the first dose of laser was 7.31 (0.94) while on MMT; the same fell to 4.0 (1.279) and 3.40 (2.697) at 1 h and 24 h respectively following first dose of laser. The change of VRS over first 24 h among all the 100 patients was statistically significant (
P
= 0.000). Laser was re-applied in 40 patients whose VRS was ≥5 (mean [SD] - 6.38 [0.868]) at 24
th
h. After receiving the 2
nd
dose of laser the VRS scores fell significantly (
P
= 0.000) and became 0 at 54
th
h. No patients required 3
rd
dose of the laser. No patient required rescue analgesic while on laser therapy.
Conclusion:
Class IV laser can be an effective technique for postoperative analgesia following OPCABG surgery through sternotomy when included as a component of MMA technique.
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Cardioversion: What to choose? Etomidate or propofol
Pushkar M Desai, Deepa Kane, Manjula S Sarkar
July-September 2015, 18(3):306-311
DOI
:10.4103/0971-9784.159798
PMID
:26139733
Context:
Electrical cardioversion is a short painful procedure to regain normal sinus rhythm requiring anaesthesia for haemodynamic stability, sedation, analgesia and early recovery.
Aims:
To compare propofol and etomidate as sedatives during cardioversion.
Settings and Design:
Single centred, prospective and randomized single blind study comprising 60 patients.
Subjects and Methods:
Patients more than 18 years, American Society of Anesthesiologists I/II/III grades undergoing elective cardioversion, randomly divided to receive propofol 1 mg/kg intravenous (IV) bolus followed by 0.5 mg/kg (Group P,
n
= 30) or etomidate (Group E,
n
= 30) 0.1 mg/kg followed by 0.05 mg/kg. All patients received IV fentanyl (1 μg/kg) before procedure. Heart rate, blood pressure (BP) (systolic BP [SBP], diastolic BP [DBP], mean arterial pressure), respiratory rate, Aldrete recovery score (ARS) and Ramsay sedation score (RSS) were assessed at 1, 2, 5, 10, 15, 20 and 30 min post cardioversion. Incidence of hypotension, respiratory depression and side effects were compared.
Statistical analysis used:
Student's unpaired
t
-test, Chi-square test and Mann-Whitney test.
P
< 0.05 was taken as significant.
Results:
Group P showed significant fall in SBP, DBP, and mean BP at 2 min after cardioversion. Hypotension (33.3% Group P vs. 16.65% Group E) occurred more with propofol (
P
< 0.05). Group E showed better ARS at 1, 2, 5, 10, 15 and 20 min. Time required to attain RSS = 2 (659.1 s Group P and 435.7 s Group E) indicated longer recovery with propofol. Left atrial size (35.5-42.5 mm) did not affect success rate of cardioversion (80% Group P vs. 83.3% Group E). Incidence of myoclonus (Group E 26.67% vs. Group P 0%) showed significant difference.
Conclusions:
Etomidate/fentanyl is superior over propofol/fentanyl during cardioversion for quick recovery and haemodynamic stability.
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CASE REPORTS
Perioperative management of a patient with Dandy Walker malformation with tetralogy of Fallot undergoing total correction and fresh homologous pericardial pulmonary valve conduit implantation: Report of a rare case
Vishnu Datt, DK Tempe, Parin Lalwani, Saket Aggarwal, Pradeep Kumar, Anitha Diwakar, AS Tomar
July-September 2015, 18(3):433-436
DOI
:10.4103/0971-9784.159824
PMID
:26139758
Perioperative management of a patient with Dandy-Walker malformation (DWM) with tetralogy of Fallot (TOF), patent ductus arteriosus, and pulmonary artery stenosis is a great challenge to the anesthesiologist. Anesthetic management in such patients can trigger tet spells that might rapidly increase intracranial pressure (ICP), conning and even death. The increase in ICP can precipitate tet spells and further brain hypoxia. To avoid an increase in ICP during TOF corrective surgery ventriculo-peritoneal (VP) shunt should be performed before cardiac surgery. We present the first case report of a 11-month-old male baby afflicted with DWM and TOF who underwent successful TOF total corrective surgery and fresh autologous pericardial pulmonary valve conduit implantation under cardiopulmonary bypass after 1 week of VP shunt insertion.
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Pulmonary edema following transcatheter closure of atrial septal defect
Keerthi Chigurupati, Liza Jose Reshmi, Shrinivas Gadhinglajkar, S Venkateshwaran, Rupa Sreedhar
July-September 2015, 18(3):441-444
DOI
:10.4103/0971-9784.159827
PMID
:26139760
We describe an incident of development of acute pulmonary edema after the device closure of a secundum atrial septal defect in a 52-year-old lady, which was treated with inotropes, diuretics and artificial ventilation. Possibility of acute left ventricular dysfunction should be considered after the defect closure in the middle-aged patients as the left ventricular compliance may be reduced due to increased elastic stiffness and diastolic dysfunction. Baseline left atrial pressure may be > 10 mmHg in these patients. Associated risk factors for the left ventricular dysfunction are a large Qp:Qs ratio, systemic hypertension, severe pulmonary hypertension and paroxysmal atrial fibrillation.
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ORIGINAL ARTICLE - JANAK MEHTA AWARD
Weight-for-age standard score - distribution and effect on in-hospital mortality: A retrospective analysis in pediatric cardiac surgery
Antony George, Pushpa Jagannath, Shreedhar S Joshi, AM Jagadeesh
July-September 2015, 18(3):367-372
DOI
:10.4103/0971-9784.159807
PMID
:26139742
Objective:
To study the distribution of weight for age standard score (Z score) in pediatric cardiac surgery and its effect on in-hospital mortality.
Introduction:
WHO recommends Standard Score (Z score) to quantify and describe anthropometric data. The distribution of weight for age Z score and its effect on mortality in congenital heart surgery has not been studied.
Methods:
All patients of younger than 5 years who underwent cardiac surgery from July 2007 to June 2013, under single surgical unit at our institute were enrolled. Z score for weight for age was calculated. Patients were classified according to Z score and mortality across the classes was compared. Discrimination and calibration of the for Z score model was assessed. Improvement in predictability of mortality after addition of Z score to Aristotle Comprehensive Complexity (ACC) score was analyzed.
Results:
The median Z score was -3.2 (Interquartile range -4.24 to -1.91] with weight (mean±SD) of 8.4 ± 3.38 kg. Overall mortality was 11.5%. 71% and 52.59% of patients had Z score < -2 and < -3 respectively. Lower Z score classes were associated with progressively increasing mortality. Z score as continuous variable was associated with O.R. of 0.622 (95% CI- 0.527 to 0.733,
P
< 0.0001) for in-hospital mortality and remained significant predictor even after adjusting for age, gender, bypass duration and ACC score. Addition of Z score to ACC score improved its predictability for in-hosptial mortality (δC - 0.0661 [95% CI - 0.017 to 0.0595,
P
= 0.0169], IDI- 3.83% [95% CI - 0.017 to 0.0595,
P
= 0.00042]).
Conclusion:
Z scores were lower in our cohort and were associated with in-hospital mortality. Addition of Z score to ACC score significantly improves predictive ability for in-hospital mortality.
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Transesophageal echocardiography estimation of coronary sinus blood flow for the adequacy of revascularization in patients undergoing off-pump coronary artery bypass graft
PS Nagaraja, Naveen G Singh, TA Patil, V Manjunath, SR Prasad, AM Jagadeesh, K Ashok Kumar
July-September 2015, 18(3):380-384
DOI
:10.4103/0971-9784.159809
PMID
:26139744
Aims
and
Objectives:
Physiologically coronary sinus (CS) drains the left coronary artery (LCA) territory. Stenosis of the branches of LCA may decrease the coronary sinus blood flow (CSBF). Any intervention that aims at restoring the flow of the stenosed vessel increases coronary artery flow that should consequently increase the CSBF. Hence, this study was undertaken to assess the CSBF before and after each branch of LCA to determine the adequacy of surgical revascularization in patients undergoing elective off pump coronary artery bypass grafting (OPCAB) using transesophageal echocardiography (TEE).
Materials
and
Methods:
Thirty consecutive patients scheduled for elective OPCAB were enrolled. CSBF was assessed before and after each branch of LCA revascularization using TEE. Left internal mammary artery (LIMA) Doppler was also obtained post LIMA to left anterior descending (LAD) grafting.
Results:
Hemodynamic and echocardiographic variables were compared by means of Student's
t
-test for paired data before and after revascularization. The CSBF per beat (1.28 ± 0.71), CSBF per minute (92.59 ± 59.32) and total velocity time integral (VTI) (8.93 ± 4.29) before LAD grafting showed statistically significant increase to CSBF per beat (1.70 ± 0.89), CSBF per minute (130.72 ± 74.22) and total VTI (11.96 ± 5.68) after LAD revascularization. The CSBF per beat (1.67 ± 1.03), CSBF per minute (131.91 ± 86.59) and total VTI (11.00 ± 5.53) before obtuse marginal (OM) grafting showed statistically significant increase to CSBF per beat (1.91 ± 1.03), CSBF per min (155.20 ± 88.70) and total VTI (12.09 ± 5.43) after OM revascularization. In 9 patients, color flow Doppler of LIMA could be demonstrated which showed diastolic predominant blood flow after LIMA to LAD grafting.
Conclusion:
Demonstration of CSBF was simple and monitoring the trend of CSBF values before and after each graft of LCA territory will guide to determine the adequacy of surgical revascularization.
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ORIGINAL ARTICLES
Heart valve surgery in patients with homozygous sickle cell disease: A management strategy
El Mehdi Moutaouekkil, Abdelmalek Najib, Rida Ajaja, Moha Arji, Anas Slaoui
July-September 2015, 18(3):361-366
DOI
:10.4103/0971-9784.159806
PMID
:26139741
Background:
Patients with the homozygous sickle cell disease have increased perioperative mortality. Some indications like heart valve surgery, may justify an exchange blood transfusion to reduce the proportion of hemoglobin S (HbS) and complications.
Subjects and Methods:
We report two female cases aged 20 and 27, of African origin with homozygous sickle cell anemia who underwent heart valve surgery to treat mitral valve regurgitation. This presentation describes the perioperative considerations including anesthesia and postoperative care.
Results:
A partial exchange blood transfusion decreased HbS levels from respectively, 90% and 84%, 9% to 27% and 34%, and simultaneously treated the anemia. Neither sickling crisis nor acidosis occurred in any patient, and no special postoperative complication occurred. Average hospital stay was 10 days. Currently, the two patients remain alive and free of cardiac symptoms.
Discussion:
Although the presence of sickle cell disorders is associated with increased risk of sickling and thus vaso-occlusive complications, they should not be taken as a contraindication for heart valve surgery. Nevertheless, monitoring of certain parameters such as venous, arterial oxygen content, pH, and body temperature is mandatory for a better outcome. Furthermore, preoperative exchange transfusion has a positive influence on the outcome of surgery and on the survival of patients undergoing heart valves surgery. Avoiding intraoperative hypoxia, hypothermia, and vaso-constrictive agents, minimizing HbS levels with preoperative exchange transfusion, and ensuring a stress-free environment with the judicious use of sedatives made surgery relatively safe in these cases.
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264
Validation of the European System for Cardiac Operative Risk Evaluation-II model in an urban Indian population and comparison with three other risk scoring systems
Biju Sivam Pillai, Kanwar Aditya Baloria, Nandini Selot
July-September 2015, 18(3):335-342
DOI
:10.4103/0971-9784.159803
PMID
:26139738
Aims and Objectives:
The aims were to compare the European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II system against three established risk scoring systems for predictive accuracy in an urban Indian population and suggest improvements or amendments in the existing scoring system for adaptation in Indian population.
Materials and Methods:
EuroSCORE-II, Parsonnet score, System-97 score, and Cleveland score were obtained preoperatively for 1098 consecutive patients. EuroSCORE-II system was analyzed in comparison to each of the above three scoring systems in an urban Indian population. Calibrations of scoring systems were assessed using Hosmer-Lemeshow test. Areas under receiver operating characteristics (ROC) curves were compared according to the statistical approach suggested by Hanley and McNeil.
Results:
All EuroSCORE-II subgroups had highly significant
P
values stating good predictive mortality, except high-risk group (
P
= 0.175). The analysis of ROC curves of different scoring systems showed that the highest predictive value for mortality was calculated for the System-97 score followed by the Cleveland score. System-97 revealed extremely high predictive accuracies across all subgroups (curve area >80%). This difference in predictive accuracy was found to be statistically significant (
P
< 0.001).
Conclusions:
The present study suggests that the EuroSCORE-II model in its present form is not validated for use in the Indian population. An interesting observation was significantly accurate predictive abilities of the System-97 score.
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196
CASE REPORTS
Diagnosis of cardiac tamponade with transesophageal echocardiography following the induction of anesthesia for suspected testicular torsion
Stephen M McHugh, Xiao Wang, Erin A Sullivan
July-September 2015, 18(3):449-452
DOI
:10.4103/0971-9784.159828
PMID
:26139762
Transesophageal echocardiography (TEE) is a valuable tool for evaluating hemodynamic instability in patients under general anesthesia. We present the case of a 28-year-old man who presented with complaints of testicular pain concerning for testicular torsion. After induction of general anesthesia for scrotal exploration and possible orchiopexy, the patient developed severe and persistent hypotension. Using intraoperative TEE, the diagnosis of pericardial tamponade was made, and an emergent pericardial window was performed.
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3,314
186
FROM THE EDITOR
Nuances of social media in medical journalism
Poonam Malhotra Kapoor
July-September 2015, 18(3):283-285
DOI
:10.4103/0971-9784.159793
PMID
:26139728
[FULL TEXT]
[PDF]
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1
2,632
171
HEART TO HEART BLOG INTERESTING IMAGES
Interventricular septal hydatid cyst: Transesophageal echocardiography as a therapeutic tool during bypass
Pawan Kumar Jain, Vishwas Malik, Abha Divya, Jitin Narula, Milind Hote
July-September 2015, 18(3):421-424
DOI
:10.4103/0971-9784.159817
PMID
:26139754
Cystic echinococcosis (hydatid disease) arising from infestation with a larval or adult form of the
Echinococcus granulosus
tapeworm is endemic in certain states of India, but affecting interventricular septum (IVS) solitarily is a scarce phenomenon. We present a rare case of transesophageal echocardiography guided management of IVS hydatid cyst even during cardiopulmonary bypass, which presented with a rather unusual complaint of repeated syncope.
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2,212
152
LETTERS TO EDITOR
Hematuria in a child eight hours, postcardiac surgery
Sarvesh Pal Singh
July-September 2015, 18(3):417-418
DOI
:10.4103/0971-9784.159815
PMID
:26139752
[FULL TEXT]
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1
2,570
143
REVIEW ARTICLES
Brugada syndrome and its relevance in the perioperative period
Dan Sorajja, Harish Ramakrishna, A Karl Poterack, Win-Kuang Shen, Farouk Mookadam
July-September 2015, 18(3):403-413
DOI
:10.4103/0971-9784.159812
PMID
:26139749
Brugada syndrome is an autosomal dominant genetic disorder associated with an increased risk of sudden cardiac death, as well as ventricular tachyarrhythmias.The defective cardiac sodium channels result in usual electrocardiographic findings of a coved-type ST elevation in precordial leads V1 to V3. The majority of patients have uncomplicated courses with anesthesia, surgery, and invasive procedures. However there is risk of worsening ST elevation and ventricular arrhythmias due to perioperative medications, surgical insult, electrolyte abnormalities, fever, autonomic nervous system tone, as well as other perturbations. Given the increasing numbers of patients with inherited conduction disorders presenting for non-cardiac surgery that are at risk of sudden cardiac death, safe anesthetic management depends upon a detailed knowledge of these conditions.
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10,761
753
CASE REPORTS
Pressure bandage over venous conduit harvesting site causing compartment syndrome in a patient with intra-aortic balloon pump: An unusual cause
Amit Rastogi, Rudrashish Haldar, Gauranga Majumdar, Akhilesh Pahade, Prabhat K Singh
July-September 2015, 18(3):453-455
DOI
:10.4103/0971-9784.159823
PMID
:26139763
Intra Aortic Balloon Pump (IABP) is conventionally used to support coronary perfusion and weaning from cardiopulmonary bypass. IABP in situ has its own share of complications. We present a case where a patient on IABP support who had reduced peripheral pulsations of the ipsilateral limb and was initially misdiagnosed as IABP catheter associated thromboembolism. A negative embolectomy ruled out the same. Further looking for the cause of reduction of ipsilateral pulses it was found that the tight compressive bandage at saphenous vein conduit harvesting site had led to development of compartment syndrome (CS).
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127
Right ventricular hydatid cyst ruptured to pericardium
Feridoun Sabzi, Siavoosh Vaziri, Reza Faraji
July-September 2015, 18(3):445-448
DOI
:10.4103/0971-9784.159825
PMID
:26139761
Cardiac hydatidosis is rare presentation of body hydatidosis. Incidence of cardiac involvements range from 5% to 5% of patients with hydatid disease. Most common site of hydatid cyst in heart is interventricular septum and left ventricular free wall. Right ventricular free wall involvement by cyst that ruptured to pericardial cavity is very rare presentation of hydatid cyst. Cardiac involvement may have serious consequences such as rupture to blood steam or pericardial cavity. Both the disease and its surgical treatment carry a high complication rate, including rupture leading to cardiac tamponade, anaphylaxis and also death. In the present report, a 43-year-old man with constrictive pericarditis secondary to a pericardial hydatid cyst is described.
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163
Use of dexmedetomidine as an adjunct in the treatment of paradoxical hypertension after surgical repair of coarctation of the aorta in infants
Manoj K Sahu, Vinod Kumar Manikala, Sarvesh Pal Singh, AK Bisoi, Ujjwal Kumar Chowdhury
July-September 2015, 18(3):437-440
DOI
:10.4103/0971-9784.159826
PMID
:26139759
Severe persistent hypertension is seen infrequently in newborns and infants, but we came across two infants who developed severe paradoxical hypertension after successful coarctation repair. Treatment of systemic hypertension following repair of coarctation of the aorta is always challenging particularly in infants. Dexmedetomidine was used successfully as an adjunct to the established anti-hypertensive drugs in the immediate postoperative period in our cases to treat postoperative paradoxical hypertension.
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ECHO TUTORIAL
Imaging coronary sinus in modified bicaval view
Monish S Raut, Arun Maheshwari
July-September 2015, 18(3):430-432
DOI
:10.4103/0971-9784.159821
PMID
:26139757
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5,860
241
EDITORIALS
Hybrid atrial fibrillation ablations and the increasing importance of the hybrid cardiovascular laboratory operating room
William J Schleifer, John F Beshai, Harish Ramakrishna
July-September 2015, 18(3):286-289
DOI
:10.4103/0971-9784.159794
PMID
:26139729
[FULL TEXT]
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2,168
162
Converting data into information and knowledge: The promise and the reality of electronic medical records
Karl A Poterack, Harish Ramakrishna
July-September 2015, 18(3):290-292
DOI
:10.4103/0971-9784.159795
PMID
:26139730
[FULL TEXT]
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2,391
141
HEART TO HEART BLOG INTERESTING IMAGES
Left subclavian artery occlusion: Incidental transesophageal echocardiography diagnosis
Dharmesh Radheshyam Agrawal, Mohammed Rehan Sayeed
July-September 2015, 18(3):419-420
DOI
:10.4103/0971-9784.159816
PMID
:26139753
[FULL TEXT]
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1,806
123
Obstructive membrane in arch of aorta in a case of Shone's complex
Divyesh H Sadadiwala, Kunal A Soni
July-September 2015, 18(3):425-426
DOI
:10.4103/0971-9784.159818
PMID
:26139755
Shone's complex is a rare congenital heart disease consisting of multisite obstruction on the left side of the heart. The obstructive membrane in the arch of aorta is never described among these obstructions. We report echocardiographic findings in a patient with Shone's complex with the obstructive membrane in the arch of aorta.
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129
Aneurysm: Sinus of valsalva or ventricular septal?
Monish S Raut, Arun Maheshwari, Sumir Dubey
July-September 2015, 18(3):427-429
DOI
:10.4103/0971-9784.159819
PMID
:26139756
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2,032
135
LETTERS TO EDITOR
In response to Evolutionary change: The new face of Annals of Cardiac Anesthesia
Mayadhar Barik
July-September 2015, 18(3):416-416
DOI
:10.4103/0971-9784.159814
PMID
:26139751
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1,710
145
ORIGINAL ARTICLES
Effect of lateral body position on transesophageal echocardiography images and the association with patient characteristics: A prospective observational study
Norikatsu Mita, Masataka Kuroda, Shigeru Saito, Sohtaro Miyoshi
July-September 2015, 18(3):299-305
DOI
:10.4103/0971-9784.159797
PMID
:26139732
Background:
Changes in heart position are occasionally observed on the transesophageal echocardiography (TEE) image screen after changing the body position from supine to lateral, although the magnitude of change in cardiac position varies individually. We hypothesized that this variation is associated with certain patient characteristics and evaluated how lateral positioning affects visualization of the heart on TEE and whether the magnitude of change in the heart position correlates with patient characteristics.
Methods:
Fifty-three lung resection patients were enrolled. Two angle and two length parameters (Dq
TV
, Dq
AP
, DL
TV
, and DL
AP
) were defined to describe location change of the lateral tricuspid annulus and right ventricular apex on the TEE image between supine and lateral position. The correlation coefficients were calculated between these four parameters and patient characteristics, including age, body mass index (BMI), epicardial fat thickness, and pulmonary function variables.
Results:
The Dq
TV
correlated positively and inversely with BMI in both right and left lateral patients (right:
r
= 0.6365,
P
= 0.0034; left:
r
= −0.6616,
P
< 0.0001, respectively). In left lateral patients, the Dq
TV
correlated inversely with epicardial fat thickness (
r
= −0.4879,
P
= 0.0182), and the DL
AP
correlated positively with the forced vital capacity percent predicted (
r
= 0.5736,
P
= 0.0082).
Conclusions:
Lateral body positioning affects cardiac visualization on TEE, and the BMI, epicardial fat thickness, and pulmonary function moderate this effect.
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VIDEO COMMENTARIES
Video Commentary 1: Tee for endoventricular patch plasty/dor procedure
Sarvesh Pal Singh, Jitin Narula, Poonam Malhotra
July-September 2015, 18(3):392-392
DOI
:10.4103/0971-9784.159820
PMID
:26139746
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Video Commentary 2: "Tee for direct closure for LV aneurysm repair"
Jitin Narula, Sarvesh Pal Singh, Poonam Malhotra
July-September 2015, 18(3):393-393
DOI
:10.4103/0971-9784.159822
PMID
:26139747
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© Annals of Cardiac Anaesthesia | Published by Wolters Kluwer -
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Online since 5
th
January, 2008