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   2014| October-December  | Volume 17 | Issue 4  
    Online since October 1, 2014

 
 
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ORIGINAL ARTICLES
Echocardiography derived three-dimensional printing of normal and abnormal mitral annuli
Feroze Mahmood, Khurram Owais, Mario Montealegre-Gallegos, Robina Matyal, Peter Panzica, Andrew Maslow, Kamal R Khabbaz
October-December 2014, 17(4):279-283
DOI:10.4103/0971-9784.142062  PMID:25281624
Aims and Objectives: The objective of this study was to assess the clinical feasibility of using echocardiographic data to generate three-dimensional models of normal and pathologic mitral valve annuli before and after repair procedures. Materials and Methods: High-resolution transesophageal echocardiographic data from five patients was analyzed to delineate and track the mitral annulus (MA) using Tom Tec Image-Arena software. Coordinates representing the annulus were imported into Solidworks software for constructing solid models. These solid models were converted to stereolithographic (STL) file format and three-dimensionally printed by a commercially available Maker Bot Replicator 2 three-dimensional printer. Total time from image acquisition to printing was approximately 30 min. Results: Models created were highly reflective of known geometry, shape and size of normal and pathologic mitral annuli. Post-repair models also closely resembled shapes of the rings they were implanted with. Compared to echocardiographic images of annuli seen on a computer screen, physical models were able to convey clinical information more comprehensively, making them helpful in appreciating pathology, as well as post-repair changes. Conclusions: Three-dimensional printing of the MA is possible and clinically feasible using routinely obtained echocardiographic images. Given the short turn-around time and the lack of need for additional imaging, a technique we describe here has the potential for rapid integration into clinical practice to assist with surgical education, planning and decision-making.
  19 4,346 232
CASE REPORTS
Large Eustachian valve: An incidental finding yet perplexing
Anju Sarupria, V Bhuvana, Manju Mani, A Sampath Kumar
October-December 2014, 17(4):309-310
DOI:10.4103/0971-9784.142073  PMID:25281632
Eustachian valve (EV), a remnant of the right valve of sinus venosus in the right atrium can be puzzling. Often it is confused with Chiari network or atrial adhesions and is reported with unusual complications. We report a case of large EV impeding cannulation of inferior vena cava (IVC) during aortic valve replacement. Transesophageal echocardiography diagnosed the presence of large EV and warned of the difficulty with IVC cannulation and helped preparedness for an alternative plan during surgery.
  6 4,552 170
ORIGINAL ARTICLES
Comparison between continuous non-invasive estimated cardiac output by pulse wave transit time and thermodilution method
Ashish C Sinha, Preet Mohinder Singh, Navneet Grewal, Mansoor Aman, Gerald Dubowitz
October-December 2014, 17(4):273-277
DOI:10.4103/0971-9784.142059  PMID:25281622
Aims and Objectives: Cardiac output (CO) measurement is essential for many therapeutic decisions in anesthesia and critical care. Most available non-invasive CO measuring methods have an invasive component. We investigate "pulse wave transit time" (estimated continuous cardiac output [esCCO]) a method of CO measurement that has no invasive component to its use. Materials and Methods: After institutional ethical committee approval, 14 adult (21-85 years) patients undergoing surgery and requiring pulmonary artery catheter (PAC) for measuring CO, were included. Postoperatively CO readings were taken simultaneously with thermodilution (TD) via PAC and esCCO, whenever a change in CO was expected due to therapeutic interventions. Both monitoring methods were continued until patients' discharge from the Intensive Care Unit and observer recording values using TD method was blinded to values measured by esCCO system. Results: Three hundred and one readings were obtained simultaneously from both methods. Correlation and concordance between the two methods was derived using Bland-Altman analysis. Measured values showed significant correlation between esCCO and TD ( r = 0.6, P < 0.001, 95% confidence limits of 0.51-0.68). Mean and (standard deviation) for bias and precision were 0.13 (2.27) L/min and 6.56 (2.19) L/min, respectively. The 95% confidence interval for bias was - 4.32 to 4.58 L/min and for precision 2.27 to10.85 L/min. Conclusions: Although, esCCO is the only true non-invasive continuous CO monitor available and even though its values change proportionately to TD method (gold standard) with the present degree of error its utility for clinical/therapeutic decision-making is questionable.
  5 4,207 425
CASE REPORTS
Right-sided aortic arch with Kommerell's aneurysm
Sanjay Orathi Patangi, Rajendra Kumar Singh, Henning Pauli
October-December 2014, 17(4):311-313
DOI:10.4103/0971-9784.142075  PMID:25281633
We present a case report of a 55-year-old lady who presented with progressive dysphagia and was diagnosed with a Kommerell's aneurysm and a right-sided aortic arch. This case report outlines our management strategy and the challenges encountered during the perioperative period in a patient with this rare anomaly.
  1 3,834 137
Intraoperative localization and monitoring of migrating foreign body using transesophageal echocardiography
Bhupesh Kumar, Ashok Kumar Badamali, Aveek Jayant, Ishwar Bhukal, Goverdhan D Puri
October-December 2014, 17(4):314-317
DOI:10.4103/0971-9784.142076  PMID:25281634
Radiological imaging is often used for the preoperative localization of foreign body following blast injury, but their utility in case of migration during intra-operative period is limited. Transesophageal echocardiography (TEE) has been used for intra-operative localization and removal of intra-cardiac foreign body; however, reports for localization of extracardiac migrating foreign body are few. Preoperative radiological imaging, in a victim of factory blast-injury, suggested foreign body in the posterior mediastinum. However, the intra-operative TEE showed it in the left atrium, which later migrated into the left ventricle necessitating a change in surgical approach for its removal.
  1 1,965 122
Successful anesthetic management in a child after traumatic rupture of left main bronchus by a single-lumen cuffed-endotracheal tube
Hamed Elgendy, Tariq Jilani
October-December 2014, 17(4):292-295
DOI:10.4103/0971-9784.142066  PMID:25281627
Tracheobronchial injury (TBI) may lead to catastrophe if remains undetected or managed improperly. The incidence of TBI is less in children as compared with adults due to their pliable chest wall. Its clinical manifestations include persistent pneumothorax, cervical subcutaneous emphysema, pneumomediastinum, cyanosis, and respiratory insufficiency. The recommended airway management is to intubate the healthy bronchus with a single-lumen or double-lumen endotracheal tube (ET) and bypassing the injured side. We report successful anesthetic management of traumatic rupture of the left main bronchus in a child by using a single-lumen cuffed-ET. Many factors affect the outcome of such injuries and include the extent of the lesion, the resulting pulmonary status, the adequacy of surgical reconstruction. More severe injury may require lobectomy or pneumonectomy. Early diagnosis and proper management result in good functional outcome.
  1 2,227 197
A proposed method to visualize the ductus arteriosus on transesophageal echocardiography
Raviraj Gogia, Bhupesh Kumar, Aveek Jayant
October-December 2014, 17(4):296-298
DOI:10.4103/0971-9784.142068  PMID:25281628
The ductus arteriosus occupies a uniquely privileged position in the management of heart disease; it initiated not only the surgical management of congenital lesions but also the percutaneous management of this subset. During trans-thoracic echocardiography (TTE) the ductus is often visualized using 'high' parasternal (or the 'ductal' view) or suprasternal windows. It is generally agreed that imaging ductus during transesophageal echo (TEE) can be sub-optimal. During TEE imaging, visualization of the ductus arteriosus is obscured by the acoustic impedance offered by the left main bronchus; adjunct techniques such as insertion of a saline filled balloon in this airway have been used. We describe a simple maneuver that allows visualization of the patent ductus arteriosus during TEE imaging without the use of any adjuncts.
  1 4,087 264
Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan
Sathish Kumar Dharmalingam, Raj Sahajanandan
October-December 2014, 17(4):306-308
DOI:10.4103/0971-9784.142072  PMID:25281631
Transesophageal echocardiography (TEE) is an important diagnostic tool. It provides structural and functional assessment of cardiac structures which can improve the overall outcome of the patient. We present a case with right atrial myxoma in which TEE helped to find the attachment of the mass so that overall surgical plan was changed.
  1 2,223 174
INTERESTING IMAGES
Left atrial band: A rare congenital anomaly
Kevin Liou, Manuja Premaratne, Gita Mathur
October-December 2014, 17(4):318-319
DOI:10.4103/0971-9784.142077  PMID:25281635
Left atrial fibromuscular band is a rare congenital cardiac anomaly. We present a patient with an incidental finding of left atrial band on an intra-operative transesophageal echocardiogram and characterize its appearance on two-dimensional and three-dimensional echocardiograms.
  1 3,918 144
JANAK MEHTA AWARD
Predicting mortality after congenital heart surgeries: Evaluation of the Aristotle and Risk Adjustement in Congenital Heart surgery-1 risk prediction scoring systems: A retrospective single center analysis of 1150 patients
Shreedhar S Joshi, G Anthony, D Manasa, T Ashwini, AM Jagadeesh, Deepak P Borde, Seetharam Bhat, CN Manjunath
October-December 2014, 17(4):266-270
DOI:10.4103/0971-9784.142057  PMID:25281620
Aims and Objectives: To validate Aristotle basic complexity and Aristotle comprehensive complexity (ABC and ACC) and risk adjustment in congenital heart surgery-1 (RACHS-1) prediction models for in hospital mortality after surgery for congenital heart disease in a single surgical unit. Materials and Methods: Patients younger than 18 years, who had undergone surgery for congenital heart diseases from July 2007 to July 2013 were enrolled. Scoring for ABC and ACC scoring and assigning to RACHS-1 categories were done retrospectively from retrieved case files. Discriminative power of scoring systems was assessed with area under curve (AUC) of receiver operating curves (ROC). Calibration (test for goodness of fit of the model) was measured with Hosmer-Lemeshow modification of χ2 test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to assess reclassification. Results: A total of 1150 cases were assessed with an all-cause in-hospital mortality rate of 7.91%. When modeled for multivariate regression analysis, the ABC (χ2 = 8.24, P = 0.08), ACC (χ2 = 4.17 , P = 0.57) and RACHS-1 (χ2 = 2.13 , P = 0.14) scores showed good overall performance. The AUC was 0.677 with 95% confidence interval (CI) of 0.61-0.73 for ABC score, 0.704 (95% CI: 0.64-0.76) for ACC score and for RACHS-1 it was 0.607 (95%CI: 0.55-0.66). ACC had an improved predictability in comparison to RACHS-1 and ABC on analysis with NRI and IDI. Conclusions: ACC predicted mortality better than ABC and RCAHS-1 models. A national database will help in developing predictive models unique to our populations, till then, ACC scoring model can be used to analyze individual performances and compare with other institutes.
  1 6,614 628
REVIEW ARTICLES
Therapeutic hypothermia after cardiac arrest
Abdullah Alshimemeri
October-December 2014, 17(4):285-291
DOI:10.4103/0971-9784.142065  PMID:25281626
Prognosis following out-of-hospital cardiac arrest is generally poor, which is mostly due to the severity of neuronal damage. Recently, the use of therapeutic hypothermia has gradually occupied an important role in managing neuronal injuries in some cases of cardiac arrests. Some of the clinical trials conducted in comatose post-resuscitation cardiac arrest patients within the last decade have shown induced hypothermia to be effective in facilitating neuronal function recovery. This method has since been adopted in a number of guidelines and protocols as the standard method of treatment in carefully selected patient groups. Patient inclusion criteria ensure that hypothermia-associated complications are kept to a minimum while at the same time maximizing the treatment benefits. In the present work, we have examined different aspects in the use of therapeutic hypothermia as a means of managing comatose patients following cardiac arrest.
  1 7,402 663
CASE REPORTS
Toe thumb: A musculoskeletal disorder related to transesophageal echocardiography
Prabhat Tewari, P.S.N Raju, PK Neema
October-December 2014, 17(4):299-301
DOI:10.4103/0971-9784.142069  PMID:25281629
The musculoskeletal disorders (MSD) are common in healthcare providers and those who are doing sonography are also affected. There are reports of MSD in healthcare providers who do transthoracic echocardiography. Transesophageal echocardiography (TEE) is being regularly used in peri-operative setting. We describe MSD of hand in a cardiovascular and thoracic anesthesiologist who has been performing TEE scanning for 10% of his work-time in operating room and critical care area for the last 8 years. As the role of TEE is increasing and many doctors are doing it on a routine basis, the knowledge of association of MSD with TEE and measures to prevent it is important.
  - 2,315 143
Severe tracheobronchial compression in a patient with Turner's syndrome undergoing repair of a complex aorto-subclavian aneurysm: Anesthesia perspectives
Christopher C .C. Hudson, Jeremie Stewart, Carole Dennie, Tarek Malas, Munir Boodhwani
October-December 2014, 17(4):302-305
DOI:10.4103/0971-9784.142071  PMID:25281630
We present a case of severe tracheobronchial compression from a complex aorto-subclavian aneurysm in a patient with Turner's syndrome undergoing open surgical repair. Significant airway compression is a challenging situation and requires careful preoperative preparation, maintenance of spontaneous breathing when possible, and consideration of having an alternative source of oxygenation and circulation established prior to induction of general anesthesia. Cardiopulmonary monitoring is essential for safe general anesthesia and diagnosis of unexpected intraoperative events.
  - 2,670 144
EDITORIAL
Exponential growth of tranesesophageal echocardiography in India in the last decade: Contribution of Indian association of cardiovascular thoracic anesthesiologists
Poonam Malhotra Kapoor
October-December 2014, 17(4):263-265
DOI:10.4103/0971-9784.142056  PMID:25281619
  - 1,641 189
INVITED COMMENTARY
Echocardiography derived three- dimensional printing of normal and abnormal mitral annuli
KK Kapur, Naveen Garg
October-December 2014, 17(4):283-284
PMID:25281625
  - 1,593 108
Predicting mortality after congenital heart surgeries: Evaluation of the Aristotle and risk adjustment in congenital heart surgery-1 risk prediction scoring systems: A retrospective single center analysis of 1150 patients
Krishna S Iyer, Parvathi U Iyer
October-December 2014, 17(4):271-272
PMID:25281621
  - 1,774 165
Comparison between continuous noninvasive estimated cardiac output by pulse wave transit time and thermodilution method
Yatin Mehta
October-December 2014, 17(4):278-278
PMID:25281623
  - 1,644 149
LETTER TO EDITOR
An uncommon presentation of partially ligated left atrial appendage on transesophageal echocardiography
Sarvesh Pal Singh, Suruchi Hasija, Sandeep Chauhan
October-December 2014, 17(4):320-321
DOI:10.4103/0971-9784.142079  PMID:25281636
  - 1,246 108