Context: The role of prophylaxis for postoperative nausea and vomiting (PONV) in cardiac surgery is under debate. Aims: To study the risk factors for PONV after cardiac surgery and the role of betamethasone with or without droperidol for its prevention. Setting and Design: Randomized open-label controlled study comparing standard care with PONV prophylaxis from February to November 2016. Methods: Five hundred and two patients with planned nonemergent cardiac surgery were included. Interventions: In the intervention arm, PONV prophylaxis (4 mg betamethasone with/without 0.625 mg droperidol) was administered in high-risk patients (two or more risk factors). Patients in the control arm were treated as per routine hospital practices. Results: Female sex, past history of PONV, and migraines were associated with a significantly increased risk of PONV, while motion sickness, smoking status, and volatile anesthetics were not. Pain and treatment with nefopam or ketoprofen were associated with an increased risk of PONV. PONV was less frequent in the active arm compared to controls (45.5% vs. 54.0%, P = 0.063; visual analogic scale 10.9 vs. 15.3 mm, P = 0.043). Among the 180 patients (35.6%) with ≥2 risk factors, prophylaxis was associated with reduced PONV (intention-to-treat: 46.8% vs. 67.8%, P = 0.0061; per-protocol: 39.2% vs. 69%, P = 0.0002). In multivariate analysis, prophylaxis was independently associated with PONV (odds ratio [OR]: 0.324, 95% confidence interval: 0.167–0.629, P = 0.0009), as were female sex, past history of PONV, and migraines (OR: 3.027, 3.031, and 2.160 respectively). No drug-related side effects were reported. Conclusion: Betamethasone with/without droperidol was effective in decreasing PONV in high risk cardiac surgical patients without any side effect.

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Visualization of aortic arch branches by transesophageal echocardiography has been technically challenging. Visualizing these vessels helps in identifying the extent of dissection of the aorta, assessing the severity of carotid artery stenosis, presence of atheromatous plaques, patency of the left internal mammary artery graft, confirmation of subclavian artery cannulation, confirming holodiastolic flow reversal in the left subclavian artery by spectral Doppler imaging in case of severe aortic regurgitation, and confirming the optimal position of the intraaortic balloon perioperatively. The information obtained is helpful for diagnosis, monitoring, and decision-making during aortic surgery.

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Objective: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. Design: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. Setting: A single-center study at a university affiliated heart center. Participants: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. Methods: Primary and staged biventricular repair of complete AV canal defects. Measurements and main results: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. Conclusion: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.

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Cyanotic congenital heart disease presents an increased tendency to bleed in view of subtle coagulation defects. Airway bleeding can be particularly difficult to manage while maintaining an adequate ventilation. An isolated lung bleed with the exclusion of possible traumatic, medical and surgical causes of bleeding, should alert the attending anesthesiologist to the possibility of the collateral-related bleeding. Preoperative coil embolization remains an important initial management step in a case of tetralogy of Fallot (TOF) with major aortopulmonary collaterals. Nevertheless, the coiling of the collaterals in certain specific case scenarios is not feasible, rendering the management of a lung bleed, all the more challenging. We, hereby discuss a case of a 7-year-old girl with a massive endotracheal bleed at the time of weaning from cardiopulmonary bypass after corrective surgery for TOF. The subsequent approach and management are discussed. The optimal management of tetralogy with collaterals mandates an effective communication among the cardiologist, radiologist, anesthesiologist, and the surgeon.

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HeartWare is a third-generation continuous flow left ventricular assist device (LVAD) and generates centrifugal pattern of blood flow. In the perioperative setting, interrogating the HeartWare devices is very difficult due to the interference of the Doppler by the impeller frequency and generation of the waterfall artifact. We present a case where using color Doppler a view “inside“ the impeller can be seen which corresponds to the centrifugal flow of blood. With time, these images can be looked into in pathological states such as pump thrombosis, to come to a more meaningful conclusion regarding the flow of blood within the centrifugal chamber. Newer technologies are constantly evolving to give us more meaningful insights into the flow of blood within the heart chambers. We believe similar technologies can be applied to see the flow of blood inside the LVAD devices.

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Objectives: The aim is to achieve the standard tools for heart health, the present study aimed to design, develop, and standardize the two questionnaires of perceived heart risk scale (PHRS) and heart health literacy scale (HHLS). Methods: The present study was a methodological research conducted on the residents of Kermanshah Province, Iran, using the multi-stage cluster sampling. Further, considering the scientific methods in the psychometric field, the design of the research questionnaires was conducted. In addition, the viewpoints of experts in different domains were qualitatively and quantitatively included to assess the validity of the questionnaires. To assess the reliability of the questionnaires, a sample including 31 subjects was first selected and studied within a fortnight's interval. Then, the reliability and validity of the scales were assessed using factor analysis and Cronbach's alpha in a sample of 771 subjects. Results: After reviewing the viewpoints of experts, the items were adjusted and implemented in the first sample at two stages. The results were indicative of the stability and acceptability of the Cronbach's alpha. In addition, the validity and reliability of the questionnaires were confirmed in the second sample too. Conclusion: According to the results of the present study, it can be concluded that the two questionnaires of PHRS and HHLS had acceptable reliability and validity.

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A 32-year-old woman with a past medical history of paroxysmal atrial fibrillation, long QT syndrome, and implantation of an automatic iimplantable cardioverter-defibrillator (AICD) following cardiac arrest presented with disabling symptoms of paroxysmal atrial fibrillation due to recurrent AICD shocks. Before curative ablation, transesophageal echocardiography was performed to assess for existing thrombi. This is a rare case of successful resolution with apixaban of a massive left atrial appendage thrombus due to non-rheumatic atrial fibrillation that was successfully treated with apixaban.

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Objective: The aim of the study was to assess the effect of dexmedetomidine on the incidence of paradoxical hypertension in patients undergoing aortic coarctation repair. Design: Randomized observational study. Setting: University hospital and cardiac center. Patients: The study included 108 pediatric patients with isolated aortic coarctation. Methods: The patients were classified into two groups (each = 54): Group D: the patients received dexmedetomidine as a loading dose of 0.5 μg/kg over 10 min followed by infusion 0.3 μg/kg/h during surgery and continued for the first 48 postoperative hours. Group C: The patients received an equal amount of normal saline. The medication was prepared by the nursing staff and given to anesthetist blindly. The collected data included the heart rate, systolic and diastolic arterial blood pressure, incidence, onset, severity and treatment of paradoxical hypertension, fentanyl dose and end-tidal sevoflurane concentration, amount of blood loss and urine output. Main Results: The heart rate, systolic and diastolic blood pressure decreased significantly with dexmedetomidine than Group C (P < 0.05). The incidence and severity of the paradoxical hypertension was lower with dexmedetomidine than Group C (P = 0.011, P = 0.017, respectively). The onset the paradoxical hypertension was earlier in Group C than dexmedetomidine (P = 0.026). The dose of fentanyl and sevoflurane concentration decreased significantly with dexmedetomidine (P = 0.034, P = 0.026, respectively). The blood loss decreased with dexmedetomidine (P = 0.020) and the urine output increased with dexmedetomidine (P = 0.024). The incidence of hypotension and bradycardia was more with dexmedetomidine (P < 0.05). Conclusion: Dexmedetomidine is safe in pediatric patients undergoing aortic coarctation repair. It minimized the incidence and severity of paradoxical hypertension. It decreased the required antihypertensive medications.

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Objective: The objective of the study is to compare the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass (CPB), the cardio protection been assessed by changes in N-terminal brain natriuretic peptide (NT proBNP). Methodology and Design: This study is designed as a participant blinded, prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India. Participants: Patients undergoing elective coronary artery bypass surgery on CPB. Intervention: Anesthesia was maintained with 0.8–1.2 end tidal concentrations of isoflurane in the isoflurane group and in the propofol group, anesthesia was maintained with propofol infusion as described by Roberts et al. Measurements: Hemodynamic data were recorded at frequent intervals during the surgery and up to 24 h in the Intensive Care Unit (ICU). The other variables that were measured include duration of mechanical ventilation, dose and duration of inotropes in ICU, (inotrope score), duration of ICU stay, NT proBNP levels before induction and 24 h postoperatively, creatine kinase-MB levels in the immediate postoperative, first and second day. Results: Mean heart rate was significantly higher in propofol group during sternotomy, (P = 0.021). Propofol group had a significantly more number of patients requiring nitroglycerine in the prebypass period (P = 0.01). The increase in NT proBNP from preoperative to postoperative value was lesser in the isoflurane group compared to propofol even though the difference was not statistically significant. The requirement of phenylephrine to maintain mean arterial pressure within 20% of baseline, mechanical ventilation duration, inotrope use, duration of ICU stay and hospital stay were found to be similar in both groups. Conclusion: Propofol exhibit comparable myocardial protective effect like that of isoflurane in patients undergoing coronary artery bypass graft surgery. Considering the unproven mortality benefit of isoflurane and the improved awareness of green OT concept, propofol may be the ideal alternative to volatile anesthetics, at least in patients with good left ventricular function.

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The prevalence of epilepsy worldwide is around 0.5%–2% of the population. Antiepileptic medications are the first line of treatment in most of the cases but approximately 25%–30% epilepsy patients are refractory to the single or combination therapy. The surgical option for temporal lobe epilepsy is temporal lobectomy, which has its inherent risk of neurological deficits after the surgery. Patients who are either refractory to combination therapy or do not want surgical temporal lobectomy are the candidates for electrical stimulation therapy. Refractory cases require implantable device such as vagal nerve stimulator (VNS). We are reporting perioperative management of a patient, with an implanted VNS, posted for pericardiectomy. It is important for the anesthesiologist to be familiar with the mechanism of VNS for proper perioperative care.

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Background: Acute renal failure after cardiac surgery is known to be associated with significant short-term morbidity and mortality. There have as yet been no major reports on long-term quality of life (QOL). This study assessed the impact of acute kidney injury (AKI) and renal replacement therapy (RRT) on long-term survival and QOL after cardiac surgery. The need for long-term RRT is also assessed. Materials and Methods: Patients who underwent cardiac surgery between 2005 and 2011 (n = 6087) and developed AKI (RIFLE criteria, n = 570) were included. They were propensity-matched 1:1 to patients without renal impairment (control). Data were prospectively collected, and health-related QOL questionnaire was sent to patients who were alive at least 1-year postoperatively at the time of the study. Results: There was no significant difference in the preoperative characteristics between the two groups (age, gender, left ventricular ejection fraction, procedure, urgency, logistic Euroscore), respectively. Median follow-up was 52 months. Survival data were available in all patients. Questionnaires were returned in 64% of eligible patients. Long-term survival was significantly lower, and QOL, in particular the physical aspect, was significantly worse for the AKI group as compared to non-AKI group (38.8 vs. 44.2, P = 0.002), especially so in patients who required RRT. In alive respondents, despite an 18% (66/359) incidence of ongoing renal follow-up, the need for late RRT was only in 1.1% (4/359). Conclusion: AKI and especially the need for RRT following cardiac surgery are associated with increased long-term mortality as well as worse quality of life in a propensity-matched control group.

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Transposition of great arteries (TGA) can be associated with left ventricle outflow tract (LVOT) obstruction. In the presence of ventricular septal defect (VSD), septal leaflet of tricuspid valve may prolapse through perimembranous VSD or rarely tricuspid valve tissue may override to produce LVOT obstruction. Occasionally, this may be mistaken for vegetation due to associated pulmonary valve endocarditis. We report a case of d-TGA with presumptive pulmonary valve endocarditis and LVOT obstruction that was found to be due to tricuspid valve straddling on transesophageal echocardiography, resulting in change in the surgical plan and thus avoiding catastrophe.

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Minimally invasive atrial septal defect (ASD) closure is a commonly performed cardiac surgical procedure and has good outcome. We report an interesting chest X-ray showing pneumopericardium in a patient who underwent ASD closure using a minimally invasive approach.

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Background: Dexmedetomidine is a selective α-2 agonist used for sedation. It has also been shown to have myocardial protective effect and prevent ischemia-reperfusion injury in off-pump coronary artery bypass patients. The aim of our study was to assess the effect of dexmedetomidine for prevention of skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery. Methodology: Sixty adult patients (Group dexmedetomidine n = 30, Group normal saline n = 30) undergoing aortobifemoral bypass surgery were recruited over 3 months. Randomization was done using a computer-generated random table. The attending anesthesiologist would be blinded to whether the drug/normal saline was being administered. He would consider each unlabeled syringe as containing dexmedetomidine and calculate the volume to be infused via a syringe pump accordingly. Dexmedetomidine infusion (1 mcg/kg) over 15 minutes was given as a loading dose, followed by maintenance infusion of 0.5 mcg/kg/h till 2 h postprocedure in Group dexmedetomidine (D) while the same volume of normal saline was given in the control Group C till 2 h postprocedure. Creatine phosphokinase (CPK) values were noted at baseline (T0), 6 h (T1), 12 h (T2), and 24 h (T3) after the procedure. Hemodynamic variables (heart rate [HR] and mean blood pressure [MAP]) were recorded at T0, T1, T2, and T3. Results were analyzed using unpaired Student's t-test, P < 0.05 was considered statistically significant. Results: MAP and HR significantly decreased in Group D as compared to control group (P < 0.05). However, the decrease was never <20% of the baseline. The CPK values at 6, 12, and 24 h were statistically significant between the two groups. Conclusion: Dexmedetomidine prevents skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery.

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Quadricuspid aortic valve (QAV) is a rare congenital anomaly frequently associated with other anomalies particularly coronary anomalies. It may be detected on transthoracic or transesophageal echocardiography. We present here a case report of a 27-year-old male patient with a QAV, the valve being regurgitant and requiring aortic valve replacement. It has been reported as isolated case reports in the literature and various theories exist to the development of QAV. The diagnosis requires a high degree of suspicion and a detailed assessment, and if asymptomatic, then patients need to be carefully followed up for the development of aortic regurgitation.

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Atrial fibrillation is the most common arrhythmia associated with significant mortality and morbidity secondary to thrombo-embolism. To prevent this thrombo-embolism oral anticoagulation therapy is the recommended treatment. In patients with contraindications to oral anticoagulation therapy, percutaneous left atrial appendage occlusion device is indicated. TEE is essential to guide in all the stages of LAA device deployment. Right from pre-procedure screening, to guiding during deployment, to rule out any complications and post-procedure surveillance and monitoring long term outcomes.

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We report a rare case of multiple hereditary exostosis where patient presented with bilateral base of neck exostoses with concurrent compression of brachial plexus and subclavian artery and vein. The patient was a young 26-year-old woman with chief complaints of pain in the left upper extremity, paresthesia in the left ring and little finger, and weakness in hand movement and grip. On referral, history, physical examination, radiological imaging, and electrodiagnostic tests evaluated the patient. Due to severe pain and disability in performing routine activities, surgical intervention was necessary. In the current case, the patient had thoracic outlet syndrome with concomitant venous, arterial, and neurogenic sub types. Radial pulse returned and pain associated with brachial plexus compression was resolved after the surgery.

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The majority of cardiac left ventricular aneurysms involve the anterior and/or apical wall. We present a case of a 50-year-old man with heart failure caused by a large inferolateral left ventricular aneurysm and associated mitral regurgitation, managed by aneurysmectomy, mitral valvuloplasty, and surgical revascularization.

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Left Atrial Appendage (LAA) is the most contractile part of Left atrium. It is also the most frequent place for thrombus formation that may lead to disastrous consequences. Complete trasoesophageal echocardiography examination always includes assessing LAA but sometimes unusually placed pectinate muscle, which is a normal structure may give baffling shadow that can only be interpreted correctly by Real time 3D echocardiography.

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Resection and reconstruction of the SVC is a challenging Intraoperative situation owing to the potential complications after clamping a patent vessel. Hemodynamic imbalance and neurological effects of SVC clamping can be life threatening. These complications can be prevented by careful intraoperative monitoring and management. Anaesthesiologist must be aware of different options to manage such challenging situations.

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During standard transesophageal echocardiographic examinations in sinus rhythm (SR) patients, the left atrial appendage (LAA) is not routinely assessed with Doppler. Despite having a SR, it is still possible to have irregular activity in the LAA. This situation is even more important for SR patients where assessment of the left atrium is often foregone. We describe a case where we encountered this situation and briefly review how to assess the left atrium and its appendage in such a case scenario.

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Thanks to Raut et al.[1] for appreciating our efforts in managing the case of biatrial myxomas. A brief discussion is warranted here on the types, size of cardiac myxomas, interleukin 6 (IL-6) levels, left ventricle (LV) dysfunction, and their relation. IL-6 is a pleiotropic cytokine with a variety of biologic activities, including differentiation of B cell, thymocytes, and T cells; activation of macrophages; and stimulation of hepatocyte to produce acute-phase proteins such as C-reactive protein.^[2],[3] It is also said to have paracrine, endocrine, and autocrine growth functions.^[3]

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Left atrial fibroma as a benign tumor is an exceedingly rare left atrial mass. It has various clinical signs and symptoms and sometimes leads to serious complications such as lethal arrhythmia and death. We report a case of right atrial fibroma in a 40-year-old male who presented with dyspnea and atrial fibrillation. Transthoracic echocardiography revealed a large sessile mass attached to interatrial septum near the coronary sinus valve in the right atrium. The patient underwent surgical resection of tumor through the right atrium. The postoperative course was unremarkable. Histopathological examination showed that it was a fibroma. The 6-month follow-up revealed that the patient was in well condition with no evidence of tumor recurrence.

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