Search

Anaesthetic management of phaeochromocytoma always remains a challenge.[1] This becomes more when congenital heart disease is associated with phaeochromocytoma.[2,3] We report the perioperative anaesthetic management of a patient of phaeochromocytoma with double outlet right ventricle (DORV) who underwent combined phaeochromocytoma excision and corrective cardiac surgery.

Objective To evaluate the efficacy and safety of tranexamic acid (TXA) versus epsilon aminocaproic acid (EACA) in patients undergoing thoracic aortic surgery. Design A prospective randomized study. Setting A tertiary care center. Participant The study was conducted on 64 consecutive adult patients undergoing thoracic aortic surgery with cardiopulmonary bypass (CPB). Interventions Group EACA received a bolus of 50 mg/kg of EACA after induction of anesthesia over 20 minutes followed by maintenance infusion of 25 mg/kg/h until chest closure. Group TXA received a bolus of 10 mg/kg of TXA after induction of anesthesia over 20 minutes followed by maintenance infusion of 1 mg/kg/h until chest closure. Measurements and Main Results Cumulated mean blood loss, total packed red blood cells, and blood product requirement up to 24 h postoperatively were comparable between groups. A significant renal injury (EACA 40% v TXA 16%; p = 0.04) and increased tendency for renal failure (EACA 10% v TXA 0%, p = 0.11; relative risk 2.15) were observed with EACA compared to TXA. There was increased tendency of seizure with TXA (EACA v TXA: 3.3% v 10%; p>0.05, relative risk 1.53). There was significant increase in the D-dimer from preoperative to postoperative values in Group EACA. (p Conclusions Both EACA and TXA were equally effective in reducing the perioperative blood loss and transfusion requirement in patients undergoing thoracic aortic surgery. While significant renal injury was observed with EACA, there was a tendency for higher incidence of seizure with TXA. Prospective placebo-controlled trials recruiting larger sample size using sensitive biomarkers are required before any recommendations.

Manas R Dikhit,1,* Bidyut Purkait,1,* Ruby Singh,1 Bikash Ranjan Sahoo,2 Ashish Kumar,1 Rajiv K Kar,3 MdYousuf Ansari,1,4 SavitaSaini,1,5 KumarAbhishek,1 Ganesh CSahoo,1 Sushmita Das,6 Pradeep Das11Department of Molecular Parasitology and Biomedical Informatics, Rajendra Memorial Research Institute of Medical Sciences, Indian Council of Medical Research, Agamkuan, Patna, Bihar, India; 2Laboratory of Molecular Biophysics, Institute for Protein Research, Osaka University, Japan; 3Biomolecular Nuclear Magnetic Resonance and Drug Design Laboratory, Department of Biophysics, Bose Institute, Kolkata, West Bengal, 4Department of Pharmacoinformatics, 5Department of Biotechnology, National Institute of Pharmaceutical Education and Research, Hajipur, 6Department of Microbiology, All India Institute of Medical Sciences, Patna, Bihar, India*These authors contributed equally to this workAbstract: New treatments for visceral leishmaniasis, caused by Leishmania donovani, are needed to overcome sustained toxicity, cost, and drug resistance. The aim of this study was to evaluate the therapeutic effects of 2-nitro-N-(pyridin-2-ylmethyl)benzenesulfonamide (2NB) against promastigote and amastigote forms of L. donovani and examine its effect in combination with amphotericin B (AmB) against AmB-resistant clinical isolates. Effects were assessed against extracellular promastigotes in vitro and intracellular amastigotes in L. donovani-infected macrophages. Levels of inducible nitric oxide and Th1 and Th2 cytokines were measured in infected 2NB-treated macrophages, and levels of reactive oxygen species and NO were measured in 2NB-treated macrophages. 2NB was active against promastigotes and intracellular amastigotes with 50% inhibitory concentration values of 38.5±1.5µg/mL and 86.4±2.4µg/mL, respectively. 2NB was not toxic to macrophages. Parasite titer was reduced by >85% in infected versus uninfected macrophages at a 2NB concentration of 120µg/mL. The parasiticidal activity was associated with increased levels of Th1 cytokines, NO, and reactive oxygen species. Finally, 2NB increased the efficacy of AmB against AmB-resistant L. donovani. These results demonstrate 2NB to be an antileishmanial agent, opening up a new avenue for the development of alternative chemotherapies against visceral leishmaniasis.Keywords: visceral leishmaniasis, AmB resistance, benzenesulfonamide, ROS, NO, Th1/Th2 cytokines

Aim: To compare the effects of propofol and etomidate induction on hemodynamic parameters and serum cortisol levels in patients with normal left ventricular function undergoing elective coronary artery bypass graft surgery on cardiopulmonary bypass. Material and Method: After approval from the Institute Ethics committee hundred American Society of Anesthesiologists (ASA) grade II or III patients undergoing scheduled coronary artery bypass surgery on cardiopulmonary bypass were enrolled in the study. Patients were allocated randomly to receive either propofol or etomidate for anesthesia induction. Anesthesia was maintained in both groups with sevoflurane, vecuronium bromide for muscle relaxation (0.1 mg/kg, boluses) and fentanyl up to a total dose of 20 mcg/kg. Result: The baseline serum cortisol values were within normal limits in both the groups. The serum cortisol levels in the propofol group increased more than two fold, whereas the values in the etomidate group decreased by close to fifty percent on weaning from cardiopulmonary bypass (CPB). There was no significant difference in serum cortisol levels in the two groups at twenty-four hours after induction, although the values were close to double the baseline levels. Hemodynamically, etomidate group was more stable than propofol group following induction of anesthesia (P < 0.05). Conclusion: The surge in serum cortisol levels on the initiation of CPB seen after the use of propofol is prevented by the use of etomidate. Serum cortisol levels in both groups are well above the baseline at twenty-four hours without any untoward effects. Etomidate provides more stable hemodynamic parameters when used for induction of anesthesia as compared to propofol.

Patients with myasthenia gravis (MG) developing coronary artery disease following irradiation of thymoma have been reported previously. Incidental preoperative diagnosis of thymoma has also been reported during cardiac surgery in the past. This case report intends to sensitize clinicians to the challenges of a redo mediastinal surgery in a post-coronary artery bypass grafting (CABG) patient with symptomatic MG and thymoma and to discuss the pros and cons of a simultaneous thymectomy in a patient undergoing cardiac surgery.

Over the years the age limit for the arterial switch operation (ASO) is being redefined with increasing expertise and adoption of extra-corporeal membrane oxygenator (ECMO) in the surgical program. We conducted a study to see the differences in ultrastructural features in eight children with transposition of the great arteries, four with prepared and the remaining four with regressed left ventricle (LV) during the ASO. Children with prepared LV had prominent Z bands with uniform and round mitochondria, few fat vacuoles and minimal collagen in the background, whereas children with regressed LV had Z band disruption with non-uniform elliptical mitochondria and myofibrillary disarray and an abundance of fat vacuoles and collagen in the background. Children with regressed LV and abundance of collagen had a prolonged postoperative course. Collagen deposition in the LV may point to the situation where the postoperative course following ASO may be prolonged due to the increased time required for the regressed LV to increase its mass and to sustain the systemic circulation.

An anomalous pulmonary venous and systemic connection associated with a partial atrioventricular septal defect (AVSD) is rare. A 23-year-old patient, who presented with dyspnea and cyanosis on exertion, was found to have an anomalous pulmonary and systemic venous drainage with separate drainage of the left superior caval vein and hepatic veins into the left atrium and a partial AVSD. A patch diversion was successfully performed using two patches of glutaraldehyde-treated pericardium to create a nonobstructive pulmonary and systemic venous drainage.

Sinus of Valsalva aneurysms are rare cardiac anomalies that may be acquired or congenital. We describe the case of a patient who had an unruptured sinus of Valsalva aneurysm causing right ventricular outflow obstruction, with an associated subaortic ventricular septal defect. Sinus of Valsalva aneurysms rarely present until rupture occurs. However, the unruptured aneurysm of the right sinus of Valsalva caused significant right ventricular outflow tract obstruction, resulting in exertional dyspnea. Intraoperative multiplane transesophageal echocardiography and color Doppler helped in precise identification of structural anomalies, shunt location, and definitive surgical repair.

Missing the diagnosis of atrial septal defect (ASD) increases morbidities to patient and may require second surgery or intervention. Chronic constrictive pericarditis produces thickening and calcification of pericardium. The detection of any intracardiac lesion may be difficult by echocardiography due to the masking or shadowing effect of calcified pericardium. We report a case of 30-year-old male presented with congestive heart failure, dyspnea and abdominal swelling. Transthoracic echocardiography diagnosed constrictive pericarditis with no evidence of ASD. The contrast enhanced computed tomography (CECT) showed extensive diffuse pericardial calcification with a large ASD. In the operating room initial transesophageal echocardiography (TEE) examination was not able to detect any ASD. Agitated saline injected through the central venous line into right atrium showed bubbles in the left atrium under TEE monitoring. Subsequent movement of TEE probe in deeper position detected the ASD. It is recommended that all the views and methods of echocardiography examination may be practiced in difficult moments to avoid missing the presence of ASD. How to cite this article Das S, Rajput RS. Coexistence of Chronic Constrictive Pericarditis can make the Echocardiographic Diagnosis of Atrial Septal Defect Challenging. J Perioper Echocardiogr 2013;1(2):66-68.

Phenoxybenzamine (PBZ) is an alpha adrenergic antagonist, used for the management of hypertension. PBZ acts by blocking alpha-adrenergic receptors, leading to vasodilatation and low systemic vascular resistance. This helps in control of blood pressure in pheochromocytoma, improvement of systemic oxygen delivery, and optimization of the Qp/Qs in pediatric cardiac surgery such as hypoplastic left heart syndrome and improving perfusion parameters during open heart surgery. The uses have further extended to causalgia, Raynaud's phenomenon, autonomic hyperreflexia, and even for patency of radial artery conduit in coronary artery bypass grafting surgery. However, its prolonged hypotensive effect limits the regular use. In this review, we discussed the mechanism of action, pharmaco-physiology of PBZ, perioperative uses in different clinical setting and controversies for its uses; publications in different scientific journals from the previous years.

Cortriatriatum with Raghib’s complex is a rarely reported entity. An 18-month-old baby who presented with tachypnea and cyanosis was diagnosed to have cortriatriatum sinistrum along with a persistant left superior caval vein draining to the left atrium through an unroofed coronary sinus. The child underwent successful surgical correction with excision of the cortriatriatum and baffling of the left superior caval vein to the right atrium.

Tetralogy of Fallot (TOF) with additional ventricular septal defect (VSD) forms a difficult surgical subset. Commonly, additional VSD is in the muscular septum and direct visualization may be difficult during surgical repair especially in arrested heart. Consequently, direct closure of these defects is performed based upon preoperative imaging and/or intraoperative transoesophageal echocardiogram. We hereby report an unforeseen occurrence of traumatic acute severe mitral regurgitation after TOF repair possibly during closure of additional muscular VSD. We discuss the possible mechanism of this unprecedented complication, which was promptly diagnosed and managed with good surgical outcomes.

Introduction: Laryngoscopy and tracheal intubation is associated with profound adverse hemodynamic changes. Coronary artery disease patients have compromised myocardial blood flow and usually have associated hypertension. If the stress response to tracheal intubation is not controlled, it may lead to severe hypertension, arrhythmias and myocardial ischemia. Dexmedetomidine is a new alpha agonist with high potency to control the stress response, pain and tachyarrhythmia. Hence, impact of dexmedetomidine on hemodynamic parameters during tracheal intubation in coronary artery bypass grafting (CABG) surgery patients was evaluated in the study. Methods: Sixty patients undergoing CABG were enrolled in the study. They were divided into 3 groups. Group 1 received thiopentone 3-5mg/kg, group 2 received thiopentone plus lignocaine 1mg/kg and group 3 received thiopentone plus dexmedetomidine 0.5µg/kg prior to laryngoscopy and tracheal intubation. Heart rate (HR), mean arterial pressure (MAP) and cardiac index (CI) were measured before induction, after anaesthetic induction, at laryngoscopy, and 1min, 3min, 6min and 10min after tracheal intubation. The extra amount of fentanyl and thiopentone required controlling hypertension to laryngoscopy and intubation was noted. The values were analyzed with SPSS 20 software with a P value of

During cardiac catheterization, a 2(1/2)-year-old boy developed sudden cardiac arrest. The presence of a long QT interval in the electrocardiogram (ECG) along with ventricular arrhythmia and syncope at that moment enabled us to diagnose long QT syndrome (LQTS). Immediate defibrillation and beta-blocker (metoprolol) therapy saved the life of the child. Cardiac catheterization was completed and the child was planned for Fontan operation. Beta-blocker coverage, prevention of sympathetic stimulation and avoidance of agents which prolong the QT interval made anesthesia uneventful. There were episodes of ventricular fibrillation (VF) in the postoperative period. The child was managed with electrical defibrillation, metoprolol and magnesium.

Right pulmonary artery to left atrial fistula is a rare congenital cardiac anomaly. A 23 years old man visited an ophthalmologist for complains of diplopia and diminished vision with cyanosis. Computerized tomography angiography diagnosed the presence of right pulmonary artery to left atrium fistula. Intraoperative use of transesophageal echocardiography confirmed the diagnosis and guided in real time for the successful ligation of fistula. Transesophageal echocardiography helped to perform the surgery without cardiopulmonary bypass. How to cite this article Das S, Irpachi K, Devagourou V. Transesophageal Echocardiography Guided Ligation of Right Pulmonary Artery to Left Atrial Fistula. J Perioper Echocardiogr 2014;2(1):38-39.

Background: Craniosynostosis (CS) syndrome is an autosomal dominant condition classically combining craniosynostosis and non-syndromic craniosynostosis with digital anomalies of the hands and feet. The majority of cases are caused by heterozygous mutations in the third immunoglobulin-like domain (IgIII) of FGFR2, whilst a larger number of cases can be attributed to mutations outside this region of the protein. Aims: To find out the FGFR1, FGFR2, FGFR3 and FGFR4 gene in craniosynostosis syndrome. Settings and Design: A hospital based prospective study. Materials and Methods: Prospective analysis of clinical records of patients registered in CS clinic from December 2007 to January 2015 was done in patients between 4 months to 13 years of age. We have performed genetic findings in a three generation Indian family with Craniosynostosis syndrome. Results: We report for the first time the clinical and genetic findings in a three generation Indian family with Craniosynostosis syndrome caused by a heterozygous missense mutation, Thr 392 Thr and ser 311 try, located in the IgII domain of FGFR2. FGFR 3 and 4 gene basis syndrome was eponymously named. Genetic analysis demonstrated that 51/56 families to be unrelated. In FGFR3 gene 10/TM location of 1172 the nucleotide changes C>A, Ala 391 Glu 19/56 and Exon-19, 5q35.2 at conserved linker region the changes occurred pro 246 Arg in 25/56 families. Conclusions: Independent genetic origins, but phenotypic similarities in the 51 families add to the evidence supporting the theory of selfish spermatogonial selective advantage for this rare gain-of-function FGFR2 mutation.

Double aortic arch (DAA) is a congenital vascular anomaly. The diagnosis was difficult till the child was symptomatic, and other causes were ruled out. We present the interesting images of a child of respiratory distress because of tracheal compression from DAA.

Background: Junctional ectopic tachycardia occurs frequently after congenital cardiac surgery and can be a cause of increased morbidity and mortality. Dexmedetomidine (DEX) is an a2 adrenoreceptor agonist, has properties of controlling tachyarrhythmia by regulating the sympatho-adrenal system. Objective: To evaluate the efficacy of DEX for control of junctional ectopic tachycardia after repair of Tetralogy of Fallot (TOF). Materials and Methods: Two hundred and twenty pediatric cardiac patients with TOFs were enrolled in a prospective randomized control study. Patients underwent correction surgery. They were divided into two groups, i.e., Group 1 (DEX) and Group 2 (control). Heart rate, rhythm, mean arterial pressure (MAP) were recorded after the anesthetic induction (T1), after termination of bypass (T2), after 04 hours (T3), and 08 hours after transferring the patient to intensive care unit (ICU; T4). Results: Heart rate was comparable between two groups before starting the drug but statistically significant after bypass until 08 hours after transferring the patient to ICU. Junctional ectopic tachycardia occurred more in Group-2 (20%) as compared to Group-1 (9.09%; P = 0.022). Junctional ectopic tachycardia occurs early in Group-2 (0.14 ± 0.527 hours) as compared to Group 1 (0.31 ± 1.29 hours; P = 0.042). The duration of junctional ectopic tachycardia was more prolonged in Group-2 (1.63 ± 3.64 hours) as compared to Group-1 (0.382 ± 1.60 hours; P = 0.012). The time to withdraw from mechanical ventilation and ICU stay of Group 1 patient was less than of Group 2 patients (P =

Context: Arterial switch operation (ASO) has become the established treatment for correction of transposition of great arteries (TGA). Despite the immediate correction of abnormal hemodynamics, acute and delayed complications related to the coronaries may cause morbidity and mortality. Aims: We evaluated the incidence of perfusion abnormalities and safety of adenosine by stress-rest myocardial perfusion single-photon emission computed tomography (SPECT) [myocardial perfusion scintigraphy (MPS)] using Tc-99m Sestamibi (MIBI) in asymptomatic children post-ASO. Settings and Design: Prospective study. Materials and Methods: We conducted a prospective, single-institutional study where stress-rest MPS was performed on 10 children of age between 1.25 and 6 years. Two of the patients had additional ventricular septal defect, one patient had left ventricular outflow tract obstruction, and another had Taussig-Bing anomaly. All the patients underwent corrective surgery as a single-stage procedure at the age of 176 ± 212 days (range 9-560 days). Adenosine was administered at a rate of 140 μg/kg/min intravenously as continuous infusion for duration of 6 min. Statistical Analysis Used: All the continuous variables were summarized as mean ± standard deviation, or range and median. Mann-Whitney test for unpaired data and Wilcoxon Rank test for paired samples were used. Results: The average increase in heart rate over the basal heart rate after adenosine stress was 59.7 ± 17.0%. No acute or remote complications were observed in any case. None of the patients demonstrated myocardial perfusion defects, either at rest or after adenosine stress. Conclusions: MPS post-adenosine induced vasodilatation is safe and feasible in patients of ASO for transposition of great arteries. One-stage repair, implantation of excised coronary buttons within neo-aortic sinus, and minimal or no mobilization of proximal coronaries may eliminate the occurrence of perfusion defects in patients of corrected TGA.

Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone ( n = 42) or control ( n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% ( n = 6) and remained so in 9.5% ( n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% ( n = 15) ( p = 0.035) and remained so in 32.5% ( n = 13) of patients till the end of surgery ( p = 0.01). At the end of first post-operative day 21.4% ( n = 9) of patients in amiodarone group and 55% ( n = 22) of patients in control group were in AF ( p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (±0.54) in amiodarone group and 2.26 (±0.73) in the control group ( p = 0.014), and the energy needed was 22.5 (±8.86) joules in the amiodarone group and 40.53 (±16.5) in the control group ( p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.