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.

Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination.

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient’s outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of “Fellowship” is by way of conducting IACTA – TEE fellowship (F‑TEE) examination. This has been done annually for the past 7 years using well‑established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F‑TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F‑TEE certification process.

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.

Glycemic control in cardiac surgery: Rationale and current evidence.

Studies in cardiac surgical patients have shown an association of hyperglycemia with increased incidences of sepsis, mediastinitis, prolonged mechanical ventilation, cardiac arrhythmias and longer intensive care and hospital stay. There is considerable controversy regarding appropriate glycemic management in these patients and in the defi nition of hyperglycemia and hypoglycemia or the blood sugar levels at which therapy should be initiated. There is also dilemma regarding the usage of “tight glycemic control” with studies showing confl icting evidences. Part of the controversy can be explained by the differing designs of these studies and the variable defi nitions of hyperglycemia and hypoglycemia.

Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists.

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

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.

The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery.

Aims and objectives: Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. Materials and Methods: The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. Results: The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. Conclusion: IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations.

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.