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Trans-Nasal Trans-Sphenoidal (TNTS) route has become the preferred conduit for operating on a surgically amenable pathology of pituitary gland. The procedure necessitates close monitoring of perioperative hemodynamic stability, especially in patients with impaired heart function. Patients with coronary artery disease (CAD) and compromized cardiac function with very low ejection fraction increase the risk of perioperative major adverse cardiac events (MACE). In this case, a 54-year-old obese female, a known case of CAD post-PTCA with left ventricular systolic dysfunction with apical hypokinesia, complete left bundle branch block with an ejection fraction of 30% with hypertension and diabetes in the last 5 years under medication posted for TNTS excision. A combination of regional and general anesthesia was adopted to curb the sympathetic stimulus, blunt the surgical stress response and pressor response at various stimulating time points, and minimize sympathetic stimulation in the perioperative period. Minimal fluctuation in heart rate and blood pressure during the surgery was observed, which was supposedly attributed to sphenopalatine ganglion (SPG) block and lignocaine. This case underscores the importance of implementation of USG-guided bilateral SPG block and lignocaine infusion and represents a novel approach in perioperative anesthetic management, particularly for cardiac patients undergoing TNTS surgery with low ejection fraction.

Heart failure poses significant challenges in perioperative settings, with an increasing prevalence in India. While much attention has been given to the management of symptomatic heart failure, there is a dearth of literature on asymptomatic left ventricular systolic dysfunction (ALVSD). In this case report, we present the successful perioperative management of a 35-year-old male with ALVSD and a low ejection fraction undergoing lower limb surgery under combined spinal epidural anesthesia. Our approach aimed to maintain hemodynamic stability, minimize myocardial overload, and mitigate the adverse effects of neuraxial blockade.

The management of resistant tuberculosis (tb) can be extremely difficult, especially in case of novel unpredicted complications. In this report, we present a case of a 48-year-old patient with pre-extensively drug-resistant (XDR) tb who received a treatment regimen including pretomanid, bedaquiline, linezolid, cycloserine, and amikacin and died due to myocarditis. Acquired resistance to first- and second-line drugs developed due to previous poor adherence to medication. The clinical presentation of the patient, along with her initial ultrasonographical, electrocardiogram (ECG), and laboratory examinations, were typical for acute myocarditis; however, the patient was considered unstable, and further investigations, including magnetic resonance imaging (MRI), pericardiocentesis, and endomyocardial biopsy were not performed. To our knowledge, this is the first case of myocarditis in such a patient, the clinical features of which raised a high suspicion of drug induction that could be attributed to the treatment regimen that was administered. Clinicians who manage cases of drug-resistant tb should be aware of this newly reported, potentially lethal, adverse event. [ABSTRACT FROM AUTHOR]

Heart failure poses significant challenges in perioperative settings, with an increasing prevalence in India. While much attention has been given to the management of symptomatic heart failure, there is a dearth of literature on asymptomatic left ventricular systolic dysfunction (ALVSD). In this case report, we present the successful perioperative management of a 35-year-old male with ALVSD and a low ejection fraction undergoing lower limb surgery under combined spinal epidural anesthesia. Our approach aimed to maintain hemodynamic stability, minimize myocardial overload, and mitigate the adverse effects of neuraxial blockade. [ABSTRACT FROM AUTHOR]

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Aim – to identify predictors of the risk of adverse events over a three-year period in patients with chronic heart failure (CHF). Material and methods. A retrospective study was conducted on 278 people diagnosed with CHF in patients with coronary heart disease (CHD). A sample of data was made, survival assessment, Charson comorbidity index was calculated. Statistical data processing was carried out using Excel and XLSTAT programs with linear regression calculations. Results. A statistically significant direct relationship between three-year survival was identified with the following indicators: age over 66 years, stage IIB-III CHF, Echo-CG data (low LVEF, left ventricular diameter, systolic pressure in the pulmonary artery (SPAP), the presence of hypertension (HBP) and atrial fibrillation (AF), Charlson comorbidity index of more than 5 points, glomerular filtration rate (GFR) less than 60 ml/min, complete blood count (CBC) data - a decrease in hemoglobin level below 131 g/l and an increase in ESR level above 14 mm/h. Surgical interventions such as coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) were associated with better patient survival. Conclusion. In order to ensure qualified monitoring of patients with CHF and ensure continuity of management of these patients, it seems relevant to create a specialized office for the management of patients with CHF.

Background: Patients with low ejection fraction undergoing lower abdominal surgeries often require careful management of anesthesia to minimize cardiovascular risks. Epidural anesthesia with local anesthetics such as levobupivacaine or ropivacaine combined with dexmedetomidine has been shown to provide effective analgesia and hemodynamic stability. However, the comparative effects of these two agents in this patient population remain unclear. Materials and methods: A prospective, randomized study was conducted on 100 patients with low ejection fraction undergoing lower abdominal surgeries. Patients were randomly allocated into two groups: one receiving epidural levobupivacaine plus dexmedetomidine (Group L) and the other receiving epidural ropivacaine plus dexmedetomidine (Group R). Hemodynamic parameters, intraoperative and postoperative analgesic requirements, postoperative pain scores, time to first analgesic request, onset of drug action, and adverse events were recorded and compared between the two groups. Results: In Group L, intraoperative mean arterial pressure (MAP) was maintained within 20% of baseline values more effectively compared to Group R (p < 0.05). Additionally, patients in Group L required significantly lower intraoperative and postoperative opioid consumption (p < 0.05). Postoperative pain scores were also lower in Group L compared to Group R at various time points (p < 0.05). Time to first analgesic request was significantly longer in Group L compared to Group R (p < 0.05). Levobupivacaine demonstrated a faster onset of action compared to ropivacaine (p < 0.05). Both groups exhibited comparable rates of adverse events. Conclusion: Epidural levobupivacaine plus dexmedetomidine provides superior hemodynamic stability, reduced intraoperative and postoperative opioid consumption, better pain control, faster onset of action, and prolonged time to first analgesic request compared to epidural ropivacaine plus dexmedetomidine in patients with low ejection fraction undergoing lower abdominal surgeries. Thus, levobupivacaine may be a preferable choice for epidural anesthesia in this patient population. [ABSTRACT FROM AUTHOR]

I Made Adi Parmana,1 Cindy Elfira Boom,1 Lisnawati Rachmadi,2 Dudy Arman Hanafy,3 Yunita Widyastuti,4 Muchtaruddin Mansyur,5 Bambang Budi Siswanto6 1Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 3Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia; 4Department of Anesthesiology and Intensive Care, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia; 5Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 6Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, IndonesiaCorrespondence: I Made Adi Parmana, Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, LetJen S. Parman St No. Kav. 87, West Jakarta, Jakarta, Indonesia, Email adiparmana13@gmail.comPurpose: On-pump coronary artery bypass graft (CABG) causes myocardial ischemia, through the cardiopulmonary bypass (CPB) and aortic cross-clamping (AoX). Glutamine supplementation protects cardiac cells during cardiac ischemia. This study analysed the correlation between cardiac index (CI), plasma troponin I, myocardial histopathology, CPB and AoX duration in low ejection fraction patients receiving glutamine and no glutamine undergoing elective on-pump CABG.Material and Methods: This was a secondary analysis of a double-blind, randomised controlled trial of 60 patients, split into control and intervention (glutamine) groups. Glutamine was administered at a dose of 0.5 g/kg/24 hours. There were 29 patients in each respective groups after a total of two patients dropped out.Results: A negative correlation (p = 0.037) was observed between CPB duration and CI at 6 hours after CPB in the glutamine group. A positive correlation (p = 0.002) was also observed between AoX duration and plasma troponin I at 6 hours after CPB in the control group. However, no correlation was observed between myocardial histopathology and plasma troponin I level at 5 minutes after CPB.Conclusion: Significant negative correlation between CPB duration and CI at 6 hours after CPB in the glutamine group, along with significant positive correlation between AoX duration and plasma troponin I level at 6 hours after CPB in the control group demonstrated the myocardial protection qualities of intravenous glutamine administration in patients with low ejection fraction undergoing elective on-pump CABG surgeries.Keywords: glutamine, myocardial protection, coronary artery bypass grafting, cardiopulmonary bypass, low ejection fraction, myocardial injury

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P <.001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P <.001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P =.03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P <.001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio:.95 (.37-2.45); P =.92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (β:.28 (.23-.33); P < 0.001) with no difference between groups (P =.85). In conclusion, TAVR could be as safe as SAVR in patients with low EF. [ABSTRACT FROM AUTHOR]

I Made Adi Parmana,1 Cindy Elfira Boom,1 Lisnawati Rachmadi,2 Dudy Arman Hanafy,3 Yunita Widyastuti,4 Muchtaruddin Mansyur,5 Bambang Budi Siswanto6 1Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia; 2Department of Anatomical Pathology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 3Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia; 4Department of Anesthesiology and Intensive Care, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia; 5Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 6Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, IndonesiaCorrespondence: I Made Adi Parmana, Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, LetJen S. Parman St No. Kav. 87, West Jakarta, Jakarta, Indonesia, Tel +62 812-4601-212, Email adiparmana13@gmail.comPurpose: Myocardial injury due to on-pump coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF) is associated with poor outcomes. This study determines whether intravenous glutamine could protect the myocardium during on-pump CABG in patients with low EF.Materials and Methods: This was a double-blind, randomized controlled trial to assess glutamine as a myocardial protector during on-pump CABG in patients with left ventricle EF of 31– 50%, conducted from January to October 2021. Patients in the glutamine group (n = 30) received 0.5 g/kg of 20% glutamine solution diluted with 0.9% NaCl up to 500 mL in total volume over a period of 24 hours. Patients in the control group (n = 30) received 0.9% NaCl over the same period. The primary outcomes were plasma troponin I and plasma glutamine levels. Secondary outcomes included α-ketoglutarate (α-KG) levels and histopathology scoring of the right atrial appendage tissue, plasma lactate levels, hemodynamic measurement, and morbidity.Results: Twenty-nine patients from each group (58 in total) were included in the analysis. Plasma troponin I levels at 6 and 24 hours after cardiopulmonary bypass (CPB) were significantly lower in the glutamine than the control group (mean 3.43 ± 1.51 ng/mL vs mean 4.41 ± 1.89 ng/mL; p = 0.034; median 3.08 ng/mL [min–max: 1.30– 6.59] vs median 3.77 ng/mL [min–max: 0.00– 36.53]; p = 0.038, respectively). Plasma glutamine levels at 24 hours after CPB were significantly higher in the glutamine than the control group (mean 935.42 ± 319.10 μmol/L vs mean 634.79 ± 243.89 μmol/L, p = 0.001). Plasma lactate levels at 6 and 24 hours after CPB were significantly lower in the glutamine than the control group (median 5.30 mmol/L [min-max: 1.20– 9.50] vs median 5.70 mmol/L [min-max: 2.80– 11.30], p = 0.042; mean 2.08 ± 0.67 mmol/L vs mean 2.46 ± 0.69 mmol/L, p = 0.044, respectively). Myocardial injury score was significantly lower in the glutamine than the control group (mean 1.30 ± 0.24 vs mean 1.48 ± 0.26, p = 0.011).Conclusion: Perioperative administration of 0.5 g/kg intravenous glutamine solution over the period of 24 hours has myocardial protection effect in patients with low EF who undergo elective on-pump CABG.Keywords: glutamine, myocardial protection, coronary artery bypass grafting, cardiopulmonary bypass, low ejection fraction, myocardial injury

Treatment of congestive heart failure (CHF) with left ventricular (LV) systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. We compared the periprocedural outcomes of TAVR in patients with an ejection fraction (EF) of ≤20% (VLEF group) to patients with an EF > 20% to ≤40% (LEF group). We included patients with severe AS and reduced LV ejection fraction (LVEF ≤ 40%) who underwent TAVR at four centers within Northwell Health between January 2016 and December 2020. Over 2000 consecutive patients were analyzed, of which 355 patients met the inclusion criteria. The primary composite endpoint was in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve re-intervention, and/or need for PPM. Secondary endpoints were length of stay, NYHA classification at 1 month and 1 year, mortality at 1 month and 1 year, mean valve gradient at 1 month, KCCQ score at 1 month, and ≥ moderate PVL at 1 month. There was no difference in the primary composite endpoint between the two groups (23.6% for VLEF vs. 25.3% for LEF, p = 0.29). During TAVR placement, 40% of patients in the VLEF group required ≥1 vasopressors for hypotension lasting ≥30 min vs. only 21% of patients in the LEF group (p < 0.01). Intra-aortic balloon pump (IABP) use during procedure was greater in the VLEF group (9% vs. 1%, p < 0.01)—all placed post TAVR. Emergency ECMO use was higher in the VLEF group as well (5% vs. 0%). Total length of stay was significantly different between the two groups as well (6 days vs. 3 days, p < 0.01). Both groups had a change in LVEF of ~10%. One-year outcomes were similar between the groups. All-cause mortality at 1 year was not significantly different at 1 year (13% for VLEF vs. 11% for LEF), and KCC scores were also similar (77.54 vs. 74.97). Mean aortic valve gradients were also similar (12 mmHg vs. 11 mmHg, p = 0.48). Our study suggests that patients with EF ≤ 20% can safely have TAVR with similar periprocedural outcomes compared to patients with EF > 20% to ≤40% despite higher rates of vasopressor and mechanical support. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement (AVR) for higher risk patients. Periprocedural TAVR complications decreased with a growing expertise of implanters. Yet, TAVR can be accompanied by life-threatening adverse events such as intraprocedural cardiopulmonary resuscitation (CPR). This study retrospectively analyzed predictors and outcomes in a cohort of patients from a high-volume center undergoing periprocedural CPR during TAVR. Methods A total of 729 patients undergoing TAVR, including 59 with intraprocedural CPR, were analyzed with respect to peri- and postprocedural outcomes. Results Patients undergoing CPR showed a significantly lower left ventricular ejection fraction (LVEF) and lower baseline transvalvular mean and peak pressure gradients. The systolic blood pressure measured directly preoperatively was significantly lower in the CPR cohort. CPR patients were in a higher need for intraprocedural defibrillation, heart–lung circulatory support, and conversion to open heart surgery. Further, they showed a higher incidence of atrioventricular block grade III , valve malpositioning, and pericardial tamponade. The in-hospital mortality was significantly higher after intraprocedural CPR, accompanied by a higher incidence of disabling stroke, new pacemaker implantation, more red blood cell transfusion, and longer stay in intensive care unit. Conclusion Impaired preoperative LVEF and instable hemodynamics before valve deployment are independent risk factors for CPR and are associated with compromised outcomes. Heart rhythm disturbances, malpositioning of the prosthesis, and pericardial tamponade are main causes of the high mortality of 17% reported in the CPR group. Nevertheless, mechanical circulatory support and conversion to open heart surgery reduce mortality rates of CPR patients. [ABSTRACT FROM AUTHOR]

Introduction and objectives Severe left ventricular dysfunction (LVD) in coronary artery disease (CAD) is linked to high risks and limited outcomes. Coronary artery bypass grafting (CABG) remains a key surgical intervention for these patients. This study aimed to assess hospital and short-term outcomes in patients with severe LVD undergoing isolated CABG and identify predictors of adverse outcomes. Methodology We conducted a retrospective study of 454 patients who underwent CABG for CAD with significant LVD at Hayatabad Medical Complex between 2018 and 2024. Data were extracted from clinical records and analyzed statistically to evaluate outcomes and predictors. Results The study included 454 patients with a mean age of 58.14 ± 9.576 years and a mean ejection fraction of 35.59 ± 3.996%. There were 396 (87.2%) male patients with common comorbidities, including hypertension (122, 26.9%), diabetes mellitus (88, 19.4%), and smoking (39, 8.6%). Intraoperative findings showed a mean cardiopulmonary bypass (CPB) time of 155.94 ± 38.120 minutes, with 451 (99.3%) achieving LIMA (left internal mammary artery) to LAD (left anterior descending artery) revascularization. Postoperative in-hospital mortality was 21 (4.6%), re-intubation occurred in 18 (4.0%), and arrhythmias were observed in 26 (5.7%). Wound infections were minimal (444 (97.8%) without infection), and 406 (89.4%) underwent elective CABG, while nine (2.0%) had emergent CABG, mostly due to ventricular septal rupture. Conclusion CABG remains a vital surgical intervention for patients with severe LVD, offering favorable short-term outcomes despite the inherent risks. Key factors contributing to these results include comprehensive myocardial revascularization, effective use of internal mammary artery grafting, and advanced myocardial protection strategies. This study highlights the potential of CABG to improve survival and functional outcomes in this high-risk population., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2025, Aasim et al.)

Anesthetic management of cardiac patients with low ejection fraction (EF) on two-dimensional echocardiography is a challenge. Underlying cardiac condition, type and duration of surgery and overall optimization of the patient determine the plan of anesthesia in these patients. Hypobaric spinal anesthesia (SA) known for its role in anorectal procedures was found to be a suitable tool in the management of cardiac patients with low EF who underwent infraumbilical surgeries in our case series. Hypobaric SA with 0.1% bupivacaine and fentanyl as an adjuvant gave a satisfactory outcome without significant hemodynamic changes with its differential blockade nature. We found it to be a simpler, safer, economical, and efficient technique which lasted for an average duration of 2½ hours, although it is a rarely practiced technique. We conclude that the practice of hypobaric SA can be considered one of the options in the anesthetic management of infraumbilical superficial surgeries of moderate duration in cardiac patients with low EF.

Introduction: Robotic‐assisted coronary artery bypass grafting (CABG) outcomes in patients with a high society of thoracic surgery (STS) score in urgent settings remain hindered. Presentation of Case: A high‐risk female patient presented with dyspnea and low ejection fraction (EF = 15%) and was diagnosed with pulmonary edema post myocardial infarction. She was medically stabilized with intraaortic balloon pump and the heart‐team decided to intervene with off‐pump robotic hybrid coronary revascularization (HCR). The patient had the planned with left internal mammary artery (LITA) anastomosis to the left anterior descending artery (LAD) and the postoperative recovery was uneventful and patients discharged after few days at home. Discussion: CABG has proven to be superior to percutaneous coronary intervention (PCI) even when guided by fractional flow rate and using the last generation stents according to fractional flow reserve versus angiography for multivessel evaluation 3 clinical trial. In moderate SYNTAX score patients that have been historically (SYNTAX trial) treated with multivessels PCI, robotic CABG has been shown to offer the advantage of LITA‐LAD in combination with stent for non‐LAD territory. Conclusion: High‐risk, fragile patients, with low EF and high STS score that undergo urgent CABG can benefit from heart‐team collaboration, and HCR is an important tool in the armamentarium. [ABSTRACT FROM AUTHOR]

Abstract Background Del Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia. Results During 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (n = 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4), P = 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL; P = 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008); P < 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days, P < 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55); P = 0.01). Conclusions Prolonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.

Purpose. This study investigated the effects of levosimendan on renal functions in patients with a preoperative low ejection fraction undergoing open-heart surgery and cardiopulmonary bypass (CPB). Materials and Methods. The study retrospectively evaluated 64 patients with a diagnosis of mitral valve insufficiency and left ventricular dysfunction undergoing open-heart surgery with CPB. Patients were divided depending on the preoperative blood creatinine level less (Group 1) or more than 1.2 mg/dL (Group 2). A bolus dose of levosimendan was administered through the aortic arch at the end of the CPB, preceding an infusion of levosimendan intravenously in all patients. Demographic data, preoperative and 48-hour postoperative echocardiographic studies were done. The blood urea and creatinine levels were collected preoperatively and on postoperative days 1, 3, and 10. The use of inotropic support, intra-aortic balloon pump, and complications were recorded. Results. The demographic data were similar between groups (p>0.05). Preoperative serum creatinine levels were higher in Group 1 in comparison to Group 2 (p=0.01, p0.05). Preoperative serum creatinine levels were higher in Group 1 in comparison to Group 2 (p0.05). Complications were similar between groups (p>0.05). Conclusions. In patients with low ejection fraction undergoing open-heart surgery, the use of levosimendan intraoperatively and 24 hours postoperatively prevents deterioration of renal functions in patients with or without preoperative disturbance in serum creatinine level.

In patients with cardiac disease, it’s always a challenge for the anaesthetist to administer general anaesthesia as well as central neuraxial blockade. The major perioperative task in these patients with low cardiac output is maintaining hemodynamic stability. Here, we are discussing a case of successful management of a geriatric patient having ischemic heart disease with ejection fraction of 25% posted for bilateral total knee replacement under graded epidural anaesthesia.

Anesthetic management of cardiac patients with low ejection fraction (EF) on two-dimensional echocardiography is a challenge. Underlying cardiac condition, type and duration of surgery and overall optimization of the patient determine the plan of anesthesia in these patients. Hypobaric spinal anesthesia (SA) known for its role in anorectal procedures was found to be a suitable tool in the management of cardiac patients with low EF who underwent infraumbilical surgeries in our case series. Hypobaric SA with 0.1% bupivacaine and fentanyl as an adjuvant gave a satisfactory outcome without significant hemodynamic changes with its differential blockade nature. We found it to be a simpler, safer, economical, and efficient technique which lasted for an average duration of 2½ hours, although it is a rarely practiced technique. We conclude that the practice of hypobaric SA can be considered one of the options in the anesthetic management of infraumbilical superficial surgeries of moderate duration in cardiac patients with low EF. [ABSTRACT FROM AUTHOR]

Selection of the ideal surgical procedure for coronary revascularization in patients with severe cardiac dysfunction at times may represent a challenge. In recent years, with the advent of surgical large microaxial pumps, e.g., Impella 5.0 (Abiomed Inc., Boston, USA), specific support and effective unloading of the left ventricle has become available. In the interventional field, good results have been achieved with smaller microaxial pumps in the setting of so-called protected percutaneous coronary intervention. In this study, we would like to share our early experience with surgical coronary revascularization under the sole support of Impella 5.0, omitting the use of heart–lung machine in three cases of severe cardiac dysfunction due to complex ischemic heart disease. Effective circulatory support intraoperatively and postoperatively speaks in favor of this technique in selected patients. [ABSTRACT FROM AUTHOR]

Objectives: To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function., Methods: From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors., Results: Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min -1  m -2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group., Conclusions: Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock., Competing Interests: Conflict of Interest Statement M.T. reported consulting and speaking honorarium with Abbott and Abiomed. E.S. receives honoraria from Abiomed, AtriCure, and Abbott. E.B. reported noncompensated statistical consultant for Abiomed and Edwards Lifesciences. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background The aim of this study was to assess the results after coronary artery bypass graft (CABG) in patients with reduced ejection fraction (EF; ≤40%) but viable myocardium and to determine the possible predictors of postoperative outcome, depending on preoperative dobutamine-stress echocardiography (DSE) results. Patients and methods The study included 110 patients who underwent isolated elective on-pump CABG with left ventricular ejection fraction (LVEF) less than 40%. This study was conducted at the Department of Cardiothoracic Surgery in Ain Shams University Hospital, Nasr City Insurance Hospital, and Minia University Hospital. This prospective observational study was conducted over 1 year with a follow-up period of 6 months. Results The study approved a statistically significant increase in New York Heart Association class I and Canadian Cardiovascular Society grades I and II. Changes in the findings of trans-thoracic echocardiography postoperatively and at the end of the follow-up period in survivors compared with preoperative values were statistically significant in the form of improvements in LV dimensions, LVEF, and segmental wall motion abnormalities. On univariable analysis of the predictors of in-hospital mortality, the significant predictors were age more than 60 years, peak wall motion score index on DSE more than 1.5, improvement of LVEF on DSE less than 10%, insertion of intra-aortic balloon pump (intraoperative or postoperative), and incomplete revascularization. On multivariable analysis of the predictors of in-hospital mortality, insertion of intra-aortic balloon pump was the only significant predictor of mortality. Conclusion CABG for dysfunctioning but viable myocardium enhances LV recovery of function and ensures acceptable survival. The results of DSE in patients with low LVEF are predictive for clinical improvement. Therefore, assessment of wall motion score index and LVEF with dobutamine echocardiography may be the optimal means of evaluating the impact of viability on prognosis. [ABSTRACT FROM AUTHOR]

Background and objective: Hypotensive attacks commonly occur during induction of anesthesia and can result in irreversible ischemic damages to the vital body organs. This study aimed to assess the effect of using ephedrine at low doses in controlling hemodynamic changes induced by anesthesia. Methods: A single centered single-blinded, prospective comparative study was conducted in Erbil cardiac center in periods between January 2018 and July 2018. A total of 150 patients with left ventricular ejection fraction

Coronary artery bypass grafting (CABG) remains a routine operation despite major advancements in angioplastic procedures. Around 200,000 CABG procedures are performed annually in the U.S. Patients who are not candidates for angioplasty intervention often have advanced coronary disease and comorbidities that raise the risk of heart failure with decreased ejection fraction to around 25%. Over the years, significant developments in various preoperative interventions have occurred; in this paper, we suggest a multidisciplinary preoperative algorithm that can be included in a regularly scheduled multidisciplinary care plan. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve replacement (TAVR) is an effective treatment for aortic valve disorder. Several studies have reported improvements in systolic and diastolic function following TAVR. However, few studies have addressed immediate post-deployment changes. Therefore, this study examines left ventricular (LV) systolic and diastolic function changes immediately after valve deployment in TAVR patients, distinguishing between those with normal and impaired LV ejection fraction (LVEF)., Methods: In this single-center retrospective cohort study, intraoperative changes in LV systolic and diastolic function were analyzed in patients undergoing TAVR from January 2012 to September 2014. Participants were categorized into two groups based on preprocedural LVEF: the low ejection fraction (EF) group (LVEF <50%) and the normal EF group (LVEF ≥50%). LVEF, as an indicator of LV systolic function, along with lateral e' and the E/e' ratio as indicators of LV diastolic function before and immediately after valve deployment were compared in the overall cohort and within each group., Results: Forty-eight TAVR cases were included, comprising 15 in the low EF group and 33 in the normal EF group. Overall, there was a significant improvement in LVEF {51.7% [standard deviation (SD)] 15.0 vs . 58.0% (SD 11.6), P=0.007}, with no significant changes in e' or E/e'. In the low EF group, a significant increase was observed in LVEF [31.8% (SD 8.0) vs . 45.5% (SD 9.9), P=0.006], e' [5.0 cm/s (SD 1.4) vs . 6.2 cm/s (SD 1.0), P=0.004], and a significant decrease was observed in E/e' [22.3 (SD 7.6) vs . 16.1 (SD 3.4), P=0.01]. The normal EF group showed a significant decrease in e' [6.2 cm/s (SD 1.8) vs . 5.9 cm/s (SD 1.6), P=0.04] without significant changes in LVEF and E/e'., Conclusions: This study revealed significant intraoperative improvements in systolic and diastolic functions immediately after valve deployment in TAVR patients with low preprocedural LVEF. These immediate improvements were not observed in patients with normal LVEF., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-784/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Background The use of cardioplegia solution is aimed to avoid myocardial muscle damage, leading to poor contraction and abnormal increased release of cardiac biomarkers enzymes during cardiac arrest. It remains the primary method for myocardial protection against ischemia–reperfusion injury during cardiac surgery. Cardioplegia was first presented as an agent for hypothermic hyperkalemic arrest. Blood was then introduced as a vehicle to convey potassium to the heart. Histidine–tryptophan–ketoglutarate solution is safe and used as a single dose that can last for up to 3 h. Comparison between custodiol cardioplegia and cold blood cardioplegia still remains a big debate till now. Objective To compare the clinical outcomes of custodiol solution with cold blood cardioplegia in mitral valve replacement (MVR) with cardiac ejection fraction less than 45%. Patients and methods This single‑center randomized prospective study was carried out from January 2018 till June 2019 at Ain Shams University hospitals. Overall, 65 patients with poor left ventricular function undergoing mitral valve replacement were divided randomly according to type of myocardial protection into two groups: group A included 30 patients who received custodiol cardioplegia, and group B included 35 patients who received cold blood cardioplegia. Data from each group were collected and compared with each other. Results Baseline demographic and intraoperative data showed no significant difference between the two groups. The need for inotropic support, length of mechanical ventilation, and ICU stay were statistically nonsignificant between the two groups. There was a statistically significant difference regarding the rhythm upon declamping [ventricular fibrillation (VF) in 17 (56.7%) cases in group A and nine (25.7%) cases in group B (P=0.016)], and also there was a significant difference in times of defibrillation cardioversion (DC) shock given after declamping (P=0.005). Overall mortality shows a statistically nonsignificant difference. There is a significant difference in postoperative echo assessment for both groups [ejection fraction in group A: 53.17±7.73 compared with 49.06±7.170 in group B (P=0.031)], and there is also a difference in hemoglobin postoperatively, with 10.35±0.843 in group A compared with 10.88±0.798 in group B (P=0.013). Conclusion Cardiac arrest using custodiol cardioplegia is a good choice in mitral valve replacement with the advantage of giving only one dose of cardioplegia without interruption of the operation, and also it gives good postoperative echo results than cold blood cardioplegia. Its disadvantages are lower hemoglobin levels postoperatively and hyponatremia during bypass in comparison with cold blood cardioplegia. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Our aim is to determine the triggering factors of paroxysmal atrial fibrillation (PAF) in ischemic heart failure (HF) patients with low ejection fraction (EF). METHODS: Sixty patients were included in this study. Echocardiography and 24-hours Holter monitoring were performed after measurement of serum NT-pro BNP concentration. The patients were classified into two groups concerning the occurrence of PAF on Holter recordings. Biochemical and echocardiographic parameters of patients with and without PAF were compared. RESULTS: PAF was detected in 28 (46%) patients. Patients with PAF demonstrated higher NT-pro BNP levels, mitral and aortic regurgitation velocities, E/A, E/E', pulmonary capillary wedge pressure, pulmonary artery systolic pressure, left atrial volume and volume indices. NT-pro BNP was established as the predictor of PAF (OR=1.23, 95% CI: 1.08-1.42; p=0.001). ROC analysis showed an NT-pro BNP value of 2188 pg/mL as cut-off value with 68% sensitivity and 84% specificity [Area under the ROC curve (AUC)=0.826, CI 95%: 0.724-0.927; p<0.001]. CONCLUSION: The triggering factors for AF are increased intracardiac pressures, left atrial dilatation and increased wall tension. As an indicator of increased wall tension, elevated levels of NT-pro BNP predict the development of PAF. [ABSTRACT FROM AUTHOR]

Introduction: In this study, we evaluated patient response and haemodynamic parameters in patients with low ejection fraction undergoing coronary bypass surgery with either fentanil or remifentanil in conjunction with etomidate. Material and methods: We evaluated 30 cases of coronary artery surgery, which were divided into two treatment groups (n = 15 each). In group F (fentanil group), the following regimen was employed for anaesthesia induction: 1 mg/kg lidocaine, 0.3 mg/kg etomidate, and, following a 1 µg/kg 60 s bolus dose of fentanil, a 0.1 µg/kg/min fentanil infusion was initiated, after which 0.6 mg/kg rocuronium was administered. In group R (remifentanil group), the following regimen was employed for anaesthesia induction: 1 mg/kg lidocaine, 0.3 mg/kg etomidate and, following a 1 µg/kg 60 s bolus dose of remifentanil, a 0.1 µg/kg/min remifentanil infusion was initiated, after which 0.6 mg/kg rocuronium was administered. Systolic artery pressure, diastolic artery pressure, mean arterial pressure, heart rate, SPO2 (saturation), cardiac output, stroke volume variance, central venous pressure, and systemic vascular resistance values were recorded for all study patients at five minutes before anaesthetic induction (T1), immediately following induction (T2), and immediately following intubation (T3). Results: The demographic values obtained for both groups were similar. We found that remifentanil use was associated with decreased cardiac output and increased fluctuations in both heart rate and mean values of arterial pressure. Conclusions: Although many studies have demonstrated remifentanil to be as safe as fentanil when titrated to an appropriate dose, our study suggests that fentanil may be a more appropriate choice during the induction of anaesthesia in patients with a low ejection fraction. [ABSTRACT FROM AUTHOR]

Background: Patients with low ejection fraction (EF) are at high risk for postoperative complication and mortality. Our aim was to assess the effect of low EF on clinical outcome after surgery. Objective: The present study evaluates our experience with coronary artery bypass grafting in patients with low EF. Materials and Methods: We analyzed the data of 35 patients with EF

Objectives: Patients with preoperative low left ventricular ejection fraction (LVEF) are known to be associated with high morbidities and mortality in cardiac surgery. The primary aim of this review was to examine the clinical outcomes of levosimendan versus placebo in patients with preoperative low LVEF ≤ 50% undergoing cardiac surgery.Data Sources: MEDLINE, EMBASE, PubMed and CENTRAL were searched systematically from their inception until June 2018.Review Methods: All the randomised clinical trials (RCTs) were included.Results: Twelve trials were eligible (n = 1867) for inclusion in the data synthesis. In comparison to the placebo cohort, the levosimendan cohort showed a significant reduction in mortality (TSA = inconclusive; ρ = 0.002; I2 = 0%; FEM: OR 0.56; 95% CI 0.39, 0.80), especially in the subgroups of preoperative severe low LVEF ≤ 30% (ρ = 0.003; OR 0.33; 95% CI 0.16, 0.69), preoperative administering of levosimendan (ρ = 0.001; OR 0.46; 95% CI 0.29, 0.74) and patients who had bolus followed by infusion of levosimendan (ρ = 0.005; OR 0.50; 95% CI 0.30, 0.81). However, the effect on mortality was not significant in the subgroup analysis of high quality trials (ρ = 0.14; OR 0.73; 95% CI 0.47, 1.12). The levosimendan cohort showed a significantly lower incidence of low-cardiac-output-syndrome (ρ < 0.001; OR 0.58; 95% CI 0.46, 0.74) and lesser need for mechanical support of cardiac assist devices (ρ = 0.02; OR 0.39; 95% CI 0.18, 0.86).Conclusions: Given the low level of evidence and inconclusive TSA, the results of this meta-analysis neither support nor oppose the use of levosimendan in cardiac patients with preoperative low LVEF ≤ 50%. Therefore, multi-centre, adequately powered, randomised controlled trials are warranted.Prospero Registration: CRD42017067572. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Implantable cardioverter defibrillator (ICD) reduces mortality in selected patients. However, its role in patients older than 75 years is not well established. Methods and results: We performed a retrospective, non‐randomized study using a historical cohort from a single centre. Between January 2008 and July 2014, we assessed patients aged ≥75 years with left ventricular ejection fraction ≤ 35%, identifying 385 patients with a Class I or IIa recommendation for ICD implantation. At the decision of the patient or attending cardiologists, 92 patients received an ICD. To avoid potential confounding factors, we used propensity‐score matching. Finally, 126 patients were included (63 with ICD). The mean age was 79.1 ± 3.1 years (86.5% male). As compared with the medical therapy group, the ICD patients had a lower percentage of chronic obstructive pulmonary disease (19.0% vs. 38.1%, P < 0.05) and more frequent use of beta‐blockers (BBs) (85.7 vs. 70.0%, P < 0.05). Other treatments were otherwise similar in both groups. There were no differences related to age, aetiology, or other co‐morbidities. During follow‐up (39.2 ± 22.4 months), total mortality was 46.0% and cardiovascular events (death or hospitalization) occurred in 66.7% of the patients. A multivariate analysis revealed that only BB therapy was shown to be an independent protective variable with respect to mortality [hazard ratio 0.4 (0.2–0.7)]. ICD therapy did not reduce overall mortality or the rate of cardiovascular events. Conclusions: According to our results, the use of ICD, as compared with medical therapy, in patients older than 75 years did not demonstrate any benefit. Well‐designed randomized controlled studies in patients older than 75 years are needed to ascertain the value of ICD therapy. [ABSTRACT FROM AUTHOR]

Both non-ischemic cardiomyopathy and extensive atherosclerosis are common diseases. Differentiating between causal and bystander coronary artery disease (CAD) can occasionally be quite difficult. Although treating CAD in patients with severe cardiomyopathy makes a lot of sense, there are currently no reliable data to back it up. Separate studies on surgical and percutaneous revascularization have been conducted. It is challenging to compare one revascularization technique to another because those trials were carried out at various points in history and with patients who varied in their patient characteristics. The most current large-scale trial investigating the impact of coronary artery bypass graft (CABG) surgery on prognosis in ischemic heart failure is called the Surgical Treatment for Ischemic Heart Failure (STICH) trial. The rate of all-cause death did not significantly differ after a five-year follow-up period. Only after a lengthy 9.8-year follow-up period did CABG demonstrate a benefit in terms of death rate. The low incidence of ICD implantation, younger patient age than in most other comparable trials, low ICD implantation rate, and absence of contemporary therapy were just a few of the trial’s severe flaws. All the aforementioned may have had a significant impact on the trial’s outcome. The REVIVED-BCIS2 investigated possible other advantages that PCI might have over conventional medical treatment.¹ This well-designed multicentric trial randomly assigned individuals to receive either PCI or the best medical care. There was no difference in death or hospitalization rates between these two groups after 3.4 years of follow-up. These two studies serve as the primary source of evidence supporting revascularization in patients with poor ejection fractions. Although trials had similar patient populations, there were still big disparities. We can infer from these two trials that patients won’t benefit from either of these two treatments in the initial stages up to five years following therapy. After five years, with modern medical therapy and an ICD, it is still questionable if any benefit might be realized. [ABSTRACT FROM AUTHOR]

A 76-year-old kyphoscoliotic female patient presented with severe pain and sudden acute abdominal distension for 1-week and was diagnosed to have right-sided massive twisted ovarian cyst. The patient was a known case of hypertension, dilated cardiomyopathy with low 20% cardiac ejection fraction. Though very few incidences of multiple co-morbid conditions existing together in a single elderly patient have been reported in the past, it is important to titrate the dosage, type of anesthetic agents and their routes of administration in high risk patients.

Introduction. The subset of patients most likely to benefit from off-pump coronary artery bypass grafting (OPCABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Coronary artery bypass grafting (CABG) with a cardiopulmonary bypass carries a significant risk for patients with severe left ventricular (LV) dysfunction. Objective. The objective of this study was to compare off-pump to on-pump CABG in patients with ejection fraction (EF) lower than 30%. Methods. Prospective randomized study was carried out between June 2004 and March 2006 at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia. Sixty prospectively randomized high-risk patients divided into two groups to undergo off-pump or on-pump CABG. All recruited patients had left ventricular ejection fraction lower than 30%. Results. Thirty patients averaging 59.2 years of age underwent 2.30 grafts on pump, and another 30 averaging 59.6 years of age underwent 2.03 grafts off pump. OPCABG patients exhibited a significantly less release of TnI (average 0.71 μ/L) than on-pump patients (3.00 μ/L). Inotropic requirements were less in the off-pump group. The patients undergoing OPCABG received fewer units of blood and had shorter postoperative length of stay in intensive care unit and hospital stay. There was no significant difference in hospital mortality and complication rate. Conclusion. The present study suggests that off-pump CABG in patients with poor LV function when compared with conventional CABG achieved similar number of grafts per patient, similar in-hospital outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Background: Patients with low ejection fraction (EF) are at high risk for postoperative complication and mortality. Our aim was to assess the effect of low EF on clinical outcome after surgery. Objective: The present study evaluates our experience with coronary artery bypass grafting in patients with low EF. Materials and Methods: We analyzed the data of 35 patients with EF <35%. All participants were assessed preoperatively with respect to patient characteristics, risk factors, and preoperative two dimension echocardiography (2D ECHO). Depending on findings of 2D ECHO patients were divided into three groups: in Group 1, we included patients with EF 30%-35%, Group 2 comprised patients with EF of 25%-30%, and Group 3 consisted of patients with EF <25%. Patients were operated by off-pump coronary artery bypass grafting; only three patients were operated by on-pump beating heart surgery. We noted a mean number of grafts required, use of intra-aortic balloon counterpulsation (intra-aortic balloon pump) intraoperatively and postoperatively, postoperative complication, mortality, mean hospital stay, postoperative improvement in EF, and postoperative control of angina and symptomatic improvement. Results: Hospital mortality rate in present series was 11%. Mean grafts were 3.02 per patient. Fourteen (40%) patient had a postoperative complication. EF improved in 78% of patients. Canadian Cardiovascular Society Angina class improved in 42% of patients. Conclusion: In patients with coronary artery disease and low EF, CABG can be performed safely, and improvement in left ventricular function can be achieved with this procedure improving the quality of life. [ABSTRACT FROM AUTHOR]

Objective: Whipple procedure is an operation performed to remove the head of the pancreas, the duodenum, the gallbladder and the bile duct. A low Ejection fraction (EF) may predispose to increase perioperative mortality by causing pump failure, cardiac dyskinesia or cardiogenic shock. We describe our perioperative evaluation of an elderly patient with an EF of 22% undergoing a pancreaticoduodenectomy, with a focus on fluid resusitation and anesthesia procedure optimisation with the help of advanced PulsioFlex monitoring. Case: A 74-year-old male (73 kg, 174 cm), who had a history of pancreas head cancer. In the transthoracic echocardiography (TTE) a reduced EF of 22%, tricuspid annular plane systolic excursion (TAPSE) 13, hypokinetic areas were detected. The epidural space (T3-T4) was identified by the loss-of-resistance technique. The patient recieved a preinduction thoracic epidural injection of 0.5% bupivacaine® (25 mg) after adrenaline test dose (50 mcg). Lidocaine (1 mg/kg), propofol (2 mg/kg), fentanyl (0.5 mcg/kg) and rocuronium bromide (0.6 mcg/kg) were applied to the preoxygenated patient for induction and then he was intubated. Advanced hemodynamic monitoring (PulsioFlex™, Pulsion Medical Systems, Germany) was used for real-time monitoring of cardiac index (CI), central venous pressure (CVP), cardiac power output (CPO), stroke volüme (SV), dPmax which is regarded as a marker of left ventricular contractility, stroke volume variation (SVV) and systemic vascular resistance (SVR), pulse pressure variation (PPV) parameters and so we decided to start norepinephrine® infusion (0.01-0.05 mcg/kg/min). We used bispectral index monitorization to follow up the depth of anesthesia. Patient’s effective intravenous volume is important to mantain hemodynamic stability, tissue perfusion and oxygenation. Conclusion: Thorough preoperative preparations as well as intraoperative close communication with surgeons allow anesthesiologist to anticipate and prevent fatal complications that may develop in the perioperative period during Whipple procedure. [ABSTRACT FROM AUTHOR]

La decisión de someter a cambio valvular a un paciente con disfunción ventricular moderada a severa, es motivo de controversia debido a las complicaciones y los malos resultados a corto y largo plazo. El objetivo de este estudio fue evaluar los resultados quirúrgicos en los pacientes con baja fracción de eyección pre-quirúrgica sometidos a cambio valvular mitral aórtico o mitro-aórtico. En este tipo de pacientes se puede obtener una aceptable sobrevida libre de sintomas. La clase funcional IV de la New York Heart Association incrementa la mortalidad temprana y tardía. La marcada reducción de la fracción de eyección preoperatoria, no debe considerse como una contraindicación para cambio valvular.The decision to submit patients with moderate to severe ventricular dysfunction to valvular replacements is subject to controversy because complications and the adverse outcomes in short and long-term. The aim of this study was to evaluate the outcomes in mitral or aortic valve replacements or combined aortic and mitral valve replacements in patients with preoperative low left ventricular ejection fraction. Good symptomatic relief and acceptable overall survival can be obtained in patients with systolic dysfunction and valvular disease. Preoperative NYHA class IV increases early and late mortality. A marked ejection fraction reduction should not be considered a contraindication for valvular replacement.

Ischaemic cardiomyopathy with low ejection fraction (EF) poses a perioperative challenge to the anesthetist due to the risk of hemodynamic instability, cardiovascular collapse, and heart failure. More so when a patient has an Automated Implantable Cardiovertor Defibrillator (AICD) in situ. We report the anesthetic management of a patient with ischaemic cardiomyopathy with an EF of 20% and AICD in situ posted for open right hemicolectomy. Dynamic hemodynamic monitoring with preparedness to manage fluid shifts, hemodynamic fluctuations, and adequate pain management is essential to successful anesthetic management in patients with an AICD, where programming is not possible., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Saini et al.)

Background Low flow (LF) can occur with reduced (classic) or preserved (paradoxical) left ventricular ejection fraction (LVEF). Objectives The objective of this study was to compare outcomes of patients with low ejection fraction (LEF), paradoxical low flow (PLF), and normal flow (NF) after aortic valve replacement (AVR). Methods We examined 1,154 patients with severe aortic stenosis (AS) who underwent AVR with or without coronary artery bypass grafting. Results Among these patients, 206 (18%) had LEF as defined by LVEF of <50%; 319 (28%) had PLF as defined by LVEF of ≥50% but stroke volume indexed to body surface area (SVi) of ≤35 ml ∙ m −2 ; and 629 (54%) had NF, as defined by LVEF of ≥50% and SVi of >35 ml ∙ m 2 . Aortic valve area was lower in low flow/LVEF groups (LEF: 0.71 ± 0.20 cm 2 and PLF: 0.65 ± 0.23 cm 2 vs. NF: 0.77 ± 0.18 cm 2 ; p < 0.001). The 30-day mortality was higher (p < 0.001) in LEF and PLF groups than in the NF group (6.3% and 6.3% vs. 1.8%, respectively). SVi and PLF group were independent predictors of operative mortality (odds ratio [OR]: 1.18, p < 0.05; and OR: 2.97, p = 0.004; respectively). At 5 years after AVR, overall survival was 72 ± 4% in LEF group, 81 ± 2% in PLF group, and 85 ± 2% in NF group (p < 0.0001). Conclusions Patients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients’ pre-operative evaluation. [ABSTRACT FROM AUTHOR]

Background: Chronic heart failure (CHF) and chronic kidney disease (CKD) are serious medical conditions with significant morbidity and mortality and often coexist. Because of perioperative risks in these patients, they may not be considered a candidate for renal transplantation (RTx). Material and methods: We compare retrospectively RTx outcomes [graft/patient survival, rejection rates and adverse cardiac events] in study group [low left ventricular ejection fraction (LVEF) ≤45% by echocardiogram, n = 63] and control group [normal LVEF ≥50%, n = 537] from a developing country. Results: The mean EF was 35 ± 5.6 and 57 ± 3% for the study and control groups, respectively ( p < 0.001). Majority of these patients (98%) showed normalization of LVEF post-transplant. The median EF was 60% at 1-3 months post-transplant. No difference was noted in graft survival, patient survival, rejection rates, serum creatinine and adverse cardiac events of study group at 1.3-year mean follow-up compared to control group. Outcome was not adversely affected by preexisting LV dysfunction. The study and control groups had nearly similar percent of patients with established CAD but significantly more hospitalization for CHF pre RTx in the study group compared with the control group. Conclusion: RTx may play a role in reversing LV systolic dysfunction. Once thought by many to be a contraindication for renal transplantation, this appears not to be the case. The outcomes between the 2 groups are comparable and transplant is an option for even low EF patients. [ABSTRACT FROM AUTHOR]

Objective: Left ventricle dysfunction is an important determinant that effects hospital mortality. At the same time, the surgery of these patients is also highly risky. In this study we aimed to evaluate the clinical outcomes of onpump or off-pump revascularizations in patients with low ejection fraction. Methods: One hundred and twenty-nine patients who have ⩽ 40% ejection fraction (EF) was scanned retrospectively. Various variables were (preoperative, intraoperative, postoperative) were compared. It was evaluated that whether patients gets preoperative, intraoperative, postoperative support or not. Results: Eighty-four (65.1%) male and 45 (34.9%) female patient were detected with main age of 65.37 ± 8.49 years. Mean basal metabolism index was detected as 26.33 ± 4.21. The distrubution of EF of patients were as follows; EF is between %40-36 in 74 (57.4%) patients, EF is between %35-31 in 38 (29.5%) patients, and EF is ⩽%30 in 17 (13.2%) patients. Mean NYHA Class was detected as 2.16 ± 1.03. Mean bypass count was determined as 3.46 per patient and left internal mammarian artery was used in 92.2% of the patients. Hospital mortality was detected as 5 (3.9%). The main important reasons were cardiac factors or concomitant multiorgan failure. Postoperatvie arrythmias were the most detected complications. Conclusion: The patients who have low left ventricular pump function are benefits myocardial revascularization, although mortality is higher than normal ventricular function. However, inspite the all risk, these patients can be sucessfully operated with experinced hands. [ABSTRACT FROM AUTHOR]

The aim of our study was to compare the efficiency of the use of intraaortic balloon counterpulsation (IABP) and levosi-mendan in patients with low left ventricular ejection fraction operated on under cardiopulmonary bypass. The study included 90 patients who were randomized into three groups according to the strategy of hemodynamic support. Group A patients received IABP 24 hours before surgery. In group B, preventive IABP was combined with intraoperative levosimendan infusion. Group C patients received intraoperative levosimendan infusion only. Hemodynamics, the markers of myocardial damage and heart failure, postoperative complications and length of hospital stay were observed. The patients treated with lev-osimendan had a more stable hemodynamic profile. Troponin I level was significantly lower in Group C six hours after cardiopulmonary bypass than that in group A. Length of stay in intensive care was significantly lower in Group C. The pre-operative concentration of BNP (>360 pg/ml) is a predictor of inotropic support in the postoperative period. The results of our study indicate that the use of levosimendan in high-risk patients is effective and shows the results comparable with those of intra-aortic balloon counterpulsation.

Objectives: The present study aimed to observe the beneficial effects of sacubitril - valsartan at a lower dose of 24/26mg BID in a third-world country (Pakistan). Methodology: This was a randomized, prospective, observational cohort study conducted at a tertiary care hospital in patients diagnosed, managed, and discharged as a case of heart failure with reduced ejection fraction and followed up in the cardiac outpatient department 6 weeks post-discharge. The required information was collected from the patients by means of a designed questionnaire containing minimal personal information, including age and gender. The questionnaire used was an FDA-approved KCCQ indicated for the use of assessing the quality-of-life change before and following the therapy indicated for HF with reduced ejection fraction. The data was analyzed using SPSS version 26. Results: This study included a total of 77 patients out of which 49 were male (63.6%) and 28 were female (36.4%). The mean age of the patients included was 60.05± 11.80 years. 68.8% of them were hypertensive and 51.9% were diabetic. All patients included were those with reduced Ejection Fraction out of which 29.9% had EF between 20-25%, 49.3 % had it between 30-35% whereas 20.8% of patients had an EF of 40%. In the case of NYHA class before starting Sacubitril/Valsartan approximately 84.4% of patients were in class 3 and 15.6% of them belonged to class 4. The functional class was improved 6 weeks post-treatment in which 79.2% of patients had functional class 2 and 20.8% of them had class 3. The comparison between KCCQ scores of heart failure patients before treatment and after treatment with sacubitril/valsartan at the dosage of 24/26mg BID were statistically significant. Conclusion: It was thus concluded from the study that even a low dose of sacubitril - valsartan results in improved quality of life as assessed by KCCQ scoring in patients with heart failure with reduced ejection fraction. [ABSTRACT FROM AUTHOR]

The operative validity of aortic valve replacement (AVR) for high-risk patients with impaired left ventricular (LV) function is controversial. We measured LV contractility, afterload, and efficiency by use of transthoracic echocardiography data obtained before, after, and approximately 1 year after isolated AVR for 335 patients with aortic stenosis (AS group; n = 160), aortic regurgitation (AR group; n = 116), or aortic stenosis and regurgitation (ASR group; n = 59). Two subgroups were created: LV ejection fraction (EF) of ≥50 % (normal-EF subgroup) and <50 % (low-EF subgroup). Contractility decreased after AVR in the normal-EF AS and normal-EF AR subgroups, but did not change after AVR in the low-EF subgroups. Afterload decreased after AVR in the AS group and increased in the AR group. LV efficiency was unchanged after AVR in the normal-EF AS and ASR subgroups, worsened in the normal-EF AR subgroup, improved in the low-EF AS and ASR subgroups, and did not improve in the low-EF AR subgroup. LV contractility and efficiency improved during the 1-year period after AVR for all patients and subgroups, but the improvements in the low-EF AR subgroup were not as good as those in the low-EF AS and ASR subgroups. Improvements in LV contractility and efficiency after AVR can be expected for patients with low EF. However, contractility and efficiency did not improve after AVR for patients with AR and low EF. Low mortality and morbidity of AVR likely conceal a latent problem among patients with AR. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Gated SPECT is an accurate technique for assessment of myocardial perfusion (MP), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV). However recent studies have concluded that there are large discrepancies in assessment of LVEF and volumes by gated SPECT in patients with multiple severe myocardial perfusion defects. We sought to investigate the correlation between LVEF and volumes calculated by gated SPECT and cardiac magnetic resonance (CMR) in patients with severe multiple perfusion defects who are referred for CMR. Methods: Twenty-nine patients (20 male and 9 female, mean age: 63years±11) with multiple severe fixed perfusion defects (mean 5±3 segments) were referred to undergo CMR. The average time between CMR and SPECT was 4weeks. LVEF, EDV, and ESV were derived automatically from gated SPECT. In the CMR studies, the endocardial and epicardial borders were delineated manually in the short axis planes to calculate the LVEF and volumes. Results: The different parameters were compared using linear regression, and correlation coefficients were calculated. Substantial correlation was found between CMR and gated SPECT for EDV: r =0.7, p <0.001. Moderate correlation between CMR and gated SPECT for LVEF: r =0.5, p <0.007 and ESV r =0.53, p <0.003. Conclusion: Our data showed that the gated SPECT correlates substantially with MRI for measurement of EDV and moderately for ESV and LVEF in patients with multiple and severe perfusion defects. Thus, when accurate measurement is required, cardiac MRI is recommended. [ABSTRACT FROM AUTHOR]

A high risk of regimen-related toxicity with allogeneic hematopoietic stem cell transplantation (allo-HSCT) limits this potentially curative treatment for patients with a left ventricular ejection fraction (LVEF) of ≥50%. We evaluated the frequency of cardiac complications and 100-day nonrelapse mortality (NRM) in 56 patients with a LVEF of ≤45%, who received allo HCT at our institution. The results were retrospectively compared with a matched control group with LVEF of ≥50%, which received an allogeneic stem cell transplantation (allo-SCT). After a median follow-up of 29 months in the study group, grade ≥2 cardiac complications were seen in 7 of 56 (12.5%) patients and cumulative incidence of 100-day NRM was 12.5% with no deaths from cardiac causes. In contrast, after a median follow-up of 49 months in the control group, grade >2 cardiac complications were seen in 19 of 161 patients (11.8%; P = 1.00) and cumulative incidence of 100-day NRM was 14.9% (P = .82). The presence of at least 1 of the 7 pretransplant cardiac risk factors (past history of smoking, hypertension, hyperlipidemia, coronary artery disease, arrhythmia, prior myocardial infarction, and congestive heart failure) was associated with a higher cardiac complication rate in the study group (P = .03). In conclusion, selected patients with a LVEF of ≤45% can safely receive allo-HCT without a significant increase in cardiac toxicity or NRM. [Copyright &y& Elsevier]