Atrial Septal Defect Occluder Device Embolization: Experience of a Tertiary Care Cardiac Center

Background: Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life?threatening complications such as device embolization. Objective: To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Settings and Design: A retrospective study was performed at a tertiary referral center for cardiac services. Material and Methods: Pre?procedure, intra?procedure, and post?procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re?exploration for bleeding, while another had an air embolism and succumbed. Conclusions: Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Factors Predicting Difficulty in Insertion of Real?Time?Three?Dimensional Transesophageal Echocardiography Probe in Adult Patients Undergoing Cardiac Surgery

Background:Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. Methods: A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick抯 maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients� predictive factors such as demographic characteristics and factors related to difficult intubation. Results: Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P?value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P?value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Conclusion: Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Comparison of Effects of Sevoflurane Versus Propofol on Left Ventricular Longitudinal Global and Regional Strain in Patients Undergoing On?Pump Coronary Artery Bypass Grafting

Background:Assessment of myocardial deformation by quantifying peak systolic longitudinal strain (PSLS) is a sensitive and robust index to detect subclinical myocardial dysfunction. We hypothesize that sevoflurane by virtue of anesthetic preconditioning preserves myocardial function better than propofol. Aims: The authors have assessed the effects of sevoflurane and propofol on global longitudinal strain (GLS) as a primary outcome in patients undergoing on?pump coronary artery bypass grafting. Our secondary aim was to assess the pattern of regional distribution of segmental PSLS between the groups. Materials and Methods: Fifty patients with normal left ventricular function undergoing coronary artery bypass grafting were analyzed in this prospective observational study. Consecutive patients received either propofol (P) or sevoflurane (S) anesthesia. Measurements: Trans?esophageal echocardiographic images (mid?esophageal four?chamber, two?chamber, and three?chamber (long?axis)) were recorded during the precardiopulmonary bypass (CPB) and post?CPB period. Strain analysis (GLS/segmental PSLS) was done offline by investigators blinded to the study. The inotropic score, duration of inotropic support, and mechanical ventilation required were recorded. Results: Following cardiopulmonary bypass and coronary revascularization, GLS reduced significantly in both the groups (P < 0.05). In the S?group, significant reduction in segmental strain was observed only in apical segments including apex, whereas in P?group significant reduction in segmental strain was seen in mid? and apical segments. The postoperative VIS, duration of inotropes/vasopressor required, and mechanical ventilation were similar in both the groups. Conclusions: There are no significant differences in global left ventricular function as assessed by GLS between patients anesthetized with sevoflurane or propofol. However, regional PSLS was better preserved in the S?group compared to P?group

Windsock deformity of interatrial septum.

Classical “Windsock deformity” is associated with ruptured aneurysmal sinus of Valsalva. The echocardiographic definition for Atrial septal aneurysm (ASA) in children based on dimensions is lacking. Rupture of an ASA, though uncommon, may lead to cardiac failure due to acute RV volume overload. An untreated ASA may be complicated with thrombus formation.

Warden repair for superior sinus venosus atrial septal defect and anomalous pulmonary venous drainage in children: Anesthesia and transesophageal echocardiography perspectives.

Objective: Review of intraoperative anesthetic challenges and the role of transesophageal echocardiography in children with sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage undergoing Warden repair. Design: A retrospective observational case series. Methodolgy: Pediatric patients who underwent Warden repair between October 2011-September 2015 were recruited. Their preoperative clinical details, anesthetic techniques, intraoperative TEE findings and postoperative events were recorded from the medical records. The categorical variables and the continuous variables were expressed as number (percentages) and mean ± SD respectively. Results: A total of 35 patients were operated for Warden repair during the study period. Anesthesia was induced with the aim to prevent any fall in pulmonary vascular resistance. The right internal jugular vein was cannulated under ultrasound guidance using a short length cannula to monitor right superior vena cava pressure. Intraoperative TEE revealed the drainage of PAPVC high into RSVC in 22 patients. Persistent LSVC was found in 9 patients. After repair, TEE imaging detected a high gradient at Warden anastomotic site in 5 patients and 3 of them required revision of surgery. Rerouted pulmonary veins required surgical correction in 2 patients in view of obstruction. None of them had pulmonary venous and SVC obstruction in the postoperative period. Conclusion: The primary aim of anesthesia is to avoid any fall in PVR. Right IJV cannulation can be beneficial. The intraoperative TEE can help in delineating the anatomy of lesion and detecting anastomotic site obstruction.

Echocardiographic detection of free‑floating thrombus in left ventricle during coronary artery bypass grafting.

We report an incident of detection of a free‑floating thrombus in the left ventricle (LV) using intraoperative two‑dimensional (2D) and three‑dimensional (3D) transesophageal echocardiography (TEE) during proximal coronary artery bypass graft anastomosis. A 58‑year‑old man presented to us with a 6‑month history of chest pain without any history suggestive of myocardial infarction or transient ischemic attacks. His preoperative echocardiography revealed the systolic dysfunction of LV, mild hypokinesia of basal and mid‑anterior wall, and the absence of an aneurysm. He was scheduled for on‑pump coronary artery bypass surgery. On intraoperative TEE before establishing cardiopulmonary bypass (CPB), a small immobile mass was found attached to LV apical area. After completion of distal coronary artery grafting, when the aortic cross‑clamp was removed, the heart was filled partially and beating spontaneously. TEE examination using 2D mode revealed a free‑floating mass in the LV, which was suspected to be a thrombus. Additional navigation using biplane and 3D modes confirmed the presence of the thrombus and distinguished it from papillary muscles and artifact. The surgeon opened the left atrium after re‑establishing electromechanical quiescence and removed a thrombus measuring 1.5 cm × 1 cm from the LV. The LV mass in the apical region was no longer seen after discontinuation of CPB. Accurate TEE‑detection and timely removal of the thrombus averted disastrous embolic complications. Intraoperative 2D and recent biplane and 3D echocardiography modes are useful monitoring tools during the conduct of CPB.

Pulmonary edema following transcatheter closure of atrial septal defect.

We describe an incident of development of acute pulmonary edema after the device closure of a secundum atrial septal defect in a 52-year-old lady, which was treated with inotropes, diuretics and artificial ventilation. Possibility of acute left ventricular dysfunction should be considered after the defect closure in the middle-aged patients as the left ventricular compliance may be reduced due to increased elastic stiffness and diastolic dysfunction. Baseline left atrial pressure may be > 10 mmHg in these patients. Associated risk factors for the left ventricular dysfunction are a large Qp:Qs ratio, systemic hypertension, severe pulmonary hypertension and paroxysmal atrial fibrillation.

Cardiac herniation following completion pneumonectomy for bronchiectasis.

Sporadic reports on cardiac herniation are available in the literature; most of them had followed intrapericardial pneumonectomies for malignant pulmonary tumors. We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic bronchiectasis. A 35-year-old male patient was operated for left completion pneumonectomy. A 6 cm Χ 4 cm area of adherent pericardium near the obtuse margin of heart was removed during surgery. During head-end elevation of the bed in postoperative intensive care unit, patient got accidentally tilted to the left side, which resulted in ventricular fibrillation. Chest cavity was re-opened for cardiopulmonary resuscitation. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall. During surgical re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the immediate postoperative period. Patients had infection of the left thoracic cavity after 5 weeks, for which he was subjected to thoracoplasty and omentopexy. Prompt recognition with timely intervention is life saving from cardiac herniation. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.

Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography.

A pacing system infection may lead to infective endocarditis and systemic sepsis. Tricuspid valve surgery may be required if the valve is severely damaged in the process of endocarditis. Although, cardiopulmonary bypass is the safe choice for performing right-heart procedures, it may carry risk of inducing systemic inflammatory response and multi-organ dysfunction. Some studies have advocated TV surgery without institution of CPB. We report tricuspid valve excision using the off-pump inflow occlusion technique in a 68-year-old man. We also describe role of intra-operative TEE as a monitoring tool at different stages of the surgical procedure. .

Role of intraoperative echocardiography in surgical correction of the superior sinus venosus atrial septal defect.

Superior type of sinus venosus atrial septal defect (SVASD) is invariably associated with the unroofing of right upper pulmonary vein (RUPV). Warden procedure and pericardial patch repair with rerouting of the RUPV are commonly performed operations for the superior SVASD. Both operations involve the risk of obstruction to the flow of superior vena cava or rerouted pulmonary vein in the postoperative period. The sinus venosus defects are well visualized on the transesophageal echocardiography (TEE) because of the proximity of the TEE probe to these structures. We are reporting two cases operated for the superior SVASD with unroofed RUPV, highlighting the intraoperative echocardiographic features before and after the surgery.

Intra-operative assessment of biventricular function using trans-esophageal echocardiography pre/post-pulmonary thromboembolectomy in patient with chronic thromboembolic pulmonary hypertension.

Postoperative studies in patients with chronic thromboembolic pulmonary hypertension (CTPH) have shown that pulmonary thromboembolectomy (PTE) results in a rapid decrease of right ventricular (RV) size, improvement in the RV systolic function and left ventricular (LV) diastolic function. However, the extent to which the biventricular function recovers immediately after embolectomy in post-cardiopulmonary bypass period is not clear. A 45-year-old male patient was operated for retrieval of thrombus from pulmonary trunk and right pulmonary artery. Intraoperative transesophageal echocardiography (TOE) before surgery revealed signs of RV dysfunction and enlargement. The interventricular septum was seen moving paradoxically during end-systole and early-diastole. E/A ratio on transmitral Doppler flow velocity profile was about 0.63 and S/D ratio on pulmonary venous Doppler profile was 2.25, indicative of LV diastolic dysfunction. After weaning the patient from bypass, navigation on TOE showed marginal recovery of the RV systolic function and abatement of septal paradox to some extent. However, significant improvement was observed in the LV diastolic parameter (normal E/A ratio, S/D ratio of 1.08). We conclude that the geometrically altered LV recovers more than the hypertrophied and hypokinetic RV in a patient with CTPH in the post-bypass period.

Surgical retrieval of embolised atrial septal occluder device from pulmonary artery: pathophysiology and role of the intraoperative transoesophageal echocardiography.

Atrial septal defect is usually closed in the cardiac catheterisation laboratory using atrial septal occluder (ASO) device. One of the complications associated with the procedure is embolisation of the device into the pulmonary artery. We are reporting two cases wherein the pulmonary embolisation of ASO device occurred during the procedure in one patient and in the early post-procedure period in another; both were retrieved surgically. We are also describing the haemodynamic consequences of this complication and the role of intraoperative transoesophageal echocardiography during surgical retrieval of the device.

Anesthesia management of awake craniotomy performed under asleep-awake-asleep technique using laryngeal mask airway: Report of two cases.

Asleep-awake-asleep technique of anesthesia is used during awake craniotomy with or without securing airway. We assessed this technique using laryngeal mask airway (LMA) in two patients. Patients underwent awake craniotomy for epilepsy surgery and the removal of a frontotemporal glioma. After anesthesia induction, airway was secured using LMA. Anesthesia was maintained using oxygen, nitrous oxide and sevoflurane, supplemented with an infusion of propofol and remifentanil. Twenty minutes before corticography, anesthesia was discontinued and LMA removed. Both patients were awake and cooperative during the neurological assessment and surgery on eloquent areas. The LMA was reinserted before the closure of the dura and remained in place until the end of surgery. Both patients had no recall of events under anesthesia, although experienced mild pain and discomfort during awake phase of surgery. Both expressed complete satisfaction over the anesthetic management. Asleep-awake-asleep technique using LMA offers airway protection. The painful aspect of surgery can be performed under anesthesia, hence minimizing the duration of stress and pain. Patients remained awake and cooperative throughout the time of neurological testing.