Perioperative management of a patient with double orifice mitral valve with supramitral ring with subaortic membrane with ventricular septal defect and severe pulmonary hypertension: Report of a rare case

Double-orifice mitral valve (DOMV) is an unusual congenital anomaly characterized by a mitral valve with a single fibrous annulus with two orifices or rarely two orifices with two separate mitral annuli opening into the left ventricle. We present a first report of a patient with a DOMV with supramitral ring (SMR), subaortic membrane (SAM), a large ventricular septal defect (VSD) with more than 50% aortic override, and severe pulmonary arterial hypertrophy (PAH). This patient underwent excision of the SAM, and SMR, with closure of the VSD together under cardiopulmonary bypass (CPB). However postoperatively, the patient developed an irreversible fatal pulmonary hypertensive crisis (PHC), immediately after transferring the patient to the cardiac intensive care unit from the operating room (OR). The PHC was refractory to intravenous and inhaled milrinone and nitroglycerine and intravenous adrenaline, dobutamine, norepinephrine, vasopressin, patent foramen oval (PFO), and CPB support. The management of DOMV and perioperative pulmonary hypertension is discussed.

A new right atrial mass following cardiopulmonary bypass mimicking a thrombus

This report describes a patient with severe mitral stenosis who underwent mitral valve replacement. After completion of cardiopulmonary bypass, an unexpected finding of a right atrial mass was noticed on transesophageal echocardiography. The actual finding, possible differential diagnosis, and the management strategy are discussed.

Comparison of hemodynamic responses to laryngoscopy and intubation with Truview PCDTM, McGrath® and Macintosh laryngoscope in patients undergoing coronary artery bypass grafting: A randomized prospective study.

Context: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation. Aim: Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope. Setting and Design: Superspecialty tertiary care public hospital; prospective, randomized control study. Methods: Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview (TV). Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra‑/post‑operative complications were also recorded and compared between groups. Statistical Analysis: SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant. Results: Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively). Conclusions: Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.

Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation.

Background: Pulmonary artery (PA) catheter provides a variety of cardiac and hemodynamic parameters. In majority of the patients, the catheter tends to float in the right pulmonary artery (RPA) than the left pulmonary artery (LPA). We evaluated the location of PA catheter with the help of transesophageal echocardiography (TEE) to know the incidence of its localization. Three views were utilized for this purpose; midesophageal ascending aorta (AA) short‑axis view, modified mid esophageal aortic valve long‑axis view, and modified bicaval view. Methods: We enrolled 135 patients undergoing elective cardiac surgery where both the PA catheter and TEE were to be used; for this prospective observational study. PA catheter was visualized by TEE in the above mentioned views and the degree of clarity of visualization by three views was also noted. Position of the PA catheter was further confirmed by a postoperative chest radiograph. Results: One patient was excluded from the data analysis. PA catheter was visualized in RPA in 129 patients (96%) and in LPA in 4 patients (3%). In 1 patient, the catheter was visualized in main PA in the chest radiograph. The midesophageal AA short‑axis, modified aortic valve long‑axis, and modified bicaval view provided good visualization in 51.45%, 57.4%, and 62.3% patients respectively. Taken together, PA catheter visualization was good in 128 (95.5%) patients. Conclusion: We conclude that the PA catheter has a high probability of entering the RPA as compared to LPA (96% vs. 3%) and TEE provides good visualization of the catheter in RPA.

Perioperative management of a patient with Dandy Walker malformation with tetralogy of Fallot undergoing total correction and fresh homologous pericardial pulmonary valve conduit implantation: Report of a rare case.

Perioperative management of a patient with Dandy–Walker malformation (DWM) with tetralogy of Fallot (TOF), patent ductus arteriosus, and pulmonary artery stenosis is a great challenge to the anesthesiologist. Anesthetic management in such patients can trigger tet spells that might rapidly increase intracranial pressure (ICP), conning and even death. The increase in ICP can precipitate tet spells and further brain hypoxia. To avoid an increase in ICP during TOF corrective surgery ventriculo‑peritoneal (VP) shunt should be performed before cardiac surgery. We present the first case report of a 11‑month‑old male baby afflicted with DWM and TOF who underwent successful TOF total corrective surgery and fresh autologous pericardial pulmonary valve conduit implantation under cardiopulmonary bypass after 1 week of VP shunt insertion.

Healed perivalvular abscess: Incidental finding on transthoracic echocardiography.

A 36‑year‑old male patient presented with the complaints of palpitations and breathlessness. Preoperative transthoracic echocardiography (TTE) revealed a bicuspid aortic valve; severe aortic regurgitation with dilated left ventricle (LV) and mild LV systolic dysfunction (ejection fraction 50%). He was scheduled to undergo aortic valve replacement. History was not suggestive of infective endocarditis (IE). Preoperative TTE did not demonstrate any aortic perivalvular abscess. Intraoperative transesophageal echocardiography (TEE) examination using the mid‑esophageal (ME) long‑axis view, showed an abscess cavity affecting the aortic valve, which initially was assumed to be a dissection flap, but later confirmed to be an abscess cavity by color Doppler examination. The ME aortic valve short‑axis view showed two abscesses; one was at the junction of the non‑coronary and left coronary commissure and the other one above the right coronary cusp. Intraoperatively, these findings were confirmed by the surgeons. The case report demonstrates the superiority of TEE over TTE in diagnosing perivalvular abscesses.

Incidence and implications of coronary artery disease in patients undergoing valvular heart surgery: The Indian scenario.

Aims and Objectives: We evaluated the incidence and implications of coronary artery disease (CAD) in patients above 40 years presenting for valve surgery. Materials and Methods: Between January 2009 and December 2010, coronary angiography (CAG) was performed in all such patients ( n = 140). Results: Coronaries were normal in 119 (Group I), and diseased in 21 (Group II). In Group II, 11 patients were < 50 years, 3 were between 51 and 60 years and 7 were > 61 years. In 8 of these, only valve replacement was performed. Coronary artery bypass grafting (CABG) and aortic valve replacement was performed in 10, CABG and mitral valve replacement in 2 and CABG with mitral and aortic valve replacement in one. The number of vessels grafted in these 13 patients was 1.54 ± 0.66. Hypertension and diabetes were significant ( P < 0.05) in this group. The mortality was significant in Group II (11 vs. 6, P < 0.05). Six patients died in Group II, 5 had severe aortic stenosis and severe left ventricular hypertrophy; the sixth patient had severe mitral stenosis and was in CHF. The predominant cause of death was congestive heart failure (CHF). Conclusions: Fifteen percentage of these patients had CAD. CAG should be performed routinely in these patients while presenting for valve surgery. Combined CABG and valve replacement carries high mortality (28.5%), especially in patients with aortic stenosis. The study suggests that the cardio-protective measures should be applied more rigorously in this subset of patients.

Anesthetic management of a child with nephrotic syndrome undergoing open heart surgery: Report of a rare case.

The congenital nephrotic syndrome (NS) in infancy and childhood is an important entity but combination with acyanotic congenital heart disease is uncommon. Anesthesia in such cases is challenging because of associated problems like hypo-protienemia, anti-thrombin III deficiency, edema, hyperlipidemia, coagulopathy, cardiomyopathy, immunodeficiency, increased lung water etc. We describe anesthetic management of a patient with childhood NS and sinus venosus atrial septal defect (ASD) undergoing open heart surgery. We also suggest guidelines for safe conduct of anesthesia and CPB in such patients.

Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure.

Asymptomatic women with mild aortic stenosis (AS) and normal left ventricular functions can successfully carry pregnancy to term and have vaginal deliveries. However, severe AS (valve area <1.0cm 2 ) can result in rapid clinical deterioration and maternal and fetal mortality. So, these patients require treatment of AS before conception or during pregnancy preferably in the second trimester. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk. It can also be used as a palliative procedure allowing deferral of aortic valve replacement until after delivery. The present patient had severe critical AS with congestive heart failure that was refractory to medical therapy and the fetus was viable (>28wks). So, combined lower segment cesarean section and aortic valve replacement were performed under opioid based general anesthesia technique to reduce the cardiac morbidity and mortality.

Congenital lobar emphysema: Pitfalls and management.

Congenital lobar emphysema is a rare entity presenting in the first month of life. It appears with varying degrees of respiratory distress, clinical and radiological evidence of over-aeration of the upper and middle lobes, mediastinal shift and hypoxia. Its early recognition and surgical intervention can be life-saving. Even today, despite advanced diagnostic techniques, pitfalls in diagnosis and management are not uncommon and the condition may be mistaken for pneumothorax or pneumonia. This report elucidates the anesthetic management of three such cases with a review of literature.

Anesthetic management of patient with myasthenia gravis and uncontrolled hyperthyroidism for thymectomy.

The relationship between myasthenia gravis (MG) and other autoimmune disorders like hyperthyroidism is well known. It may manifest earlier, concurrently orafter the appearance of MG. The effect of treatment of hyperthyroidism on the control of MG is variable. There may be resolution or conversely, deterioration of the symptoms also. We present a patient who was diagnosed to be hyperthyroid two and half years before the appearance of myasthenic symptoms. Pharmacotherapy for three months neither improved the myasthenic symptoms nor the thyroid function tests. Thymectomy resulted in control of MG as well as hyperthyroidism. In conclusion, effective control of hyperthyroidism in the presence of MG may be difficult. The authors opine that careful peri-operative management of thymectomy is possible in a hyperthyroid state.

Acute normovolemic hemodilution is not beneficial in patients undergoing primary elective valve surgery.

The objective of this study was to evaluate the effectiveness of acute normovolemic hemodilution (ANH) as a sole method of reducing allogenic blood requirement in patients undergoing primary elective valve surgery. One hundred eighty eight patients undergoing primary elective valve surgery were prospectively randomized into two groups: Group I (n=100) acted as control and in Group II (n=88) autologous blood was removed (10% of estimated blood volume in patients with hemoglobin (Hb) >12g% and 7% when the Hb was <12g%) in the pre-cardiopulmonary bypass (CPB) period for subsequent re-transfusion after protamine administration. The autologous blood withdrawn was replaced simultaneously with an equal volume of hydroxyl-ethyl starch solution. Banked blood was transfused in both the groups when Hb was ≤6g % on CPB and ≤8g% after CPB. Platelets were transfused when the count fell to <100´10 9 /L and fresh frozen plasma (FFP) was transfused whenever there was diffuse bleeding with laboratory evidence of coagulopathy. The two groups were comparable as regards demographic data, type of surgical procedures performed, duration of CPB and ischemia, duration of elective ventilation and re-exploration for excessive bleeding. The autologous blood withdrawn in patients with Hb≥12g% was 288.3±69.4 mL and 244.4±41.3 mL with Hb<12g% (P=NS). The Hb concentration (g %) was comparable pre-operatively (Group I= 12.1±1.6, Group II= 12.4±1.4), on postoperative day 1 (Group I =10.3±1.1, Group II= 10.6±1.2) and day 7 (Group I = 10.9±1.5, Group II=10.4±1.5). However, the lowest Hb recorded on CPB was significantly lower in Group II (Group I =7.7±1.2, Group II=6.7±0.9, p0 <0.05). There was no difference in the chest tube drainage (Group I =747.2±276.5 mL, Group II=527.6±399.5 mL), blood transfusion (Group I=1.1±1.0 units vs. Group II=1.3±1.0 units intra-operatively and Group I=1.7±1.2 units vs. Group II=1.7±1.4 units post-operatively) and FFP transfusion (Group I =581.4±263.4 mL, Group II=546.5±267.8 mL) in the two groups. We conclude that low volume autologous blood pre-donation does not seem to provide any added advantage as a sole method of reducing allogenic blood requirement in primary elective valve surgery.

Pulmonary Artery Catheter Placement in High-risk Coronary Artery Bypass Grafting: Should it be done Before or After Induction of Anaesthesia?

Pulmonary artery catheter (PAC) is generally inserted after induction of general anaesthesia (GA). However, in high-risk coronary artery disease patients (left main disease / ejection fraction (35%), it may be desirable to insert it before the induction of GA. Thirty patients with left main coronary artery disease and / or left ventricular ejection fraction < 35% undergoing coronary artery bypass grafting (CABG) surgery were prospectively randomized into 2 groups of 15 each. In group A, pulmonary artery catheter was inserted before induction and in group B, after induction of GA. Haemodynamic parameters like heart rate (HR), mean arterial pressure (MAP), cardiac index (CI) and other derived parameters were obtained serially up to 10 min after tracheal intubation in group A and the haemodynamic management was based on these parameters. In group B, the haemodynamic management was based on HR and MAP. The demographic data was similar in both the groups. The time required for insertion of PAC was also similar in the two groups (7.6 +/- 1.8 and 6.2 +/- 1.3 min, p > 0.05). The number of interventions in the form of infusions of volume, nitroglycerin or dopamine were significantly more in group A before tracheal intubation. The patients in group A maintained better haemodynamics at 10 min after tracheal intubation as compared with group B (CI 2.8 +/- 0.67 vs 2.1 +/- 0.49, p < 0.05; stroke volume 54 +/- 18 vs 51 +/- 0.65, p < 0.05; systemic vascular resistance 1431 +/- 409 vs 1724 +/- 430, p < 0.05; pulmonary vascular resistance 109 +/- 34 vs 181 +/- 110, p < 0.05). Insertion of PAC before induction of GA provides informative data and can be utilized to treat haemodynamic alterations in high-risk patients undergoing CABG.

Effect of muscle relaxants on heart rate, arterial pressure, intubation conditions and onset of neuromuscular block in patients undergoing valve surgery.

Sixty six patients undergoing elective valve surgery were randomized to receive rocuronium bromide 0.6 mg/Kg (Group R, n=22), pancuronium bromide 0.1 mg/Kg (Group P, n= 22) and vecuronium bromide 0.1 mg/Kg (Group V, n=22), Measurements of heart rate and arterial pressure (systolic, diastolic and mean) were noted at the following stages: 1) baseline when haemodynamics were stable for 2 minutes after induction of anaesthesia (2) one, (3) three, (4) five minutes after administration of muscle relaxants, (5) One, (6) three, and (7) five minutes after intubation. In group R, the heart rate decreased 5 min after injection of muscle relaxant from 93.9 +/- 21.3 to 82.4 +/- 20.7 beats/min (p<0.001). However, it increased to 128.3 +/- 25.8 beats/min (p<0.001) following intubation and returned to baseline at 5 min after intubation. In group P, heart rate increased from 98.8 +/- 32.6 to 109.6 +/- 32.7 beats/min (p<0.001), 1 min after injection of pancuronium and this increase persisted throughout the study period. In group V, heart rate decreased from 99.9 +/- 22.3 to 83.8 +/-19.6 beats/min (p<0.001) at 5 min after injection of the drug. It increased to 118.6 +/- 22.4 beats/min (p<0.001), 1 min after intubation and returned to baseline at 5 min after intubation. The decrease in heart rate in group R and V was accompanied by a significant decrease in systolic, diastolic and mean arterial pressure. In group P, only the systolic pressure decreased significantly at 5 min after injection of the drug. Intubation was accompanied by a significant increased in systolic, diastolic and mean arterial pressure in all the groups. Excellent intubation conditions (intubation score 3-4) were observed with all the three drugs, however, there were number of patients in group P who showed diaphragmatic movement during intubation. Onset of action of muscle relaxant, was fastest with rocuronium (group R=132.7 +/- 0.3 sec, P=182.6 +/- 68.5 sec, V= 144.8 +/- 46.1 sec, Group P vs Group R). To conclude, pancuronium causes significant increase in heart rate and should be preferred in patients with regurgitant lesions having slower baseline heart rate. Vecuronium and rocuronium decrease the heart rate and should be preferred in patient with faster baseline heart rate. In terms of intubating conditions rocuronium and vecuronium provide best conditions, but onset is faster with rocuronium.

Comparison of cardiac output in OPCAB: bolus thermodilution technique versus pulse contour analysis.

The study was designed to evaluate the clinical agreement between intermittent bolus thermodilution technique and pulse contour analysis technique. Sixty patients with normal left ventricular function undergoing elective off-pump coronary bypass surgery were included in this prospective study. In addition to routine monitoring, a 7.5F pulmonary artery thermodilution catheter via right internal jugular vein and a 4F arterial thermodilution catheter into femoral artery were also placed. Cardiac output measurements were compared before induction, after induction, after sternotomy, during the various anastomoses, post-protamine and post-sternal closure. Statistical analysis was performed using analysis of agreement to assure bias distribution of differences between the two methods by using Bland and Altman analysis. The cardiac output values obtained at preinduction, post-induction, and post-sternal closure time points showed good agreement, whereas the values obtained during the various anastomoses showed significant differences (p <0.05). Therefore it was concluded that pulse contour analysis cannot be relied upon completely whenever there is a change in the position of heart or alteration in systemic vascular resistance. But the trends in cardiac output were in complete agreement during the entire procedure.