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   2012| July-September  | Volume 15 | Issue 3  
    Online since July 4, 2012

 
 
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REVIEW ARTICLE
Clinical Review: Management of weaning from cardiopulmonary bypass after cardiac surgery
Marc Licker, John Diaper, Vanessa Cartier, Christoph Ellenberger, Mustafa Cikirikcioglu, Afksendyios Kalangos, Tiziano Cassina, Karim Bendjelid
July-September 2012, 15(3):206-223
DOI:10.4103/0971-9784.97977  
A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. Various crisis management scenarios can be anticipated which emphasizes the importance of basic knowledge in applied cardiovascular physiology, knowledge of pathophysiology of the surgical lesions as well as leadership, and communication between multiple team members in a high-stakes environment. Since the mid-90s, transoesophageal echocardiography has provided an opportunity to assess the completeness of surgery, to identify abnormal circulatory conditions, and to guide specific medical and surgical interventions. However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.
  116,708 4,710 23
ORIGINAL ARTICLES
The effect of weight loss on the outcome after coronary artery bypass grafting in obese patients
Remez Kocz, Mahmoud Abdalla Hassan, Padmavathi Rao Perala, Sohrab Negargar, Hassan Javadzadegan, Nader D Nader
July-September 2012, 15(3):190-198
DOI:10.4103/0971-9784.97975  
The role of body mass index (BMI) in the setting of coronary artery bypass graft (CABG) surgery has been a focus of past studies. However, the effects of postoperative weight loss in patients after CABG is yet to be known. We performed a retrospective study of 899 patients who underwent CABG at our institution. Perioperative patient information was collected from an onsite electronic record system. Patients were grouped into four BMI categories: normal controls, overweight, obese and morbidly obese. Based on the postoperative BMI changes, patients were then grouped into three categories: gainers, no change and losers. Statistical analyses were performed using analysis of variance and linear regression to establish an association among the data. Hazard ratios (HR) and cumulative survival were obtained by the Cox-Mantel and Kaplan-Meier analyses, respectively. The normal controls exhibited a markedly higher mortality postoperatively, at 27.9%, especially when compared with the obese individuals (16.1%). Patients who lost weight faced a significantly increased risk of mortality than those who experienced no changes or gained weight after surgery. This trend was especially salient among the obese patients, who more than tripled their mortality risk (HR = 3.24) versus individuals who gained weight, and more than doubled their risk (HR = 2.87) versus those who had no changes. We conclude that obesity confers a survival advantage in the setting of the CABG surgery. Weight loss among all BMI categories of patients studied results in an adverse effect on postoperative survival.
  10,759 279 7
ICU sedation with haloperidol-propofol infusion versus midazolam-propofol infusion after coronary artery bypass graft surgery: A prospective, double-blind randomized study
Farhad Etezadi, Atabak Najafi, Kourosh Karimi Yarandi, Reza Shariat Moharari, Mohammad Reza Khajavi
July-September 2012, 15(3):185-189
DOI:10.4103/0971-9784.97974  
Combinations of hypnotics with or without opiates are commonly used in agitated patients. We hypothesized that combination of haloperidol-propofol in comparison with midazolam-propofol would lower consumption of propofol and lead to better hemodynamic and respiratory profile during sedation of agitated patients. Among 108 patients admitted in our ICU, 60 patients were agitated according to Ramsay Sedation Score (RSS) and randomly divided into two groups. Morphine sulfate (0.05 mg/kg) was administered to all patients for relief of postoperative pain. In one group, sedative infusion was started with 1 mg/h of haloperidol plus 25 μg/kg/min of propofol after bolus injection of 2 mg haloperidol. In the other group, midazolam1 mg/h and propofol 25 μg/kg/min were infused after a bolus injection of 2 mg midazolam. Propofol infusion was adjusted to keep bi-spectral index between 61-80 and the RSS between 3-5. Hourly propofol consumption was recorded during 24 h of sedation and compared statistically. We also compared SpO 2 , arterial blood gas variables, hemodynamic parameters and episodes of respiratory depression (SpO 2 ≤85%) requiring respiratory support between the groups. Haloperidol, when added to propofol infusion, decreased its consumption at all the measured times (P = 0.001). There was no significant difference in hemodynamic variables between two groups, but the episodes of respiratory depression was significantly higher in propofol-midazolam group (P = 0.02). We conclude that haloperidol-propofol infusion decreases propofol requirements in the agitated patients. Besides, this combination showed a better profile in terms of occurrence of respiratory depression.
  8,225 530 5
A comparison of a continuous noninvasive arterial pressure (CNAP™) monitor with an invasive arterial blood pressure monitor in the cardiac surgical ICU
AM Jagadeesh, Naveen G Singh, Subramanyam Mahankali
July-September 2012, 15(3):180-184
DOI:10.4103/0971-9784.97973  
Accurate measurement and display of arterial blood pressure is essential for rational management of adult cardiac surgical patients. Because of the lower risk of complications, noninvasive monitoring methods gain importance. A newly developed continuous noninvasive arterial blood pressure (CNAP™) monitor is available and has been validated perioperatively. In a prospective study we compared the CNAP™ monitoring device with invasive arterial blood pressure (IAP) measurement in 30 patients in a cardiac surgical Intensive Care Unit (ICU). Patients were either mechanically ventilated or spontaneously breathing, with or without inotropes. CNAP™ was applied on two fingers of the hand contralateral to the IAP monitoring catheter. Systolic, diastolic and mean pressure data were recorded every minute for 2 h simultaneously for both IAP and CNAP™. Statistical analysis included construction of mountain plot and Bland Altman plots for assessing limits of agreement and bias (accuracy) calculation. Three thousand and six hundred pairs of data were analyzed. The CNAP™ systolic arterial pressure bias was 10.415 mmHg and the CNAP™ diastolic arterial pressure bias was −5.3386 mmHg; the mean arterial pressure (MAP) of CNAP™ was close to the MAP of IAP, with a bias of 0.03944 mmHg. The Bland Altman plot showed a uniform distribution and a good agreement of all arterial blood pressure values between CNAP™ and IAP. Percentage within limits of agreement was 94.5%, 95.1% and 99.4% for systolic, diastolic and MAP. Calculated limits of agreement were −4.60 to 25.43, −13.38 to 2.70 and −5.95 to 6.03 mmHg for systolic, diastolic and mean BP, respectively. The mountain plot showed similar results as the Bland Altman plots. We conclude CNAP™ is a reliable, noninvasive, continuous blood pressure monitor that provides real-time estimates of arterial pressure comparable to those generated by an invasive arterial catheter system. CNAP™ can be used as an alternative to IAP.
  7,978 564 15
CASE REPORTS
Dexmedetomidine controls junctional ectopic tachycardia during Tetralogy of Fallot repair in an infant
Michelle LeRiger, Aymen Naguib, Mark Gallantowicz, Joseph D Tobias
July-September 2012, 15(3):224-228
DOI:10.4103/0971-9784.97978  
Dexmedetomidine is a highly selective α2 -adrenergic agonist approved for short-term sedation and monitored anesthesia care in adults. Although not approved for use in the pediatric population, an increasing number of reports describe its use in pediatric patients during the intraoperative period and in the intensive care unit. Dexmedetomidine can potentially have an adverse impact on the cardiovascular system secondary to its negative chronotropic and dromotropic effects. However, it is these cardiac effects that are currently being explored as a therapeutic option for the treatment of perioperative tachyarrhythmias in pediatric patients with congenital heart disease (CHD). We report the use of dexmedetomidine to treat junctional ectopic tachycardia (JET), which developed following cardiopulmonary bypass for surgical correction of Tetralogy of Fallot in a 6-week-old infant. Within 15 min of increasing the dexmedetomidine infusion from 0.5 to 3 μg/kg/h, JET converted to normal sinus rhythm. This case report provides additional anecdotal evidence that dexmedetomidine may have a therapeutic role in the treatment of perioperative tachyarrhythmias in pediatric patients with CHD. The specific effects of dexmedetomidine on the cardiac conduction system are reviewed followed by a summary of previous reports describing its use as a therapeutic agent to treat perioperative arrhythmias.
  6,642 442 11
EDITORIAL
Dexmedetomidine in pediatric cardiac anesthesia
Praveen Kumar Neema
July-September 2012, 15(3):177-179
DOI:10.4103/0971-9784.97972  
  5,930 708 4
LETTERS TO EDITOR
Resistance to withdraw a Swan-Ganz catheter: A word of caution
Monish S Raut, Arun Maheshwari, Vishal Garg
July-September 2012, 15(3):254-255
DOI:10.4103/0971-9784.97989  
  5,053 179 -
ORIGINAL ARTICLES
N-terminal pro-brain natriuretic peptide identifies patients at risk for occurence of postoperative atrial fibrillation in cardiac surgery with cardiopulmonary bypass
Kallel Samy, Jarraya Anouar, Emna Mnif, Frikha Imed, Ayadi Fatma, Karoui Abdelhamid
July-September 2012, 15(3):199-205
DOI:10.4103/0971-9784.97976  
Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery with cardiopulmonary bypass (CPB).The value of N-terminal (Nt)-pro brain natriuretic peptide (BNP) in predicting AF complicating cardiac surgery is not well studied. Our objective is to determine its predictive value in the occurrence of AF after cardiac surgery with CPB. In a prospective observational study, including patients scheduled for cardiac surgery with CPB, we collected blood samples for each patient: the first one immediately after the induction of anesthesia and before CPB. The subsequent samples were taken at the end of the CBP (H0), 4 hours later (H4), and every day during the first four days (H24, H48, H72 and H96). Nt-proBNP and cardiac troponin (cTnI) were measured in each sample. The levels of Nt-proBNP were significantly increased in patients who developed AF. The receiver operating characteristic curve (ROC) analysis of Nt-proBNP studied at different times showed that assays at the end of the CPB and at H4 had the maximum area under the curve (AUC). A threshold value of 353.5 pg/mL of Nt-proBNP at the end of the CPB showed a sensitivity of 71% and a specificity of 84% for the prediction of AF and an AUC of 0.711. The threshold value (307.5 pg/mL) of Nt- proBNP measured at H4 had the same sensitivity but a lower specificity (74%) and AUC = 0.709. We conclude that Nt-proBNP values of 353 and 307 pg/mL at 0 and 4 hour after CPB could predict occurrence of AF.
  4,320 265 5
CASE REPORTS
Open surgical repair of abdominal aortic aneurysm: Proximal aortic control by endoaortic balloon - A novel approach
Balakrishnan Soundaravalli, M Palaniappan, Rajani Sundar, P Chandrasekar
July-September 2012, 15(3):236-239
DOI:10.4103/0971-9784.97981  
Patients with infrarenal abdominal aortic aneurysm with unfavorable anatomy for endovascular aneurysm repair have to undergo open surgical repair. Open surgery has its own morbidity in terms of proximal clamping and declamping, bleeding and prolonged hospital stay and mortality. We present two such patients with juxtarenal abdominal aortic aneurysm who underwent open surgical repair. The proximal aortic control during open surgical repair of the aneurysm was achieved by endoaortic balloon occlusion technique.
  4,389 178 -
Headache and seizures after cervical epidural injection in a patient undergoing coronary artery bypass grafting
Dheeraj Arora, Yatin Mehta, Aashish Jain, Naresh Trehan
July-September 2012, 15(3):244-246
DOI:10.4103/0971-9784.97983  
Epidural analgesia is widely used in cardiothoracic surgery. Most of the complications associated with epidural analgesia are related to the insertion techniques of epidural catheter. A 68-year-old obese patient posted for coronary artery bypass grafting surgery developed headache followed by seizures after insertion of the thoracic epidural catheter. Magnetic resonance imaging revealed air in the basal cisterns and in the left frontal region. The patient was managed conservatively and the symptoms subsided after 24 h. Later, the patient underwent coronary angioplasty.
  4,253 180 1
TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy
Rajesh Chand Arya, Naresh Kumar Sood, Sarju Ralhan, Gurpreet Singh Wander
July-September 2012, 15(3):229-232
DOI:10.4103/0971-9784.97979  
Biventricular pacing has demonstrated improvement in cardiac functions in treating congestive cardiac failure patients. Recent trials have proven the clinical and functional benefits of cardiac resynchronization therapy in severe heart failure and intraventricular cardiac delays, mainly left bundle branch block. Biventricular pacing improves the exercise tolerance, quality of life, systolic heart function, reduces hospitalization and slows progression of the disease. A 54-year-old lady, a known case of dilated cardiomyopathy, was on biventricular pacing since 2 years. She presented in emergency with sudden deterioration of dyspnea to NYHA class III/IV. When investigated, the coronary sinus lead was found displaced; thus, left ventricle (LV) was not getting paced. After multiple failures to reposition the coronary sinus lead, it was decided to surgically place the epicardial lead for LV pacing under general anesthesia. Lateral thoracotomy was done and LV pacing lead was placed at different sites with simultaneous monitoring of cardiac output (CO) and stroke volume (SV) by transesophageal echocardiography (TEE). Baseline CO and SV were 1.9 l/min and 19.48 ml respectively and increased at different sites of pacing at LV, the best CO and SV were 4.2 l/min and 42.39 ml respectively on lateral surface. Intraoperative TEE can calculate beat to beat stroke volume and thus CO and helps to choose optimal site for placement of epicardial pacing lead.
  4,209 147 3
Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion
Vishal Garg, Reena Joshi, Raja Joshi
July-September 2012, 15(3):233-235
DOI:10.4103/0971-9784.97980  
Transesophageal echocardiography (TEE) has become an important monitoring tool for the anesthesiologist during repair of intracardiac defects. Although the incidence of reported complications associated with its use is low, one should be careful during the insertion and use of TEE probe, as it may result in potential devastating problems. We present a case of undiagnosed aberrant right subclavian artery (ARSA) that got compressed by the TEE probe during its insertion. It was noticed because of the presence of the right radial artery catheter, else it would have passed unnoticed.
  3,605 124 -
LETTERS TO EDITOR
40-year-old externalized pacemaker lead: To extract or not to extract - That is the risk assessment question
Vicko Gluncic, Dalip Singh, G Hossein Almassi
July-September 2012, 15(3):252-253
DOI:10.4103/0971-9784.97987  
  3,296 94 -
CASE REPORTS
Giant right coronary artery aneurysm with unusual physiology: Role of intraoperative transesophageal echocardiography
David M Orozco, Mauricio Abello, Javier Osorio, Ivan Melgarejo
July-September 2012, 15(3):240-243
DOI:10.4103/0971-9784.97982  
A 65-year-old woman presented with a history of dyspnea and atypical chest pain. She was diagnosed with a non-ST-segment elevation myocardial infarction due to a giant right coronary artery aneurysm. After a failed percutaneous embolization, she was scheduled for right coronary artery aneurysm resection, posterior descending artery revascularization and mitral valve repair. During the induction of anesthesia and institution of mechanical ventilation, the patient suffered cardiovascular collapse. The transesophageal echocardiographic examination revealed tamponade physiology owing to compression of the cardiac chambers by the unruptured aneurysm, which resolved with the sternotomy. The surgery was carried out uneventfully.
  2,923 193 -
INTERESTING IMAGES
Left ventricular pseudoaneurysm following mitral valve surgery
Shashikanth Manikappa, Brendan Ingram
July-September 2012, 15(3):247-249
DOI:10.4103/0971-9784.97984  
  2,435 137 1
Intermittent obstruction of left ventricular assist device due to prolapsing papillary muscle
Clint G Humpherys, Steven T Morozowich, Harish Ramakrishna
July-September 2012, 15(3):250-251
DOI:10.4103/0971-9784.97986  
  2,430 111 1
LETTERS TO EDITOR
Effect of prophylactic amiodarone in a patient with rheumatic valve disease undergoing valve replacement surgery
Vivek Chowdhry
July-September 2012, 15(3):253-254
DOI:10.4103/0971-9784.97988  
  2,134 171 -
ERRATUM
Erratum

July-September 2012, 15(3):249-249
  1,516 72 -