Pecto-intercostal Fascial Plane Block: A Novel Technique for Analgesia in Patients with Sternal Dehiscence.

ABSTRACT: Sternal wound complications following sternotomy need a multidisciplinary approach in high-risk postoperative cardiac surgical patients. Poorly controlled pain during surgical management of such wounds increases cardiovascular stress and respiratory complications. Multimodal analgesia including intravenous opioids, non-opioid analgesics, and regional anesthesia techniques, like central neuraxial blocks and fascial plane blocks, have been described. Pecto-intercostal fascial plane block (PIFB), a novel technique, has been effectively used in patients undergoing cardiac surgery. Under ultrasound (US) guidance PIFB is performed with the aim of depositing local anesthetic between two superficial muscles, namely the pectoralis major muscle and the external intercostal muscle. The authors report a series of five cases where US-guided bilateral PIFB was used in patients undergoing sternal wound debridement. Patients had excellent analgesia intraoperatively as well as postoperatively for 24 hours with minimal requirement of supplemental analgesia. None of the patients experienced complications due to PIFB administration. The authors concluded that bilateral PIFB can be effectively used as an adjunct to multimodal analgesia with general anesthesia and as a sole anesthesia technique in selected cases of sternal wound debridement.

Influence of time interval between coronary angiography to off-pump coronary artery bypass surgery on incidence of cardiac surgery associated acute kidney injury.

BACKGROUND AND AIMS: Cardiac surgery associated acute kidney injury (CSA-AKI) is serious complication after cardiac surgery. The time interval between coronary angiography (CAG) to coronary artery bypass surgery (CABG) is proposed as modifiable risk factor for reduction of CSA-AKI. The aim of this study was to assess influence of time interval between CAG to off-pump CABG (OPCABG) on incidence of CSA-AKI. METHODS: This was a retrospective observational study of 900 consecutive OPCABG patients who were classified into 2 groups based on time interval between CAG and OPCABG: ≤7 days or longer. RESULTS: The incidence of CSA-AKI was 24% (214/900) by Kidney Disease: Improving Global Outcomes (KDIGO) definition. The incidence of CSA-AKI was not significantly different in two groups (22% in >7 days groupvs. 28% in ≤7 days group, P = 0.31). The factors independently associated with CSA-AKI were: Age (OR 1.04; P = 0.002), baseline creatinine (OR 1.99,; P = 0.03), moderate LV dysfunction (OR 1.64,; P = 0.007) and blood transfusion (OR 3.3,; P < 0.001), but not the time interval between CAG and OPCABG. The incidence of CSA-AKI was highest in patients with creatinine clearance (CC) <50 mL/min when OPCABG was performed ≤7 days of CAG (16/38; 42%, OR 2.7, 1.4-5.4; P = 0.005) compared to lowest incidence of CSA-AKI in patients with CC >50 mL/min and OPCABG performed >7 days of CAG (114/543; 21%). CONCLUSION: This study demonstrated that there is no increased incidence of CSA-AKI if OPCABG is performed ≤7 days of CAG; but we recommend to postpone OPCABG for seven days if CC is <50 mL/min and there is no urgent indication for OPCABG in order to reduce incidence of CSA-AKI.

Mitral Annular Plane Systolic Excursion: A Simple, Reliable Echocardiographic Parameter to Detect Left Ventricular Systolic Dysfunction in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting with Transesophageal Echocardiography.

OBJECTIVES: This study's objective was to test the hypothesis that transesophageal echocardiography (TEE)-based mitral annular plane systolic excursion (MAPSE) measurement is useful in perioperative settings to detect left ventricular (LV) systolic dysfunction in patients undergoing off-pump coronary artery bypass grafting (OPCAB). DESIGN: Retrospective observational study. SETTING: Tertiary-care level hospitals. PARTICIPANTS: The study comprised 116 patients undergoing OPCAB to obtain cutoffs of MAPSE to detect LV dysfunction. These cutoffs were validated in another 105 patients from 2 other institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In 116 patients who had undergone OPCAB during the study period with TEE monitoring, MAPSE was measured post hoc at the lateral and septal mitral (and average) annulus using the software tool M.mode.ify (http://www.ultrasoundoftheweek.com/M.mode.ify). Receiver operating curves were constructed to obtain cutoff values of MAPSE at the lateral and septal (and average) annulus of the mitral valve to predict LV systolic dysfunction, which was defined by an ejection fraction <52% for men and <54% for women as measured using the biplane method of disks. These cutoff values then were validated in another 105 patients. LV systolic dysfunction was present in 43% patients. Youden's index values of 9mm for lateral MPASE (area under the receiver operating curve [AUC] 0.93 [confidence interval {CI} 0.87-0.97]; p < 0.0001); 7mm for septal MAPSE (AUC 0.87 [CI 0.79-0.92]; p < 0.0001); and 9mm for average MAPSE (AUC 0.92 [CI 0.86-0.96]; p < 0.0001) were obtained. These cutoffs were statistically significant in the validation cohort (p < 0.0001) with an AUC of 0.84 (CI 0.75-0.90), sensitivity of 86.2%, specificity of 80.8%, positive predictive value of 84.8%, and negative predictive value of 82.6%. CONCLUSIONS: MAPSE is a simple, rapid, and reliable method to detect LV dysfunction using TEE in patients undergoing OPCAB. Its use as screening tool for LV dysfunction is recommended.

Intraoperative conversion to on-pump coronary artery bypass grafting is independently associated with higher mortality in patients undergoing off-pump coronary artery bypass grafting: A propensity-matched analysis.

CONTEXT: One of the main limitations of off-pump coronary artery bypass grafting (OPCAB) is the occasional need for intraoperative conversion (IOC) to on-pump coronary artery bypass grafting. IOC is associated with a significantly increased risk of mortality and postoperative morbidity. The impact of IOC on outcome cannot be assessed by a randomized control design. AIMS: The objective of this study was to analyze the incidence, risk factors, and impact of IOC on the outcome in patients undergoing OPCAB. SETTINGS AND DESIGN: Three tertiary care level hospitals; retrospective observational study. SUBJECTS AND METHODS: This retrospective observational study included 1971 consecutive patients undergoing  OPCAB from January 2012 to October 2015 at three tertiary care level hospitals by four surgeons. The incidence, patient characteristics, cause of IOC, and its impact on outcome were studied. STATISTICAL ANALYSIS USED: The cohort was divided into two groups according to IOC. Univariate logistic regression was performed to describe the predictors of IOC. Variables that were found to be significant in univariate analysis were introduced into multivariate model, and adjusted odds ratio (OR) was calculated. To further assess the independent effect of IOC on mortality, propensity score matching with a 5:1 ratio of non-IOC to IOC was performed. RESULTS: The overall all-cause in-hospital mortality was 2.6%. IOC was needed in 128 (6.49%) patients. The mortality in the IOC group was significantly higher than non-IOC group (21 of 128 [16.4%] vs. 31 of 1843 [1.7%], P = 0.0001). The most common cause for IOC was hemodynamic disturbances during grafting to the obtuse marginal artery (51/128; 40%). On multivariate logistic regression analysis, left main disease, pulmonary hypertension, and mitral regurgitation independently predicted IOC. We obtained a propensity-matched sample of 692 patients (No IOC 570; IOC 122), and IOC had OR of 16.26 (confidence interval 6.3-41; P < 0.0001) for mortality in matched population. CONCLUSIONS: Emergency IOC increases odds for mortality by 16-fold. Hence, identification of patients at higher risk of IOC may improve the outcome.

Monitoring diastolic dysfunction using a simplified algorithm in patients undergoing off-pump coronary artery bypass grafting surgery.

CONTEXT: Left ventricle diastolic dysfunction (LVDD) is gaining importance as useful marker of mortality and morbidity in cardiac surgical patients. Different algorithms have been proposed for the intraoperative grading of DD. Knowledge of the particular grade of DD has clinical implications with the potential to modify therapy, but there is a paucity of literature on the role of diastolic function evaluation during off-pump coronary artery bypass grafting (OPCABG) surgery. AIMS: The aim of this study was to monitor changes in LVDD using simplified algorithm proposed by Swaminathan et al. in patients undergoing OPCABG. SETTINGS AND DESIGN: The study was conducted in a tertiary care level hospital; this was a prospective, observational study. SUBJECTS AND METHODS: Fifty consecutive patients undergoing OPCABG were enrolled. Hemodynamic and echocardiographic parameters were measured at 6 stages in every patient namely after anesthetic induction (baseline), during left internal mammary artery (LIMA) to left anterior descending (LAD) grafting (LIMA → LAD), saphenous vein graft (SVG) to obtuse marginal (OM) grafting (SVG → OM), SVG to posterior descending artery (PDA) grafting (SVG → PDA), during proximal anastomosis of SVG to aorta, and postprotamine. The patients were classified in grades of LVDD as per simplified algorithm proposed by Swaminathan et al. using only intraoperatively measured E and E'. RESULTS: The success rate of measurement and classification of LVDD was 98.92% (277 out of 280 measurements). The grades of LVDD varied significantly as per surgical steps with maximum downgrading occurring during OM and LAD grafting. During OM grafting, none of the patients had normal diastolic function while 29% of patients exhibited restrictive pattern (Grade 3 LVDD). Patients with normal baseline LV diastolic function also exhibited downgrading during OM and LAD grafting. Postprotamine, 37% of patients with normal baseline diastolic function continued to exhibit some degree of DD. CONCLUSIONS: The LVDD changes dynamically during various stages of OPCABG, which can be successfully monitored with simplified algorithm.

Malignant triton tumor of the right vagus.

We report on the successful surgical resection of a mediastinal malignant triton tumor of the vagus, an exceedingly rare tumor in this location. Malignant triton tumor is a subtype of malignant peripheral nerve sheath tumors, in which the characteristic histologic finding is of rhabdomyoblastic differentiation among schwannoma cells. A 35-year-old man with associated neurofibromatosis type-1 underwent surgical resection and has been followed up for 18 months.

Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass.

BACKGROUND: Recent studies examining neuroprotective effects of off-pump coronary artery bypass grafting (CABG) have shown inconsistent results. We examined our database to quantify the independent effects of avoidance of cardiopulmonary bypass (CPB) and aortic manipulation on neurologic outcomes after CABG. METHODS: A total of 2,327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified at our two institutions. Patients were divided into three groups: on CPB, off-pump with aortic manipulation, and off-pump without aortic manipulation. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, redo operations, diabetes, chronic obstructive pulmonary disease, neurologic disease, peripheral vascular disease, ejection fraction, and priority of operation. RESULTS: A total of 1,210 cases were performed on CPB, compared with 520 off-pump with aortic manipulation, and 597 off-pump without aortic manipulation. The incidence of focal neurologic deficit was 1.6% (n = 19) in the on-pump group, 0.4% (n = 2) in the off-pump with aortic manipulation group, and 0.5% (n = 3) for the off-pump without aortic manipulation group (p for trend = 0.027). The results of the multivariate logistic regression analysis demonstrated that use of CPB was a risk factor for focal neurologic deficit, with an odds ratio of 3.82 (95% confidence interval, 1.41 to 10.34; p = 0.005). Aortic manipulation did not significantly influence neurologic outcome in off-pump patients. CONCLUSIONS: Off-pump operation, with or without aortic manipulation, reduces adverse neurologic outcomes compared with on-pump procedures.