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Objective: The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients., Design: A prospective, randomized, double-blind, comparative study., Setting: At a single institution tertiary referral cardiac center., Participants: A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy., Interventions: Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia., Measurements and Main Results: The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups., Conclusion: Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate the efficacy of incisional ropivacaine infiltration by presternal multi-orifice catheter to manage poststernotomy pain in pediatric cardiac surgery., Design: A prospective, randomized, and double-blind comparative study., Setting: At a single-institution tertiary referral cardiac center., Participants: The study comprised 200 children undergoing cardiac surgeries through a midline sternotomy., Interventions: Children were allocated randomly to 1 of 3 groups. Group A (n = 65) and group B (n = 64) received 0.375% ropivacaine infusion and intermittent bolus, respectively, by presternal multi-orifice catheter, whereas Group C (n = 64) did not receive any local anesthetic (LA) drug. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl was given as rescue analgesia, respectively., Measurements and Main Results: Pain was assessed by a Modified Objective Pain Score (MOPS) for 48 hours postextubation. Group B had significantly lower early MOPS at the first hour, but in the later period, the mean MOPS was lower in group A. The requirement of the first rescue analgesia was 3 ± 1.51, 6.1 ± 2.26, and 2.6 ± 0.87 hours for groups A (n = 60), B (n = 60), and C (n = 60), respectively. The 48-hour fentanyl consumption was significantly lower (p < 0.001) in group A (0.5 ± 0.68 µg/kg) and group B (0.7 ± 0.86 µg/kg) than the control group (3.4 ± 0.68 µg/kg). The length of intensive care unit stay was lower (p < 0.001) in groups A and B than in group C; however, the length of hospital stay was comparable (p = 0.07)., Conclusion: LA bolus and infusion through presternal multi-orifice catheter provided effective analgesia postoperatively. However, the bolus was more efficacious in the early phase but equivalent in later periods. Therefore, bolus and LA infusion can be used for steady poststernotomy pain relief in children undergoing cardiac surgeries., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To determine the dosage of bivalirudin as the anticoagulant for cardiac surgery in neonates and infants., Design: Pilot study., Setting: Tertiary-care hospital., Participants: Twenty-five neonates and infants with congenital heart disease (CHD) undergoing cardiac surgery., Interventions: The children received a 1 mg/kg bivalirudin bolus followed by a 2.5 mg/kg/h infusion as the anticoagulant for cardiac surgery. The dose was adjusted subsequently to maintain an activated clotting time (ACT) >480 s., Measurements and Main Results: The mean age and weight were 5.3 months and 5.2 kg, respectively. Out of the 25 children, 16 were cyanotic. Baseline rotational thromboelastometry (ROTEM) (Tem Innovations GmbH, Munich, Germany) analysis revealed an underlying coagulation defect across EXTEM, INTEM, FIBTEM, and ADPTEM parameters. The dose of anticoagulant required was 1 mg/kg, followed by a 2.2 ± 0.4 mg/kg/h infusion. Only 1 child required an additional bolus dose. The ACT remained elevated for 4 hours after discontinuation of infusion. The mean 24-h postoperative chest tube drainage was 92 ± 36 mL. Excessive bleeding occurred in 4 children, 1 of whom required re-exploration. The platelet count remained low for 5 days, and, postoperatively, the prothrombin time and activated partial thromboplastin time remained low for 2 days., Conclusions: Effective anticoagulation was achieved with bivalirudin in the neonates and infants undergoing cardiac surgery. The dose required to maintain an ACT >480 s was 1.0 mg/kg, followed by 2.2 ± 0.4 mg/kg/h. The ACT remained elevated for 4 h after the discontinuation of bivalirudin infusion, resulting in an increased chest-tube output in some patients. Randomized, controlled trials are needed to further evaluate the safety of bivalirudin in the neonates and infants with complex congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To compare the changes in thoracic fluid content, PaO 2 /F I O 2 ratio, plateau pressure, compliance, and postoperative ventilation duration in off-pump coronary artery bypass grafting (OPCAB) and on-pump coronary artery bypass grafting (ONCAB)., Design: Prospective observational study., Setting: Tertiary-care cardiac center., Participants: Over an 18-month period, from December 2019 to May 2021, 111 patients who underwent CAB grafting were enrolled. Group I constituted OPCAB patients and Group II the ONCAB patients., Interventions: After induction, the authors measured thoracic fluid content (TFC), pulmonary compliance, airway pressures, and the PaO 2 /F I O 2 ratio before skin incision (T 1 ) and after skin closure (T 2 ). The input, output, as well as the duration of postoperative ventilation, also were recorded., Results: At T 2 , the ONCAB group had a significantly higher change in TFC than the OPCAB group (5.4 ± 1.86 kOhm -1 v 4.32 ± 1.84 kOhm -1 , p = 0.012). The fluid balance was significantly higher in the OPCAB group compared with the ONCAB group (2,159.21 ± 108.73 mL v 1,792.50 ± 151.88 mL, p = 0.0001). The decrease in PaO 2 /F I O 2 ratio was significantly lower in the OPCAB group compared with the ONCAB group (-71.34 ± 23.42 v -123.65 ± 36.81, p = 0.000). The increase in plateau pressure, decrease in compliance, and postoperative ventilation period were significantly higher in the patients who underwent ONCAB than the patients who underwent OPCAB (p < 0.05)., Conclusion: The change in TFC was greater in the ONCAB group, despite the fact that the fluid balance was higher in the OPCAB group. A higher TFC in ONCAB led to lower PaO 2 /F I O 2 ratio, lower compliance, higher plateau pressures, and longer postoperative ventilation., Competing Interests: Conflict of Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To determine the efficacy of pectointercostal fascial block in relieving postoperative pain in patients undergoing cardiac surgery., Design: Single-blinded, prospective, randomized controlled trial., Setting: Single-center tertiary care teaching hospital., Participants: A total 40 participants undergoing cardiac surgery aged 18 to 80 years., Interventions: Subjects were categorized into 2 groups of 20 each. In group 2 participants (interventional group), bilateral pectointercostal fascial block was given using ropivacaine injection 0.25% after completion of surgery, before shifting to the intensive care unit., Measurements and Main Results: Postoperative pain was measured after extubation at 0, 3, 6, and 12 hours, using a numeric rating scale. Pain in group 2 was significantly less and lasted for a longer duration than in group 1. Fentanyl requirement was significantly higher in group 1 (1.06 ± 0.12 µ/kg) than in group 2 (0.82 ± 0.19 µ/kg)., Conclusions: Pectointercostal fascial block is an easy and efficient technique to reduce postoperative pain after cardiac surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Regional analgesia continues to evolve with the introduction of ultrasound-guided fascial plane blocks. Erector spinae plane block (ESPB) is a novel technique gaining recent acceptability as a perioperative modality of analgesia in various thoracic and abdominal surgeries. However, literature on the use of ESPB in pediatric cardiac surgery is limited., Design: A prospective, randomized, single-blind, comparative study., Setting: Single-institution tertiary referral cardiac center., Participants: Eighty children with acyanotic congenital heart disease undergoing cardiac surgery through midline sternotomy., Interventions: The subjects were allocated randomly into 2 groups: ESPB (group B, n = 40) received ultrasound-guided bilateral ESPB at the level of T 3 transverse process and control (group C, n = 40) receiving no block., Measurements and Main Results: The postoperative pain was assessed using Modified Objective Pain Scores (MOPS) which were evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours after extubation. Group B demonstrated significantly reduced MOPS as compared with group C until the 10th postoperative hour (p < 0.0001), with comparable MOPS at the 12th hour. The consumption of postoperative rescue fentanyl was also significantly less in group B in comparison to group C (p < 0.0001) with a longer duration to first rescue dose requirement in group B. In addition, the group B showed lower postoperative sedation scores and intensive care unit stay in contrast to group C., Conclusion: Ultrasound-guided bilateral ESPB presents a simple, innovative, reliable, and effective postoperative analgesic modality for pediatric cardiac surgeries contemplated through a midline sternotomy., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Augmentation of coronary artery flow by surgical grafting increases coronary sinus blood flow (CSBF), which can be quantified on transesophageal echocardiography (TEE). However, transit time flowmetry (TTF) technology remains the most used intraoperative technique for coronary artery graft assessment. The purpose of the present pilot study was to evaluate the predictive value of TEE-based CSBF estimation for identifying favorable TTF graft measurements., Design: Prospective observational study., Setting: Single university hospital., Patients: Forty patients undergoing triple vessel coronary artery bypass grafting., Measurements and Main Results: CSBF was assessed on TEE examination before and after revascularization, estimating the percentage increase in CSBF (∆CSBF). Postoperative TTF graft measurements were averaged to compute mean diastolic filling (DF) and pulsatility index (PI). Subjects were grouped based on favorable (PI ≤ 3, DF ≥ 50%) and unfavorable (PI > 3, DF < 50%) parameters. The group with PI ≤ 3 (n = 32) had significantly higher ∆CSBF compared with the group with PI > 3 (n = 8) (38.22% ± 12.05%, 13.75% ± 3.37%, p < 0.001). ∆CSBF was higher in the DF ≥ 50% group (n = 35) (36.40 ± 12.99) in contrast to DF < 50% group (n = 5) (11.80 ± 2.59%). A strong negative and significantly positive correlation was observed between ∆CSBF with PI, DF (r = -0.903, 0.571, respectively, p < 0.001). A ∆CSBF ≥15.5% was found to predict a mean PI ≤ 3 and DF ≥ 50% with sensitivity and specificity of 100% and 62.5% for PI and 100% and 100% for DF. A ∆CSBF ≥19% demonstrated a sensitivity and specificity of 100% and 100%, 100% and 91.4% for prediction of PI ≤ 3 and DF ≥ 50%, respectively., Conclusion: TEE-based demonstration of an augmented CSBF can ensure favorable TTF graft parameters, guiding the adequacy of surgical revascularization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate the role of echocardiographic right ventricular function parameters in predicting postoperative vasoactive inotrope requirement after tetralogy of Fallot repair., Design: Prospective observational study., Setting: A tertiary care hospital., Participants: Fifty-two children undergoing elective intracardiac repair., Interventions: Comprehensive transesophageal echocardiography was performed before and after surgery. Fractional shortening, fractional area change, tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index, tricuspid annular velocities (S', E', A'), and right ventricular global longitudinal strain and strain rate (RV Gls and RV Glsr) were measured. The ratio of peak systolic pressure of the right and left ventricles (P rv/lv ) was measured directly from the surgical field pre- and post-repair. The inotrope requirement during first 24 postoperative hours was calculated using the mean Vasoactive-Inotropic Score (VIS). Pearson correlation analysis was used to study the relation between echocardiographic parameters and VIS as well as P rv/lv and VIS. Receiver operating characteristic analysis was used to study the predictive strength of parameters., Measurements and Main Results: Among the measured parameters, both pre- and post-repair TAPSE had significant negative correlation with the mean VIS (p < 0.05). Both pre- and post-repair right ventricular myocardial performance index and S', E', A', RV Gls, RV Glsr, P rv/lv also had significant correlation with the mean VIS (p < 0.05). Of these, TAPSE, RV Gls, RV Glsr, and P rv/lv had significant predictive strength (p < 0.05) and reasonable sensitivity and specificity (area under the curve > 0.6) for predicting high mean VIS (VIS > 20)., Conclusion: Tricuspid annular plane systolic excursion, RV Gls, RV Glsr, and P rv/lv could predict a postoperative high mean VIS with significant strength and reasonable sensitivity and specificity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To know the effects of psychological preparation on perioperative stress, anxiety, and mood in children undergoing cardiac surgery and their parents., Design: Prospective randomized control nonblinded trial., Setting: Single-center tertiary teaching hospital., Participants: A total of 60 children aged 5 to 15 years undergoing cardiac surgery were included in the study. One of the parents, preferably the father, was selected from the respective children., Interventions: Subjects were randomized into 2 groups: noninterventional (group 1) and interventional (group 2). Intervention was in the form of toys and video games in children, and counseling and information in parents. Preoperative and postoperative anxiety in parents was measured using the State-Trait Anxiety Inventory (STAI), stress using the Index of Clinical Stress (ICS) scale by Abell, and the Ottawa mood scale. In children, the STAI-C (child version of STAI), Ottawa mood and Ottawa stress scales, and Wong-Baker faces pain scale were applied and serum cortisol was measured., Measurements and Main Results: Group 2 children had significantly less (p < 0.001) stress, anxiety, and pain and improved mood. Group 2 parents had a significant reduction in state anxiety (42 ± 4.4 v 54.5 ± 7.8; p < 0.001) and ICS score (68.1±9.6 v 84.2 ± 9.2; p < 0.001) and an improvement in mood (7.5 ± 0.7 v 5.9 ± 1; p < 0.001) compared with group 1. Postoperatively, cortisol levels in group 2 were lower than group 1 (571.3 nmol/L [123.3 -1247.14] v 718.9 nmol/L [53-1642.0])., Conclusion: Providing video games and toys preoperatively reduced postoperative stress and anxiety and improved mood in children undergoing congenital cardiac surgery. Parents were relieved of anxiety and stress with proper counseling and information., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery., Design: A prospective, randomized, single-blind, comparative study., Setting: Single-institution tertiary referral cardiac center., Participants: The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy., Interventions: Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia., Measurements and Main Results: A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups., Conclusion: SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: To examine the analgesic efficacy of bilateral erector spinae plane (ESP) block compared with conventional treatment for pain after cardiac surgery in adult patients., Design: A prospective, randomized, controlled, single-blinded study., Setting: Single-center tertiary teaching hospital., Participants: One hundred and six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass., Interventions: Patients were randomized into 2 groups. Patients in group 1 (ESP block group, n = 53) received ultrasound-guided bilateral ESP block with 3 mg/kg of 0.375% ropivacaine before anesthesia induction at the T6 transverse process level. Patients in group 2 (paracetamol and tramadol group, n = 53) received paracetamol (1 gm every 6 hours) and tramadol (50 mg every 8 hours) intravenously in the postoperative period. The primary study outcome was to evaluate pain at rest using an 11-point numeric rating scale (NRS). Mann-Whitney U test was used for comparing NRS scores., Measurements and Main Results: The postoperative pain level after extubation and duration of analgesia during which NRS was < 4 of 10 was compared between the groups. The median pain score at rest after extubation in group 1 was 0 of 10 until hour 6, 3 of 10 at hour 8, and 4 of 10 at hours 10 and 12 postextubation. These were significantly less in comparison with group 2 (p = 0.0001). Patients in group 1 had a significantly higher mean duration of analgesia (8.98 ± 0.14 hours), during which NRS was < 4 of 10, compared with group 2 (4.60 ± 0.12 hours) (p = 0.0001)., Conclusion: ESP block safely provided significantly better pain relief at rest for longer duration as compared to intravenous paracetamol and tramadol., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To determine the safety and efficacy of bivalirudin as an anticoagulant for pediatric open heart surgery (OHS) and to determine its appropriate dosage for this purpose., Design: Prospective, randomized controlled trial., Setting: Tertiary care hospital., Participants: Fifty acyanotic children aged 1-12 years undergoing OHS., Interventions: The children were randomized to receive either 4 mg/kg of heparin (n = 25, group H) or 1 mg/kg of bivalirudin bolus followed by 2.5 mg/kg/h infusion (n = 25, group B) as the anticoagulant. The doses were adjusted to maintain activated clotting time (ACT) above 480 seconds. At the conclusion of surgery, protamine (1.3 mg/100 U of heparin) was administered to children in group H., Measurements and Main Results: The children were comparable in both groups with regard to demographic characteristics. The mean age and weight were 51.5 months and 13.4 kg in group H, and 59.3 months and 13.4 kg in group B. The dose of anticoagulant required was 4.0 ± 0.2 mg/kg in group H and 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion in group B (p < 0.001). One child in group H required an additional dose compared to 13 (54.2%) children in group B. Intraoperatively, the ACT achieved was higher in group H compared to group B (p < 0.05). The ACT returned to baseline value after protamine administration in group H, but it remained elevated for 2 hours after termination of cardiopulmonary bypass (CPB) in group B (p < 0.01). The ACT was higher in group B compared to group H for 6 hours after termination of CPB (p < 0.05). Heparin prolonged the onset of clotting, decreased the rate and strength of thrombus formation, and inhibited platelet function to a greater extent than bivalirudin on viscoelastic coagulation testing. The total duration of surgery was prolonged in group B. The postoperative chest tube drainage was similar in group B (4.9 mL/kg) as in group H (5.9 mL/kg) in spite of higher ACT. The transfusion requirements were similar. No adverse event occurred in any patient., Conclusion: Bivalirudin is a safe and effective anticoagulant for pediatric OHS. Though it is not suitable as a routine anticoagulant for this purpose, it may be used as a heparin alternative in instances when heparin cannot be used. The dose required to maintain ACT for more than 480 seconds was 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion. The ACT remained elevated for 2 hours after stopping the infusion. Bivalirudin did not increase postoperative bleeding and transfusion requirement., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Diastolic strain and strain rate, combined with E (peak transmitral velocity), have been proposed as novel noninvasive predictors of left ventricle (LV) filling pressures, avoiding angulation errors inherent to tissue Doppler indices (TDI). The primary objective was to study the correlation of strain-based indices (SBI) and TDI with pulmonary artery catheter-derived LV end-diastolic pressures (LVEDP). The secondary aim was to determine appropriate cut-off of indices to predict LVEDP ≥15 mmHg., Design: A prospective observational clinical study., Setting: Single university hospital., Participants: One hundred twenty adults with preserved ejection fraction (EF) undergoing coronary artery bypass grafting., Interventions: None., Measurements and Main Results: Two-dimensional speckle-tracking echocardiography estimated global longitudinal diastolic strain (Ds) and strain rate (DSr) at peak mitral filling to compute E/Ds and E/10DSr. TDI was measured as the ratio of E and e' (mitral annular diastolic velocity). E/e', E/Ds, and E/10DSr were significantly higher (p < 0.001) in patients with LVEDP ≥15 mm Hg (31/120). Correlation of E/Ds, E/10DSr with LVEDP was R = 0.86 and 0.88 (p < 0.001), respectively, compared with a correlation of R = 0.63 (p < 0.001) for E/e'. SBI correlated well with LVEDP ≥15 mm Hg compared with TDI. E/Ds ≥11 and E/10DSr ≥12 had higher sensitivity and specificity (96.77%, 93.26%; 100%, 96.63%, respectively; area under the curve [AUC] = 0.99) than E/e'≥13 (74%,75%; AUC = 0.84) for prediction of LVEDP ≥15 mmHg. SBI accurately predicted elevated LVEDP in the indeterminate zone of 8

Objective: Comparison of cardiac output (CO) obtained using electric cardiometry (EC) and pulmonary artery catheterization (PAC) in pediatric patients with congenital structural heart disease., Design: Prospective, observational study., Setting: A tertiary hospital., Participants: The study comprised 50 patients scheduled to undergo cardiac catheterization., Interventions: CO data triplets were obtained simultaneously from the cardiometry device ICON (Osypka Medical, Berlin, Germany) and PAC at the following predefined time points-(1) T1: 5 minutes after arterial and venous cannulation and (2) T2: 5 minutes postprocedure; the average of the 3 readings was calculated. Reliability analysis and Bland-Altman analysis were performed to determine the limits of agreement, mean bias, and accuracy of the CO measured with EC., Measurements and Main Results: The measured EC-cardiac index 4.22 (3.84-4.60) L/min/m 2 and PAC-cardiac index 4.26 (3.67-4.67) L/min/m 2 were statistically insignificant (p value>0.05) at T1. Bland-Altman analysis revealed a mean bias of 0.0051 L/min/m 2 and precision limits of±0.4927 L/min/m 2 . The intraclass correlation coefficient was 0.789 and Cronbach's alpha was 0.652, indicating good reproducibility and internal consistency between the two techniques. Postcatheterization analysis also revealed strong agreement and reliability between the two techniques., Conclusions: This study demonstrated that cardiac indices measured in children with a variety of structural heart diseases using EC reliably represent absolute values obtained using PAC. EC technology is simple and easy to use and offers noninvasive beat-to-beat tracking of CO and other hemodynamic parameters in children with structurally abnormal hearts., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction is often unpredictable. Therefore, the aim of this study was to identify predictors of poor postoperative outcome in this subset of patients., Design: Prospective observational study SETTING: Single university hospital PARTICIPANTS: Forty patients with severe LV systolic dysfunction undergoing isolated on-pump CABG INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Comprehensive transesophageal echocardiographic examination was performed to obtain the indices of systolic and diastolic LV function after induction of anesthesia. A poor postoperative outcome was defined as patient death or vasoactive inotropic score≥20 for at least 6 hours and/or requiring intra-aortic balloon counterpulsation and/or mechanical ventilation for≥24 hours. Poor postoperative outcome was observed in 40% (16/40) of patients. Patients with poor postoperative outcomes had a significantly higher systolic dyssynchrony index, septal-lateral delay with a significantly lower global longitudinal strain and isovolumic acceleration, end-diastolic volume, end-systolic volume, and lateral and medial mitral annulus systolic velocity. In a binary logistic regression model, global longitudinal strain (odds ratio, 1.5, confidence interval [CI] 95%, 1.19-1.88, p = 0.001), septal-lateral delay (odds ratio, 1.02, 95% CI, 1.01-1.03; p = 0.001) and systolic dyssychrony index (odds ratio, 1.3, 95% CI, 1.13-1.48; p = 0.000) were found to be predictors of poor postoperative outcome., Conclusion: Global longitudinal strain, systolic dyssynchrony index, and septal-lateral delay were reliable and accurate predictors of adverse outcomes in patients with severe LV systolic dysfunction undergoing on-pump CABG., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Concerns have been raised about differences in the safety profile of potato- versus waxy maize-derived hydroxyethyl starch (HES). The objective of this study was to compare 2 HES solutions derived from 2 different source materials (potato versus waxy maize) for their dose-related effects on hemostasis and organ function when used to prime the cardiopulmonary bypass circuit (CPB)., Design: A prospective, randomized, controlled study., Setting: Tertiary care center., Participants: Eighty patients undergoing coronary artery bypass grafting (CABG) on CPB., Interventions: For priming the CPB circuit, the HESPRL group received 1000 mL of potato-derived balanced 6% HES 130/0.42 along with 500 mL of Ringer's lactate; the HESP group received 1,500 mL of potato-derived balanced 6% HES 130/0.42; the HESMRL group received 1000 mL of waxy maize-derived balanced 6% HES 130/0.4 along with 500 mL of Ringer's lactate, and the HESM group received 1500 mL of waxy maize-derived balanced 6% HES 130/0.4., Measurements and Main Results: There were no significant differences in 24-hour mediastinal drainage, rate of re-exploration, blood product usage, coagulation parameters, and measures of pulmonary, renal, and hepatic function with respect to plant source of HES, when equivalent doses were used. Sonoclot activated clotting time (SonACT) was significantly higher and clot rate (CR) significantly lower at end of surgery (T1) and 24 hours after surgery (T2) in the HESP and HESM groups compared with the HESPRL and HESMRL groups. Compared with baseline, CR and platelet function were significantly lower at T1, PaO2/FIO2 ratio decreased significantly at T1 and T2, and serum bilirubin and transaminases increased significantly at T2 in all 4 groups., Conclusions: There was no significant difference in cumulative 24-hour mediastinal drainage when potato-derived balanced 6% HES 130/0.42 or waxy maize-derived balanced 6% HES 130/0.4 was used to prime the CPB circuit in patients undergoing CABG. In equal doses, both starches exerted the same effect on blood coagulation and pulmonary, renal, and hepatic function., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery., Design: A randomized, controlled, prospective, double-blind study., Setting: A tertiary care teaching hospital., Participants: Thirty children scheduled for cardiac surgery with a median sternotomy., Interventions: A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure., Measurements and Main Results: The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001)., Conclusions: Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The authors investigated the effects of intravenous etomidate on hemodynamics in children with congenital cardiac shunts., Design: Prospective observational study., Setting: Catheterization laboratory in tertiary referral cardiac center., Participants: Thirty children with congenital cardiac shunt lesions., Interventions: Fifteen children having congenital right to left shunts (group A) and 15 children with left to right shunts (group B) were studied. Systemic mean arterial pressure (SMAP), mean pulmonary artery pressures (MPAP), right atrial pressures (RAP), and pulmonary artery wedge pressure (PAWP) were recorded. Systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), and pulmonary-to-systemic blood flow ratio (Qp/Qs) were calculated on room air at baseline and following a single dose of 0.3 mg/kg of etomidate., Measurements and Main Results: Heart rate (HR), SMAP, RAP, systemic blood flow (Qs), Qp/Qs, and SVRI did not show any significant change; whereas systemic arterial saturation increased from 77.3% to 79.3%, which was statistically but not clinically significant in the authors' opinion following etomidate in group A. No significant differences in HR, SMAP, MPAP, PAWP, PVRI, SVRI, Qs, pulmonary blood flow (Qp), and Qp/Qs ratio were seen; whereas RAP, systemic, and pulmonary artery saturation decreased in group B after etomidate. Although statistically significant, the decreases were not clinically significant., Conclusion: Etomidate at 0.3 mg/kg produces very minimal changes in hemodynamic parameters and shunt fraction in children with congenital shunt lesions., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to compare the effects of continuation versus discontinuation of the angiotensin-converting enzyme (ACE) inhibitor ramipril and assess the efficacy of prophylactic vasopressin infusion on hemodynamic stability and vasoactive drug requirements in patients undergoing coronary artery bypass graft (CABG) surgery., Design: A prospective, randomized, double-blinded, single-center clinical study., Setting: Tertiary care hospital., Participants: Forty-seven patients on the ACE inhibitor ramipril for 6 weeks before undergoing elective primary CABG surgery on cardiopulmonary bypass (CPB)., Interventions: Patients were randomly divided into 3 groups: group A (n = 16), patients discontinued ramipril 24 hours before surgery; group B (n = 16), patients continued ramipril until the morning of surgery; and group C (n = 15), patients continued ramipril until the morning of surgery and received vasopressin infusion (0.03 U/min) from the onset of rewarming until the hemodynamics were stable without vasopressor agents. The anesthetic technique and conduct of CPB were standardized for all the groups. Hemodynamic parameters and vasoactive drug requirements were recorded for 3 days postoperatively., Measurements and Main Results: Patients in group A maintained stable mean arterial pressure (MAP) and systemic vascular resistance (SVR). In group B, MAP and SVR decreased after the induction of anesthesia and remained so throughout surgery (p < 0.05). In group C, MAP and SVR decreased upon the induction of anesthesia (p < 0.05) but normalized after CPB., Conclusions: Preoperative ACE inhibitor continuation predisposed to hypotension upon the induction of anesthesia and in the post-CPB period. Prophylactic low-dose vasopressin infusion prevented post-CPB hypotension. Low-dose vasopressin can be considered as potential therapy in these patients., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: Hypothermia followed by rewarming during cardiopulmonary bypass can lead to cerebral hyperthermia, which has been implicated as 1 of the causes for postoperative deterioration in neurocognitive function in patients undergoing coronary revascularization. Hence, the authors studied the effects of 2 different rewarming strategies on postoperative neurocognitive function in adult patients undergoing coronary artery bypass graft surgery with the aid of cardiopulmonary bypass., Design: This was a randomized clinical trial., Setting: A cardiothoracic center of a tertiary level referral, teaching hospital., Participants: A total of 80 adult patients aged 45 to 70 years undergoing elective primary isolated coronary artery bypass graft surgery with cardiopulmonary bypass under moderate hypothermia at 30 degrees C were included in this study., Interventions: The patients were randomly allocated into 2 groups of 40 each. In group A, patients were rewarmed to a nasopharyngeal temperature of 37 degrees C; whereas, in group B, patients were rewarmed to a nasopharyngeal temperature of 33 degrees C before weaning off bypass. The anesthetic and bypass management were standardized for both groups., Measurements: All patients were assessed for neurocognitive function preoperatively and on the fifth postoperative day using the Post Graduate Institute Memory Scale. The amount of blood loss and need for blood and blood product transfusion postoperatively, the need for pacing, increased inotrope or vasodilator use, and time to extubation were also noted. Serum S100beta levels were measured after anesthetic induction and at 24 hours postoperatively. The jugular venous oxygen saturation and oxygen tension were noted at 30 degrees C and at the end of full rewarming (ie, at 37 degrees C or 33 degrees C, respectively, in the 2 groups)., Results: There was a significant deterioration in neurocognitive function postoperatively as compared with preoperative function in patients of group A (37 degrees C). This was associated with higher S100beta levels 24 hours postoperatively in group A (37 degrees C) compared with group B (33 degrees C) patients. Also, there was a significant decrease in jugular venous oxygen saturation in group A (37 degrees C) as compared with group B (33 degrees C) at the end of rewarming. The time to extubation was longer in group B (33 degrees C). No significant differences were noted in the amount of postoperative blood loss, blood and blood product use, inotrope or vasodilator use, and the need for pacing., Conclusion: Weaning from CPB at 33 degrees C may be a simple and useful strategy to lower the postoperative impairment of neurocognitive function and may be used as a tool to decrease morbidity after coronary revascularization.

Objective: Cyanotic congenital heart diseases (CCHD) with secondary polycythemia and hyperviscosity state are associated with a reduction in blood flow, stagnation of blood, and thrombosis. Sufficient hemodilution in cyanotic children results in higher blood flow and significant reductions in perioperative blood loss. The aim of this study was to investigate similar beneficial effects of hemodilution in preventing shunt thrombosis and decreasing postoperative blood loss after modified Blalock-Taussig (BT) shunt operations in children with CCHD., Design: Prospective, randomized, controlled study., Setting: Cardiac center of a tertiary care, referral hospital., Participants: Fifty children with CCHD undergoing modified BT shunt operations., Interventions: Patients were randomized into 2 groups. The study group (n = 25) received a calculated amount of 6% hydroxyethyl starch (200/0.5) solution to bring down the hematocrit to 45%, whereas the control group (n = 25) received 5% dextrose solution intraoperatively as per the authors' normal protocol., Measurements and Main Results: Effects of hemodilution on shunt patency, postoperative blood loss at 24 hours, blood and blood component usage, and re-exploration rates were recorded. The shunt patency rate was significantly higher in the study group than the control group (100% and 84%, respectively, p < 0.05). Postoperative blood loss at 24 hours was significantly higher in the control group than in the study group (14.4 +/- 11.8 mL/kg and 9.9 +/- 8 mL/kg, respectively, p < 0.05). The number of recipients and the amount of blood and blood components administered were higher in the control group, but they were not statistically significant. The re-exploration rate (for excessive postoperative chest-tube drainage) was significantly higher in the control group than the study group (12% and 0%, respectively, p < 0.05)., Conclusion: Hemodilution in CCHD patients undergoing modified BT shunt surgery has beneficial effects including improved shunt patency because of higher blood flow through the graft and less postoperative blood loss, which may be attributed to the lower viscosity produced by hemodilution.

Objective: This study compared the efficacy of aminocaproic acid and tranexamic acid in reducing postoperative blood loss, as well as blood and blood product requirements in children with cyanotic congenital heart disease., Design: A prospective randomized study., Setting: Cardiac center of a tertiary care, referral hospital., Participants: One hundred fifty children in the age group of 2 months to 14.5 years with cyanotic congenital heart disease undergoing corrective surgery on cardiopulmonary bypass (CPB)., Interventions: Patients were randomized into 3 groups. Group A was given aminocaproic acid in a dose of 100 mg/kg after anesthetic induction, 100 mg/kg on CPB and 100 mg/kg after protamine. Group T was given tranexamic acid, 10 mg/kg, after anesthetic induction, 10 mg/kg on CPB, and 10 mg/kg after protamine. Group C was the control group., Main Result: Control group had the longest sternal closure time, maximum blood loss at 24 hours, and maximum requirements of blood and blood products. Among the 2 groups given antifibrinolytics, there was no significant difference in postoperative blood loss, blood and product requirement, and reexploration rates., Conclusion: Aminocaproic acid and tranexamic acid are equally effective in reducing postoperative blood loss, as well as blood and blood product requirements in children with cyanotic heart disease undergoing corrective surgery as compared with the control group.