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Byline: Bhagya. Jena, Rajeeb. Mishra, Surya. Dube, Girija. Rath, Vishwas. Malik, Hitesh. Gurjar Severe stenotic aortic valve poses serious anesthetic challenges because of the fixed cardiac output and complex hemodynamics. [...]

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a congenital acyanotic heart disease where the left coronary artery (LCA) arises from the pulmonary artery. This results in the LCA receiving blood supply from the low-pressure right ventricle having minimal extractable oxygen. The oxygen delivery to the left ventricle (LV) is severely hampered causing severe hypoxic LV dysfunction early in life. Early surgery prior to serious, irreversible LV dysfunction is the key to survival. Children with ALCAPA usually present in their first few weeks of life, with severe LV dysfunction. After surgical correction of the defect, the myocardium may not recover early from the presurgery myocardial dysfunction. We describe a case where extracorporeal membrane oxygenator was utilized as a means of ventricular support during this critical postoperative period resulting in a favorable outcome.

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author′s institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.

Noonan syndrome (NS) is one of the most common non chromosomal syndrome presenting to the cardiac anesthesiologist for the management of various cardiac lesions, predominantly pulmonary stenosis (PS) (80%) and hypertrophic obstructive cardiomyopathy (HOCM) (30%). The presence of HOCM in NS makes these children susceptible to acute congestive heart failure due to hemodynamic fluctuations, thus necessitating optimization of drug and fluid therapy, careful conduct of anesthesia and providing adequate analgesia in the perioperative period. We describe a case of four year old boy with NS who presented to us for the management of PS and HOCM. In our case, transesophageal echocardiography (TEE) played a major role in confirmation of the preoperative findings, detection of any new anomalies missed during the preoperative evaluation, intraoperative monitoring and assessment of the adequacy of repair in the immediate postoperative period. TEE provided invaluable help in taking critical surgical decisions, resulting in a favorable outcome.

Indian patients undergoing cardiac surgery have different demographics, clinical profile as well as risk profile, compared to the western population. The purpose of this study was to validate the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification model in Indian patients undergoing cardiac surgery in a single cardiac center. Data from 1000 consecutive adult patients undergoing cardiac surgery (coronary artery bypass grafting or valve surgery) were prospectively collected as per the EuroSCORE model. The model′s validity was assessed on the basis of its calibration power (Hosmer-Lemeshow test) and discriminatory power [area under receiver operating characteristic curve]. The patients were divided into three risk groups on the basis of their EuroSCORE. The Hosmer-Lemeshow test revealed a good calibration power (P = 0.73) and the area under the ROC curve was 0.8278, suggesting a good discriminative power. The predicted mortality was similar to observed mortality in low- and moderate-risk patients but the observed mortality in high-risk patients (15.6%) was double that of predicted mortality (7.5%). The risk factors prevalent in European population were not observed in Indian population. EuroSCORE accurately predicts mortality in low and moderate-risk Indian patients undergoing cardiac surgery but is less predictive for high-risk Indian patients. Updating and improvisation of EuroSCORE by incorporation of risk factors associated with rheumatic valvular heart disease which is more prevalent in India, may enable it to accurately predict mortality in high-risk patients also.

Open in new tab Download slide OBJECTIVES The most severe combinations of cardiac malformations exist in individuals having jumbled-up thoracic and abdominal organs. These patients make up 2 distinct syndromes. As yet, the consensus is lacking on how best to describe the subsets. The subsets are frequently grouped together in terms of 'heterotaxy'. The surgical approaches to the subsets, however, are markedly different. We reviewed our experiences with regard to the anatomy as observed in the autopsy room, by the analysis of computed tomographic studies, and in the operating room, to assess whether the lesions might be segregated on the basis of isomerism of the atrial appendages. METHODS AND RESULTS A review of our findings from the examination of specimens from several archives, along with investigation of a large cohort of patients being prepared for surgical treatment, showed that individuals can uniformly be segregated into subgroups on the basis of isomeric arrangement of the atrial appendages. In all instances, this was made possible by using the criterion of the extent of the pectinate muscles within the appendages as judged relative to the atrial vestibules. Segregation on this basis, which correlated excellently with the bronchial arrangement, sets the scene for an appropriate description of the remainder of the heart, providing the cardiac surgeon with all the inferences required for appropriate surgical intervention. CONCLUSIONS When assessing individuals having the features of so-called 'heterotaxy', it is possible to segregate the groups into subsets of individuals having either isomeric right or left atrial appendages. This approach provides the framework for the assessment of appropriate surgical management. [ABSTRACT FROM AUTHOR]

Introduction: Discrepancies have been reported in grading of severity of aortic stenosis. We propose to compare Aortic valve area by continuity equation, Dimensionless Index and Acceleration time/Ejection time in patients with documented severe aortic stenosis with normal left ventricular function by TEE after induction of anesthesia. This might give use insight about the best parameter we can rely on intra-operatively for decision making.Methodology: 60 patients with severe AS undergoing elective cardiac surgery were enrolled in our study. Post intubation trans-thoracic echocardiography (TEE) was performed and above mentioned parameters was noted.Results: 96.7 % of patients continued in severe AS category when AS was measured using AVA as echo parameter. So there is 3.3 % disparity. There was disparity in 13.3% of cases when DI was considered. And there was 43.3% disparity when AT/ET was considered.Conclusion: Perioperative grading of aortic stenosis continues to be a challenge for cardiac anesthesiologists. Multiple echocardiographic parameters have to be considered. We have found AVA and DI to have less disparity compared to AT/ET. [ABSTRACT FROM AUTHOR]

Introduction: Intraoperative trans-esophageal echocardiography (TEE) has been found to underestimate severity of aortic stenosis (AS) compared to trans-thoracic echo (TTE). We conducted a prospective study comparing pre induction TTE and intra operative TEE grading of AS in patients posted for aortic valve replacement surgeries.Methods: Sixty patients with isolated AS who were undergoing aortic valve replacement were enrolled in our study. Baseline TTE was done and after induction of anesthesia, TEE was done. Mean gradient across aortic valve, peak jet velocity, aortic valve area (AVA) by continuity equation and dimensionless index (DI) were assessed in both.Results: Mean gradient decreased from 56.4 in TTE to 39.8 mm Hg in TEE leading to underestimation of AS in 74.5% of patients (P < 0.0). Mean of peak jet velocity also decreased from 500 in TTE to 386cm/s in TEE (P < 0.01). In 76 % of patients this led to reduction of AS grade from severe to moderate. Mean AVA was 0.67 cm2 in TTE and 0.69 cm2 in TEE. Though there was 0.02 cm2 increase, it was not statistically significant (P = 0.07). All the patients remained as severe AS in TEE. DI mean was 0.19 in both TTE and TEE (P = 0.14).It led to underestimation of severity in 6% of patients in TEE.Conclusion: Our study shows that AVA measurement by continuity equation and DI are reliable in grading aortic stenosis while performing intraoperative TEE. Mean gradient and jet velocity can be significantly reduced. [ABSTRACT FROM AUTHOR]

Background and Aims: In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery. Material and Methods: In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS (n = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group (n = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well‑being. Results: Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 (P < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients (n = 14) (P < 0.05) in Control Group demanded additional analgesia as compared to TENS Group (n = 5). Feeling of well‑being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group. Conclusion: We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well‑being during chest tube removal after cardiac surgery. [ABSTRACT FROM AUTHOR]

Diastolic dysfunction is common in cardiac disease and an important finding independent of systolic function as it contributes to the signs and symptoms of heart failure. Tissue Doppler mitral early diastolic velocity (Ea) combined with peak transmitral early diastolic velocity (E) to obtain E/Ea ratio provides an estimate of the left ventricular (LV) filling pressure. However, E/Ea has a significant gray zone and less reliable in patients with preserved ejection fraction (>50%). Two-dimensional echocardiographic speckle tracking measure myocardial strain and strain rate (Sr) avoiding the Doppler-associated angulation errors and tethering artifacts. Global myocardial peak diastolic strain (Ds) and diastolic Sr (DSr) at the time of E and isovolumic relaxation combined with E (E/Ds and E/10 DSr) have been recently proposed as novel indices to determine LV filling pressure. The present article elucidates the methodology of studying diastology with strain echocardiography along with the advantages and limitations of the novel technique in light of the available literature. [ABSTRACT FROM AUTHOR]

Cardiac practice involves the application of a range of pharmacological therapies. An anesthesiologist needs to keep pace with the rampant drug developments in the field of cardiovascular medicine for appropriate management in both perioperative and intensive care set-up, to strengthen his/her role as a perioperative physician in practice. The article reviews the changing trends and the future perspectives in major classes of cardiovascular medicine. [ABSTRACT FROM AUTHOR]

Continuously growing patient's demand, technological innovation, and surgical expertise have led to the widespread popularity of minimally invasive cardiac surgery (MICS). Patient's demand is being driven by less surgical trauma, reduced scarring, lesser pain, substantially lesser duration of hospital stay, and early return to normal activity. In addition, MICS decreases the incidence of postoperative respiratory dysfunction, chronic pain, chest instability, deep sternal wound infection, bleeding, and atrial fibrillation. Widespread media coverage, competition among surgeons and hospitals, and their associated brand values have further contributed in raising awareness among patients. In this process, surgeons and anesthesiologist have moved from the comfort of traditional wide incision surgeries to more challenging and intensively skilled MICS. A wide variety of cardiac lesions, techniques, and approaches coupled with a significant learning curve have made the anesthesiologist's job a challenging one. Anesthesiologists facilitate in providing optimal surgical settings beginning with lung isolation, confirmation of diagnosis, cannula placement, and cardioplegia delivery. However, the concern remains and it mainly relates to patient safety, prolonged intraoperative duration, and reduced surgical exposure leading to suboptimal treatment. The risk of neurological complications, aortic injury, phrenic nerve palsy, and peripheral vascular thromboembolism can be reduced by proper preoperative evaluation and patient selection. Nevertheless, advancement in surgical instruments, perfusion practices, increasing use of transesophageal echocardiography, and accumulating experience of surgeons and anesthesiologist have somewhat helped in amelioration of these valid concerns. A patient-centric approach and clear communication between the surgeon, anesthesiologist, and perfusionist are vital for the success of MICS. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB).Patients and Methods: Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB.Results: Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal "cut-off" value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94).Conclusions: Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage. [ABSTRACT FROM AUTHOR]

Newer noninvasive parameters are being used for perioperative detection of myocardial ischaemia. TDI and global strain rate are some of these parameters. TDI signal is a modification of the routine Doppler flow signal. It is obtained by using thresholding and filtering algorithms that reject echoes originating from the blood pool (by-passing the high pass filter). Set-Up of the machine by activating the TDI function allows decreasing the system gain using a low pass filter and eliminates the signal produced by blood flow. Doppler shift obtained from myocardial tissue motion are of higher amplitudes (reflectivity 40 dB higher) and move about 10 times slower than blood (velocity range: 0.06 to 0.24 m/s). Speckle tracking echocardiography (tissue tracking, 2D strain) utilizes routine gray-scale 2D echo images to calculate myocardial strain. Interactions of ultrasound with myocardium result in reflection and scattering. These interactions generate a finely gray-shaded, speckled pattern (acoustic marker). This speckled pattern is unique for each myocardial region and relatively stable throughout the cardiac cycle. Spatial and temporal image processing of acoustic speckles in both 2D and 3D allows for the calculation of myocardial velocity, strain, and Strain rate. [ABSTRACT FROM AUTHOR]