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   2021| April-June  | Volume 24 | Issue 2  
    Online since April 19, 2021

 
 
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REVIEW ARTICLE
Impact of frailty in cardiac surgical patients—Assessment, burden, and recommendations
Akshay Shanker, Preeti Upadhyay, Valluvan Rangasamy, Kanchi Muralidhar, Balachundhar Subramaniam
April-June 2021, 24(2):133-139
DOI:10.4103/aca.ACA_90_20  PMID:33884967
Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.
  2,914 218 -
Perioperative care of heart transplant recipients undergoing non-cardiac surgery
Jose R Navas-Blanco, Raj K Modak
April-June 2021, 24(2):140-148
DOI:10.4103/aca.ACA_130_19  PMID:33884968
The life expectancy of patients with end-stage heart disease undergoing Orthotopic Heart Transplantation (OHT) has increased significantly in the recent decades since its original introduction into the medical practice in 1967. Substantial advances in post-operative intensive care, surgical prophylaxis, and anti-rejection drugs have clearly impacted survivability after OHT, therefore the volume of patients presenting for non-cardiac surgical procedures is expected to continue to escalate in the upcoming years. There are a number of caveats associated with this upsurge of post-OHT patients requiring non-cardiac surgery, including presenting to healthcare facilities without the resources and technology necessary to manage potential perioperative complications or that may not be familiar with the care of these patients, facilities in which a cardiac anesthesiologist is not available, patients presenting for emergency procedures and so forth. The perioperative care of patients after OHT introduces several challenges to the anesthesiologist including preoperative risk assessments different to the general population and intraoperative management of a denervated organ with altered response to medications and drug-drug interactions. The present review aims to synopsize current data of patients presenting for non-cardiac surgery after OHT, surgical aspects of the transplant that may impact perioperative care, physiology of the transplanted heart as well as anesthetic considerations.
  2,583 243 -
ORIGINAL ARTICLES
Plasma concentrations of cefazolin in pediatric patients undergoing cardiac surgery
Saowaphak Lapmahapaisan, Wiriya Maisat, Kriangkrai Tantiwongkosri, Pinpilai Jutasompakorn, Waraphorn Sisan
April-June 2021, 24(2):149-154
DOI:10.4103/aca.ACA_106_19  PMID:33884969
Background: The guideline for antibiotic prophylaxis in pediatric cardiac surgery is currently unavailable, and the effects of cardiopulmonary bypass (CPB) may result in low plasma cefazolin concentrations and subsequent postoperative surgical site infections (SSIs). Aims: To demonstrate the calculated-unbound plasma concentrations of cefazolin during uncomplicated pediatric cardiac surgery. Settings and Design: A prospective observational study that included 18 patients <seven years of age, undergoing elective cardiac surgery with CPB. Materials and Methods: An intravenous infusion of cefazolin (25 mg.kg-1) was administered to patients over 30 minutes within 1 hour before skin incision (first dose). Another 25 mg.kg-1 infusion was administered to the CPB prime volume (second dose). Blood samples were obtained at eight time points: 15 minutes after the first dose (T1); before aortic cannulation (T2); immediately after CPB initiation (T3); 30 (T4), 60 (T5), and 120 (T6) minutes after CPB; 15 minutes after CPB discontinuation (T7), and at skin closure (T8). The total plasma cefazolin concentrations were measured using liquid chromatography tandem mass spectrometry. Results: The unbound cefazolin concentrations were calculated assuming 80%-protein binding. The median cefazolin levels were 18.1 (range 4.3-27.0), 11.9 (2.8-24.1), 31.4 (18.3-66.1), 23.4 (13.7-35.9), 20.2 (15.4-24.9), 17.7 (14.8-18.0), 15.6 (9.8-26.2), and 13.3 (8.3-24.6) μg.mL-1 from T1-T8, respectively. The cefazolin levels remained four times above the minimum inhibitory concentrations (MICs) for Methicillin-sensitive S. aureus (MSSA) and S. epidermidis in most patients, but they were inadequate for Enterobacter and E. coli. Conclusion: This regimen produced adequate plasma cefazolin concentrations for common organisms that cause SSIs after cardiac surgery.
  2,328 154 1
EDITORIALS
Are current prophylactic antibiotic dosing regimens in pediatric cardiac surgery sufficient to prevent surgical-site infections?
Priscilla Hui Yi Phoon, Nian Chih Hwang
April-June 2021, 24(2):129-130
DOI:10.4103/aca.ACA_156_19  PMID:33884965
  2,316 143 -
Frailty: Watch ageing, not the age
Anil Karlekar
April-June 2021, 24(2):131-132
DOI:10.4103/aca.ACA_159_20  PMID:33884966
  1,952 127 -
ORIGINAL ARTICLES
Clinical efficacy of levosimendan vs milrinone in preventing low cardiac output syndrome following pediatric cardiac surgery
Kaushik Jothinath, Soundaravalli Balakrishnan, Vijayakumar Raju, Shoba Menon, Jenit Osborn
April-June 2021, 24(2):217-223
DOI:10.4103/aca.ACA_160_19  PMID:33884979
Background: Prophylactic milrinone is commonly used to prevent Low Cardiac Output Syndrome (LCOS) after pediatric cardiac surgery. This study compares the use of levosimendan with milrinone when used as the primary inotrope following pediatric cardiac surgery. Subjects and Methods: Forty infants undergoing corrective surgery for congenital heart disease were recruited during the study and randomized into two groups (group L and group M). During rewarming, a loading dose of levosimendan or milrinone was administered followed by a 24-hour infusion of the chosen inotrope. Echocardiographic variables were measured postoperatively. Statistical analysis was done with SPSS-20 computer package. Association between the variables was found by independent t test. P < 0.05 was considered statistically significant. Results: Mean age and weight of the patient in Group L was 8.55 ± 5.83 months and 6.05 ± 2.09 kgs, while that in group M was 6.85 ± 3.57 months and 5.26 ± 2.11 kgs. 4 patients (20%) treated with levosimendan had LCOS in comparison with 6 (30%) patients in those treated with milrinone. Echocardiographic parameters in both groups L and M were comparable (cardiac index 3.47 ± 0.76 vs 3.72 ± 1.05 L/min/m2, EF 66.10 ± 7.82% vs 59.34 ± 10.74%, stroke volume index 25.4 ± 6.3 vs 27.74 ± 10.35 mL/m2). The duration of ventilation, ICU stay and hospital stay were lesser in group L (12.75 ± 9.69, 35.95 ± 12.11, 119.10 ± 46.397 vs 23.60 ± 22.03, 51.20 ± 29.92, 140.20 ± 52.65 hours). Conclusions: The incidence of LCOS was lesser in those patients treated with levosimendan, when compared with those treated with milrinone. Cardiac index and stroke volume index were comparable between the two groups. Thus, levosimendan provides a non-inferior alternative to milrinone when used as the primary inotrope following pediatric cardiac surgery.
  1,604 225 -
Less is more: We are administering too much protamine in cardiac surgery
Francesco De Simone, Pasquale Nardelli, Margherita Licheri, Giovanna Frau, Martina Baiardo Redaelli, Fabrizio Monaco, Alberto Zangrillo, Giovanni Landoni
April-June 2021, 24(2):178-182
DOI:10.4103/aca.ACA_26_19  PMID:33884973
Context: Protamine is routinely administered to neutralize the anticlotting effects of heparin, traditionally at a dose of 1 mg for every 100 IU of heparin—a 1:1 ratio protamine sparing effects—but this is based more on experience and practice than literature evidence. The use of Hemostasis Management System (HMS) allows an individualized heparin and protamine titration. This usually results in a decreased protamine dose, thus limiting its side effects, including paradox anticoagulation. Aims: This study aims to assess how the use of HMS allows to reduction of protamine administration while restoring the basal activated clotting time (ACT) at the end of cardiac surgery. Settings and Design: A retrospective observational study in a tertiary care university hospital. Subjects and Methods: We analyzed data from 42 consecutive patients undergoing cardiopulmonary bypass (CPB) for cardiac surgery. For all patients HMS tests were performed before and after CPB, to determine how much heparin was needed to reach target ACT, and how much protamine was needed to reverse it. Results: At the end of cardiopulmonary bypass, 2.2 ± 0.5 mg/kg of protamine was sufficient to reverse heparin effects. The protamine-to-heparin ratio was 0.56:1 over heparin total dose (a 44% reduction) and 0.84:1 over heparin initial dose (a 16% reduction). Conclusion: A lower dose of protamine was sufficient to revert heparin effects after cardiopulmonary bypass. While larger studies are needed to confirm these findings and detect differences in clinically relevant outcomes, the administration of a lower protamine dose is endorsed by current guidelines and may help to avoid the detrimental effects of protamine overdose, including paradox bleeding.
  1,300 179 1
Venoarterial extra corporeal membrane oxygenation and blood component usage in pediatric patients undergoing cardiac surgery: Single centre experience
Jigar Surti, Imelda Jain, Amit Mishra, Trushar Gajjar, Atul Solanki, Jigar Patel, Jatin Shah, Sapna Shah
April-June 2021, 24(2):203-208
DOI:10.4103/aca.ACA_112_19  PMID:33884977
Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery. Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients. Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients. Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days). Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers.
  1,194 118 -
Comparative study of intranasal dexmedetomidine v/s midazolam for sedation of pediatric patients during transthoracic echocardiography
Suvendu Panda, Jigisha Pujara, Ankit Chauhan, Abhishek Varma, Rajesh venuthurupalli, Himani Pandya, Sanjay Patel
April-June 2021, 24(2):224-229
DOI:10.4103/aca.ACA_17_20  PMID:33884980
Background: Procedural sedation required to improve the quality of Transthoracic Echocardiography (TTE) in infants and children. The ideal drug and route for sedation in children should have a rapid and reliable onset, atraumatic, palatable with minimal side effects, and rapid recovery. So, the aim of our study to evaluate and compare the efficacy and safety of intranasal midazolam and intranasal dexmedetomidine in pediatric patients for sedation during TTE. Materials and Method: Hundred children under three year of age, belonging to the American Society of Anaesthesiologists class-I and II, scheduled for TTE were divided into two groups by standard randomization technique. Patients in group-M received intranasal midazolam 0.2 mg/kg, whereas patients in group-D received intranasal dexmedetomidine 2 μg/kg prior to TTE under an adequately monitored anesthesia care. Onset and duration of sedation, heart rate, oxygen saturation, sonographer's, and parent's satisfaction scores were recorded. Results: All patients were successfully sedated for TTE. The average onset time, sedation time, awakening time and total time for Group-M were 7.3, 18.8, 29.51, 51 min and group-D were 10.1, 14.2, 24.9, 46.3 min, respectively and all were statistically significant (P < 0.001). TTE scan time of Group-M is 8.84 min and Group-D is 9.18 min and was statistically significant. Sonographer's and Parent's average satisfaction score for Group-M was 9.88, 10 and for Group-D was 7.64, 8.76, respectively, which were statistically significant (P < 0.001). Conclusion: Intranasal midazolam and dexmedetomidine are safe and effective for sedation in TTE. Intranasal midazolam was found to be comparatively more effective in view of onset of action, sonographers, and parental satisfaction score, while sedation time, awakening time and total duration was significantly higher as compared to intranasal dexmedetomidine.
  1,152 133 -
Effect of perioperative acetaminophen on body temperature after cardiovascular surgery with cardiopulmonary bypass: A single-center retrospective study
Shohei Kaneko, Taiga Ichinomiya, Shuntaro Sato, Motohiro Sekino, Hiroaki Murata, Tetsuya Hara
April-June 2021, 24(2):155-162
DOI:10.4103/aca.ACA_153_20  PMID:33884970
Context: Postoperative hyperthermia, which may lead to cognitive decline, is a common complication of cardiovascular surgery with cardiopulmonary bypass (CPB). Aims: The aim of this study was to examine the effectiveness of perioperative intravenous acetaminophen on body temperature in adult patients after cardiovascular surgery with CPB. Settings and Design: This was a single-center retrospective study focusing on adult patients who underwent elective cardiovascular surgery with CPB at a university hospital in Japan. Subjects and Methods: Patients were divided into two groups based on whether they received acetaminophen perioperatively. In the acetaminophen group, 15 mg/kg intravenous acetaminophen solution was infused at 30 min after discontinuation of CPB and every 6 h after intensive care unit (ICU) admission. Statistical Analysis Used: The primary outcome was the maximum axillary temperature within 12 h after ICU admission. The effects of acetaminophen on postoperative body temperature were estimated by the standardization and inverse probability weighting using propensity scores. Results: A total of 201 patients were included in the final analysis (acetaminophen group, n = 101; non-acetaminophen group, n = 100). The maximum axillary temperature within 12 h after ICU admission was 37.20 ± 0.54°C in the acetaminophen group and 37.78 ± 0.59°C in the non-acetaminophen group. Acetaminophen lowered the standardized mean of primary endpoint (−0.54°C, 95% confidence interval, −0.69 to −0.38) compared to non-acetaminophen. Conclusions: Perioperative intravenous acetaminophen inhibited body temperature elevation after cardiovascular surgery with CPB, compared with the non-acetaminophen group.
  1,091 116 -
Combined off pump coronary artery bypass graft and liver transplant
Rajiv Juneja, Ajay Kumar, Rajeev Ranjan, PM Hemantlal, Yatin Mehta, Harpreet Wasir, Vijay Vohra, Naresh Trehan
April-June 2021, 24(2):197-202
DOI:10.4103/aca.ACA_194_19  PMID:33884976
Background: Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods: The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results: The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions: Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.
  1,071 127 -
Factors associated with delirium after cardiac surgery: A prospective cohort study
Lina Maria Ordonez-Velasco, Edgar Hernández-Leiva
April-June 2021, 24(2):183-189
DOI:10.4103/aca.ACA_43_20  PMID:33884974
Background: Delirium is a frequent complication after cardiac surgery and is associated with a higher incidence of morbidity and mortality and a prolonged hospital stay. However, knowledge of the variables involved in its occurrence is still limited; therefore, in this study, we evaluated the perioperative risk factors independently associated with this complication. Methods: This study was conducted in a referral tertiary care university hospital with a cardiovascular focus. A total of 311 consecutive adult patients undergoing any type of cardiac surgery were evaluated. The subjects were examined at regular intervals in the postoperative period using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) tool. Results: The incidence of postoperative delirium (PD) was 10%. Among the 18 pre-, intra- and postoperative variables evaluated, the logistic regression analysis showed that low education level, history of diabetes or stroke, type of surgery, prolonged extracorporeal circulation, or red blood cell transfusion in the intra- or postoperative period were independently associated with delirium after cardiac surgery. An increased body mass index was identified as a protective factor. Conclusions: The aforementioned risk factors are significantly and independently associated with the presentation of PD. Because some of these factors can be treated or avoided, the results of this study are highly relevant to reduce the risk of this complication and improve the care of patients undergoing cardiac surgery.
  1,030 164 1
BRIEF COMMUNICATION
A kid-friendly approach to Incentive Spirometry
Anish Gupta, Priyanka Mishra, Bhavna Gupta, Kamna Kakkar
April-June 2021, 24(2):238-240
DOI:10.4103/aca.ACA_188_19  PMID:33884984
Incentive spirometer (IS) is a popular choice for chest physiotherapy. It is used to optimize preoperative respiratory status and prevent postoperative pulmonary complications. However, the use of conventional forms of IS pose a challenging task in children due to the lack of cooperation, compliance, and submaximal effort on the part of pediatric patients. To tackle this problem, we describe an innovative and fascinating technique of spirometry. It employs a toy as a better acceptable incentive spirometry device in pediatric population. This toy has a mouthpiece and a long inflatable plastic strip at the other end. As the child blows into the mouthpiece, a captivating sound from the toy keeps buzzing progressively till the air is being blown during exhalation and is accompanied with inflation of the strip in an elongated fashion. Hence, this device incorporates the two best enjoyed incentives for children, namely, visual and audio to ensure patient compliance and participation.
  1,004 112 -
ORIGINAL ARTICLES
Evaluation of high-dose atorvastatin pretreatment influence in patients preconditioning of post coronary artery bypass graft surgery: A prospective triple blind randomized clinical trial
Misagh Bastani, Mohammad Bagher Khosravi, Masih Shafa, Simin Azemati, Behzad Maghsoodi, Elham Asadpour
April-June 2021, 24(2):209-216
DOI:10.4103/aca.ACA_34_19  PMID:33884978
Context: Atorvastatin is considered as lipid reductive drugs with anti-inflammatory and pleotherapic effects in coronary artery bypass graph (CABG). Aim: This study is conducted to evaluate the effects of atorvastatin in CABG. Setting and Design: Patients with a coronary bypass graph procedure in Nemazee hospital in Shiraz were divided into two 50-groups receiving high-dose (80 mg) and low-dose (20 mg) atorvastatin. Materials and Methods: Troponin I, creatinine kinase-MB (CK-MB), atrial fibrillation (AF) after CABG, duration of mechanical ventilation, inotrope duration of consumption, blood sugar profile, liver and renal function, death during 30 days of CABG, MACE (major advance cardiac events) during admission in ICU, and 1 month follow up were surveyed. Statistical Analysis: Collected data were analyzed by independent and paired t-test and Chi square. Results: AST was increased, ALT, ALK-P after CABG were decreased, and urine volume in the second day of admission in ICU was increased in the high-dose group. There was an increase and following decrease in blood sugar of patients in the high-dose after CABG. An inflammatory marker after CABG was raised in both groups, ck-mb had an increase, and then followed by a reduction. Troporin had no significant differences between groups. Patients with high-dose atorvastatin had better glomerular filtration rate and renal performance. Along with decreasing AF in the case group, hemodynamics' disorder reduced and there was less bleeding. Conclusion: According to the above, it seems that a short-time prescription of high dose of atorvastatin in CABG can lead to better renal function, decreasing of arrhythmia and AF.
  962 145 -
LETTERS TO EDITORS
Enhanced recovery after cardiac surgery: Is it just about putting the bundles together?
Rohan Magoon, Arindam Choudhury, Sourangshu Sarkar, Sandeep Joshi
April-June 2021, 24(2):276-278
DOI:10.4103/aca.ACA_91_19  PMID:33884997
  859 74 -
CASE REPORTS
Airway management by i-gel for open tracheal resection and reconstruction via combined cervicotomy and sternotomy surgical approach: A case report
Silvia Fiorelli, Giorgia Saltelli, Leonardo Teodonio, Domenico Massullo
April-June 2021, 24(2):260-262
DOI:10.4103/aca.ACA_59_19  PMID:33884991
Surgical resection and tracheal reconstruction are the most effective treatment options for airway stenosis. Tracheal surgery is challenging and requires a multidisciplinary approach and a highly specialized team of anesthesiologists and thoracic surgeons that are “sharing the airways”. Several airway management tools, different devices, and various approaches can be required to ensure ventilation and gas exchange. We describe the case of a patient affected by tight tracheal stenosis, submitted to tracheal resection and reconstruction via combined cervicotomy and sternotomy surgical approach. Airway management was successfully performed by i-gel® (Intersurgical, UK) supraglottic device.
  838 93 -
ORIGINAL ARTICLES
A comparison of sevoflurane versus sevoflurane-propofol combination on renal function in patients undergoing valvular heart surgery—A prospective randomized controlled pilot study
Reshmi L Jose, Deepa Damayanathi, Koniaparambil P Unnikrishnan, Puthuvassery R Suneel
April-June 2021, 24(2):172-177
DOI:10.4103/aca.ACA_171_19  PMID:33884972
Aim: The objective of the present study was to compare the effect of sevoflurane with the sevoflurane-propofol combination on renal function in patients undergoing valvular heart surgery. The renal protective effect was assessed using a novel marker called neutrophil gelatinase-associated lipocalin (NGAL). Materials and Methods: This was a prospective randomized controlled pilot study conducted at a tertiary care center in India. The study enrolled 36 patients undergoing elective valvular heart surgery, but only 31 were included. All the patients were randomized into two groups, that is, 15 in the sevoflurane group (S-group) and 16 in the sevoflurane–propofol group (SP-group). The baseline NGAL level and test NGAL level at 4 h after cardiopulmonary bypass were measured. Results: There was a significant rise in the test NGAL levels compared to baseline in both the groups. The test NGAL level in the S-group was significantly high compared to that of the SP-group (P = 0.034). The number of patients with acute kidney injury was less in the SP-group without reaching statistical significance (P = 0.210). Conclusion: Renal function was better preserved in patients anesthetized with a combination of sevoflurane and propofol. This could be due to the enhanced protective effect on renal function by both sevoflurane and propofol.
  754 93 1
CASE REPORTS
Hypoxia due to unusual right to left shunt after arterial switch surgery
Suresh Rao Kemundel Genny, Vignesh Kumar, Ganapathy Subramaniam, KR Balakrishnan
April-June 2021, 24(2):241-243
DOI:10.4103/aca.ACA_152_19  PMID:33884985
Hypoxia can occur after repair of transposition of great arteries. The most common cause of right to left shunt after arterial switch surgery is related to increased right ventricular pressures and persistent neonatal pulmonary arterial hypertension. We report a case of TGA repair causing right to left shunt with normal right ventricular pressures. Persistence of Eustachian valve with patent foramen ovale (PFO) is the unusual cause of hypoxia and desaturation. The patient was successfully managed by excision of Eustachian valve and closure of PFO.
  739 94 -
ORIGINAL ARTICLES
Validated tool for quality assessment of anesthesia services by cardiac surgeons
Rahul Guhabiswas, Saibal Roy Chowdhury, Pradeep Narayan
April-June 2021, 24(2):190-196
DOI:10.4103/aca.ACA_108_20  PMID:33884975
Background and Aim: The role of the cardiac anaesthesiologists extends beyond mere patient wellbeing to diagnostic input and active participation in decision making during cardiac surgery. The quality of service provision should therefore be judged not only by patient satisfaction but also by the satisfaction of cardiac surgeons. Unfortunately, quantification of cardiac surgeon satisfaction remains a challenge due to the absence of a reliable and validated tool. We therefore attempted to develop a robust, validated, pilot psychometric questionnaire, to measure satisfaction of cardiac surgeons' to cardiac anesthesia services. Methods: The questionnaire was developed with the help of senior cardiac anesthesiologist, cardiac surgeon and statistician with database search in PubMed and the Cochrane Library. The questionnaire was tested for content validity, comprehensibility, and identification of new items. This generated the second version of the questionnaire with nine socio-demographic and professional questions, 46 Likert type questions, an abridged Marlowe Crowne Social Desirability scale and one open ended question. This questionnaire was e-mailed to 100 cardiac surgeons requesting them to participate via a web-based survey application. Results: Content validity of the responses was tested by Aiken's content validity coefficient (V). Internal consistency was tested with Chronbach's alpha. Fifty-two cardiac surgeons participated in the survey. Twelve Likert type questions were deleted due to low V values. Excellent Chronbach's alpha (0.94) was obtained in the remaining 34 items. Conclusions: We have developed a questionnaire that includes 34 variables and allows quantifying surgeon satisfaction in a reliable fashion and is validated for the purpose.
  730 99 -
CASE REPORTS
Aortic valve and coronary artery bypass surgery in a patient with factor VII deficiency
Larissa Henze, Christian Junghanss, Alper Öner, Pascal M Dohmen, Anthony Alozie
April-June 2021, 24(2):244-246
DOI:10.4103/aca.ACA_181_20  PMID:33884986
Congenital factor VII (FVII) deficiency is a rare bleeding disorder (RBD) with phenotypes ranging from asymptomatic state to life threatening bleeding episodes. There is no established recommendation for the perioperative management of patients scheduled for cardiac surgery. We have described the perioperative management of a patient with FVII deficiency treated for aortic valve stenosis, coronary artery disease, and atrial fibrillation. Balancing perioperative bleeding risk and risks of thrombotic events thereafter in such patients is difficult and requires a multidisciplinary approach.
  748 79 -
INTERESTING IMAGES
Pulmonary artery sheath hematoma
Daniel L Plack, Kent H Rehfeldt, James A Nelson, Marissa L Kauss
April-June 2021, 24(2):232-233
DOI:10.4103/aca.ACA_135_20  PMID:33884982
Dissection of the ascending aorta (AA) represents a life-threatening condition typically treated by emergent surgical repair. A rare, potential complication of AA dissection is pulmonary artery (PA) sheath hematoma. Due to the presence of a common adventitial layer between the proximal AA and the PA, dissection can propagate between both vessels, potentially compromising the PA lumen. The resultant acute narrowing of the PA lumen may abruptly increase right ventricular (RV) afterload. Recognition of PA sheath hematoma is important; when seen on echocardiography it is suggestive of AA dissection and has the potential to result in RV hypertension and dysfunction if significant PA compression occurs.
  768 58 -
CASE REPORTS
Coronary subclavian steal syndrome causing myocardial Infarction
Paurush Ambesh, Khalid Sawalha, Kevin Groudan, Amir Lotfi, Gregory Giugliano
April-June 2021, 24(2):256-259
DOI:10.4103/aca.ACA_83_20  PMID:33884990
Coronary subclavian steal syndrome (CSSS) is a rare complication of the internal mammary artery (IMA) grafting in coronary artery bypass surgery. The technical definition is myocardial ischemia due to the reduced flow of blood, or flow reversal in the IMA graft. This in most cases results from hemodynamically significant proximal subclavian artery stenosis. The clinical presentation is variable and ranges from unstable angina to myocardial infarction, and in some cases, sudden cardiac arrest. CSSS is an entity that is hard to diagnose if one is not actively looking for it. The clinical diagnosis is often complicated, and the prevalence of the disorder is frequently underestimated. In this case presentation, we report a case of myocardial infarction that resulted from significant proximal subclavian artery stenosis.
  740 85 -
Anesthesia for laryngotracheal reconstruction in a child with single ventricle
Masood Mohseni, Aslan Ahmadi, Ayda Sanaei
April-June 2021, 24(2):269-271
DOI:10.4103/aca.ACA_103_19  PMID:33884994
The number of children with congenital heart requiring anesthetic care is increasing. We describe the anesthetic management of a child with single ventricle candidate for laryngotracheal reconstruction. The patient suffered from severe subglottic stenosis due to prolonged intubation following Glenn shunt procedure. Anesthetic considerations in the care of patients with single ventricle for non-cardiac surgeries are reviewed. Particular concerns in the airway management of children with severe subglottic stenosis and during the tracheal surgery are also reviewed.
  717 85 -
INTERESTING IMAGES
Incidental finding of interrupted inferior venacava during minimally invasive cardiac surgery
Subash Sundar Singh, Shaji Palangadan, Manish Yadav
April-June 2021, 24(2):234-237
DOI:10.4103/aca.ACA_170_19  PMID:33884983
We report a case of 44-year-old female patient with congenital heart disease, ostium secundum atrial septal defect (ASD) with moderate mitral regurgitation for minimally invasive ASD repair along with mitral valve repair. Venous cannulations were performed through right internal jugular vein and right femoral vein (RFV) and arterial cannulation was accomplished through right femoral artery. Intraoperative transesophageal echocardiography (TEE) could not visualize venous cannula through RFV. However, cardiopulmonary bypass (CPB) was initiated and surgery was proceeded. During surgery, patients abdomen became tense and distened, ontable ultrasound examination of abdomen was done after completion of the surgery to rule out hemoperitoneum but was inconclusive, patient was evaluated further under fluoroscopy in cathlab and found to have interrupted inferior vena cava. Postoperative course of the patient was uneventful. We discuss the importance of preoperative evaluation and the role of TEE in placement of cannulas during minimally invasive cardiac surgery.
  724 75 -
CASE REPORTS
Erector spinae plane block: An effective analgesic technique for pleurodesis after senning operation
Arindam Choudhury, Sourangshu Sarkar, Rohan Magoon, Subhajit Sahoo
April-June 2021, 24(2):263-265
DOI:10.4103/aca.ACA_105_19  PMID:33884992
Pain emanating from pleurodesis is significantly distressing and presents an important management concern. Despite encouraging evidence on the application of fascial plane blocks for cardiothoracic surgery, the literature on the use of erector spinae block for pleurodesis remains scarce. We describe a case of bilateral recurrent pleural effusion following congenital heart surgery where erector spinae block was employed as an analgesic technique for pleurodesis. Finally, we discuss its regional analgesic effects in comparison to the conventional intravenous/systemic analgesia in a cross over fashion.
  708 90 -
Bilateral whole lung lavage by lung isolation in a child with pulmonary alveolar proteinosis: A new technique
Brajesh Kaushal, Sandeeps Chauhan, Suruchi Hasija
April-June 2021, 24(2):266-268
DOI:10.4103/aca.ACA_90_19  PMID:33884993
We present two rare cases of children who presented with progressive exertional breathlessness and dry cough. They also had history of bluish discoloration of mucous membranes, hands and feet on exertion. Both were diagnosed to have pulmonary alveolar proteinosis after a high-resolution computed tomography and bronchoalveolar lavage. They were subjected to bilateral whole lung lavage (WLL) as a salvage therapy. Bilateral WLL was performed in a single sitting with the help of a modified endotracheal tube. The anesthetic technique included a modified cuffed endotracheal tube for accomplishing WLL. After the procedure, both children improved clinically and functionally.
  710 79 -
Pulsatile flow in descending aorta: Can coarctation of aorta be ruled out by transesophageal echocardiography?
Anitha Diwakar, Kolli S Chalam, CS Hiremath, PK Dash
April-June 2021, 24(2):253-255
DOI:10.4103/aca.ACA_8_19  PMID:33884989
A 5-year-old child with L posed great arteries, large subpulmonic ventricular septal defect (VSD), atrial septal defect (ASD), and a large patent ductus arteriosus (PDA) with mild isthmic narrowing was scheduled for surgical correction. Intraoperatively, it was a case of anatomically corrected malposition of great arteries. Due to abnormal positioning of great vessels, the isthmus was ligated instead of the large PDA. The postoperative transesophageal echocardiography showed pulsatile flow in descending aorta as it was being filled by large PDA, and thus iatrogenic coarctation (CoA) was missed. It was detected in the intensive care unit due to the onset of acidosis on blood gas analysis and the presence of gradient between radial and femoral arterial line pressures. The patient was taken for redo surgery, the PDA was then ligated, resection of the isthmic narrowing and repair by end-to-end anastomosis was done.
  646 84 -
INTERESTING IMAGES
Biventricular apical thrombi in a patient presenting with new-onset dilated cardiomyopathy
Nicholas Suraci, Daniella Galtes, Saberio Lo Presti, Orlando Santana
April-June 2021, 24(2):230-231
DOI:10.4103/aca.ACA_157_19  PMID:33884981
The diagnosis of an apical left ventricular thrombus in the setting of a dilated cardiomyopathy is not uncommon. However, biventricular apical thrombi in this setting is unusual. We present a case of a 67-year-old man who was admitted with new onset heart failure with biventricular apical thrombus formation in the absence of a hypercoagulable state.
  606 93 -
CASE REPORTS
Posterior mediastinal mass in a neonate causing airway compression: Perioperative anesthetic management
Amit Rastogi, Nishat Nasar, Ankur Mandelia, Tapas K Singh
April-June 2021, 24(2):250-252
DOI:10.4103/aca.ACA_74_19  PMID:33884988
Posterior mediastinal masses by their location pose a risk of compression of heart, great vessels and airway. These risks are further exaggerated, with the use of neuromuscular relaxants and lateral positioning during anesthesia. We report a case of a 2.5 months old baby with posterior mediastinal mass causing compression of left bronchus and significant mediastinal shift with respiratory distress as a primary complaint. This posterior mediastinal Mass (PMM) was removed by right lateral thoracotomy without the initial use of neuromuscular blockade till the pleura was opened.
  600 72 -
Anesthetic and intensive care management of left main coronary artery to main pulmonary artery fistula diagnosed in postoperative case of tetralogy of fallot
Suvendu Panda, Hemang Gandhi, Jigar Surti, Amit Mishra, Bhavik Champaneri
April-June 2021, 24(2):272-274
DOI:10.4103/aca.ACA_87_20  PMID:33884995
Cases of coronary to pulmonary artery fistula are seen in patients of pulmonary atresia with ventricular septal defect (VSD). These fistulas are rarely seen in patients of Tetralogy of Fallot (TOF). In this case report, we have presented ICU management of a postoperative case of TOF, with missed diagnosis of left main coronary artery (LMCA) to main pulmonary artery (MPA) fistula.
  584 73 -
ORIGINAL ARTICLES
Intraoperative comparison of 2D versus 3D transesophageal echocardiography for quantitative assessment of mitral regurgitation
Pravin S Lovhale, Shrinivas Gadhinglajkar, Rupa Sreedhar, Subin Sukesan, Vivek Pillai
April-June 2021, 24(2):163-171
DOI:10.4103/aca.ACA_28_20  PMID:33884971
Background: Effective regurgitant orifice area (EROA) can be represented by 3D echocardiographic vena contracta cross-sectional area (3D-VCA) as a reference method for the quantification of mitral regurgitation (MR) without making any geometrical assumptions. EROA can also be derived from 3D PISA technique with a hemispherical (HS) or hemielliptical (HE) assumption of the proximal flow convergence. However, it is not clear whether HS-PISA and HE-PISA has better agreement with 3D-VCA. Aims: This study was conducted to compare the EROA and Rvol obtained from 3D-VCA with those obtained from 2D-VC, 2D-HS-PISA, 3D-HS-PISA, and 3D-HE-PISA. Setting: Tertiary care hospital. Design: Prospective observational study. Materials and Methods: After anesthesia induction, 43 consecutive patients were evaluated with RT-3D-TEE after acquiring images from midesophegeal views and performing the offline analysis of volume dataset. 3D-VCA was measured using multiplanar reconstruction mode and EROA and regurgitant volume were estimated using HS-PISA and HE-PISA methods. The HE-PISA was calculated by using the Knud Thomsen formula. Statistical Analysis: Agreement between methods to estimate EROA and regurgitant volumes were tested using Bland–Altman analysis. The interobserver variability and intraobserver variability were assessed using an intraclass correlation coefficient. Results: The EROA estimated by 3D-VCA was larger than EROA obtained by 2D-HS-PISA and 3D-HS-PISA, which were significantly greater than 3D-HE-PISA. 3D-HS-PISA-EROA showed the best agreement with 3D-VCA (bias: 0.21; limits of agreement: −0.01 to 0.41; SD: 0.1). Correlation between various methods as compared to 3D-VCA was better in the organic MR group than functional MR group. Conclusion: 3D-HS-PISA showed the best agreement with 3D-VCA compared to other PISA methods. Better correlation between PISA-EROA and 3D-VCA was observed in patients with organic MR than functional MR.
  575 81 -
CASE REPORTS
Aortocoronary saphenous vein graft aneurysm misdiagnosed as aortic arch aneurysm
Nikolaos A Papakonstantinou, Ilias Samiotis, Theodoros Kratimenos, Panagiotis Dedeilias
April-June 2021, 24(2):247-249
DOI:10.4103/aca.ACA_74_20  PMID:33884987
Coronary artery bypass grafting is the mainstay of revascularization worldwide. However, the most widely used saphenous vein grafts are related to a number of late sequelae. Aortocoronary saphenous vein graft aneurysms mainly diagnosed incidentally are one of these complications. Although rare, given the fatal risk of rupture if left untreated, management either with percutaneous intervention or open redo surgery should be considered. However, no guidelines are established in current scarce literature. Hereby, we present the successful percutaneous management of a huge saphenous vein graft aneurysm via coiling, avoiding the risks of repeat sternotomy.
  574 63 -
LETTERS TO EDITORS
An unusual cause of double-lumen tube obstruction in mechanically ventilated patient
Ankur Gupta, Shalendra Singh, Ankur Khandelwal, Saurabh Sud
April-June 2021, 24(2):275-276
DOI:10.4103/aca.ACA_22_19  PMID:33884996
  548 54 -
Massive gastro-intestinal bleed in a case of aorto-enteric fistula: An intraoperative nightmare
Rohan Magoon, Neeti Makhija, Aayush Goyal, Pradeep Ramakrishnan, Ankita Singh
April-June 2021, 24(2):278-279
DOI:10.4103/aca.ACA_144_19  PMID:33884998
  498 64 -