Jitin Narula

Electrical Cardiometry: A Reliable Solution to Cardiac Output Estimation in Children With Structural Heart Disease

OBJECTIVE Comparison of cardiac output (CO) obtained using electric cardiometry (EC) and pulmonary artery catheterization (PAC) in pediatric patients with congenital structural heart disease. DESIGN Prospective, observational study. SETTING A tertiary hospital. PARTICIPANTS The study comprised 50 patients scheduled to undergo cardiac catheterization. INTERVENTIONS CO data triplets were obtained simultaneously from the cardiometry device ICON (Osypka Medical, Berlin, Germany) and PAC at the following predefined time points-(1) T1: 5 minutes after arterial and venous cannulation and (2) T2: 5 minutes postprocedure; the average of the 3 readings was calculated. Reliability analysis and Bland-Altman analysis were performed to determine the limits of agreement, mean bias, and accuracy of the CO measured with EC. MEASUREMENTS AND MAIN RESULTS The measured EC-cardiac index 4.22 (3.84-4.60) L/min/m2 and PAC-cardiac index 4.26 (3.67-4.67) L/min/m2 were statistically insignificant (p value>0.05) at T1. Bland-Altman analysis revealed a mean bias of 0.0051 L/min/m2 and precision limits of±0.4927 L/min/m2. The intraclass correlation coefficient was 0.789 and Cronbachs alpha was 0.652, indicating good reproducibility and internal consistency between the two techniques. Postcatheterization analysis also revealed strong agreement and reliability between the two techniques. CONCLUSIONS This study demonstrated that cardiac indices measured in children with a variety of structural heart diseases using EC reliably represent absolute values obtained using PAC. EC technology is simple and easy to use and offers noninvasive beat-to-beat tracking of CO and other hemodynamic parameters in children with structurally abnormal hearts.

Assessment of Changes in Hemodynamics and Intrathoracic Fluid Using Electrical Cardiometry During Autologous Blood Harvest

OBJECTIVE To evaluate the effect of autologous blood harvest (ABH)-induced volume shifts using electrical cardiometry (EC) in patients with pulmonary artery hypertension secondary to left heart disease. DESIGN Prospective, randomized, controlled trial. SETTING A tertiary care hospital. PARTICIPANTS The study comprised 50 patients scheduled to undergo heart valve replacement. INTERVENTIONS Patients were divided randomly into 2 experimental groups that were distinguished by whether ABH was performed. Blood volume extracted in the test group was replaced simultaneously with 1:1 colloid (Tetraspan; B Braun Melsungen, Melsungen, Germany). Hemodynamic, respiratory, and EC-derived parameters were recorded at predefined set points (T1 [post-induction/pre-ABH] and T2 [20 minutes post-ABH]). MEASUREMENTS AND MAIN RESULTS Withdrawal of 15% of blood volume in the ABH group caused significant reductions in thoracic fluid content (TFC) (-10.1% [-15.0% to -6.1%]); right atrial pressure (-23% [-26.6% to -17.6%]); mean arterial pressure (-12.6% [-22.2% to -3.8%]); airway pressures: (peak -6.2% [-11.7% to -2.8%] and mean -15.4% [-25.0% to -8.3%]); and oxygenation index (-10.34% [-16.4% to -4.8%]). Linear regression analysis showed good correlation between the percentage change in TFC after ABH and the percentage of change in right atrial pressure, stroke volume variation, autologous blood extracted, peak and mean airway pressures, and oxygen index. CONCLUSIONS In addition to its proven role in blood conservation, therapeutic benefits derived from ABH include decongestion of volume-loaded patients, decrease in TFC, and improved gas exchange. EC tracks beat-to-beat fluid and hemodynamic fluctuations during ABH and helps in the execution of an early patient-specific, goal-directed therapy, allowing for its safe implementation in patients with pulmonary hypertension secondary to left heart disease.

Unidirectional ventricular septal valved patch for repair of late presenting ventricular septal defect with aortopulmonary window

Management of long standing left to right shunt lesion resulting in elevated pulmonary vascular resistance (PVR) is challenging. Limited surgical options are further complicated by an unpredictable postoperative period. Unidirectional valve patch (UVP) closure has shown to be useful in cases of the large ventricular septal defect (VSD) who present late. We report a case of large aortopulmonary window coexisting with a large VSD with severe pulmonary artery hypertension and significantly elevated PVR that was managed surgically by closure of the window by sandwich technique and closure of the septal defect with a UVP. This report emphasizes the importance of UVP in the management of such patients.

Valved patch closure of aortopulmonary window

The case of an 8-year-old boy with an aortopulmonary window who underwent unidirectional valved patch closure of the window is described. The advantages of unidirectional valved patch closure in this setting are discussed.

Intracardiac fungal ball in an infant causing right ventricular inflow obstruction secondary to tricuspid valve fungal endocarditis: management options

We report a 50-day-old infant with infective endocarditis and a large fungal vegetation on the tricuspid valve (TV) obstructing the right ventricular inflow. Emergency excision of the vegetation and TV reconstruction failed. Because of failure to wean off cardiopulmonary bypass support, a rescue bidirectional superior cavopulmonary anastomosis (BDG) was performed. Various management options with appropriateness and efficacy of this procedure are discussed.

Right-to-left shunting through the unidirectional valved patch after closure of ventricular septal defect

Postoperative transesophageal echocardiography images of a patient undergoing unidirectional valved patch closure of ventricular septal defect in the setting of severe pulmonary hypertension are presented. The images and videos elegantly demonstrate a functioning valve without any obstruction to the left ventricular outflow.

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions.

Introduction: Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes. Materials and Methods: Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded. Results: The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB ( r2 = 0.6321), ICU stay ( r2 = 0.7447) and incidence of oliguria ( r2 = 0.8803). Conclusions: The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk.

Giant Left Atrial Myxoma

A 45-year-old female presented with increasing dyspnea, ascites, and pitting edema. A chest X-ray showed left atrial enlargement, an ill-defined right heart border, and splaying of the carina (Fig. 1). A computed tomographic angiogram showed an 11 12.5cm left atrial intracavitary mass (Fig. 2). Transesophageal echocardiography confirmed the presence of the left atrial mass and revealed a 16mmHg gradient across themitral valvewith moderate tricuspid regurgitation (Fig. 3). At the time of surgery, cardiopulmonary bypass was initiated with an ascending aortic cannula and venous cannulae in the superior and inferior vena cavae. Following cardioplegic arrest, transverse biatrial incisions were performed and the entire fossa ovalis was removed revealing the bulging mass (Fig. 4). The tumor extended from the inter atrial septum along the left atrial wall up to the right inferior pulmonary veins. It was completely removed in two pieces. The atrial septumwasclosedprimarily and themitral valve remained competent. The patient had an uneventful postoperative course. The histopathology revealed an atrial myxoma.

Inverted left atrial appendage: a complication of de-airing during cardiac surgery

A male patient with a bicuspid aortic valve associated with severe aortic stenosis and a dilated aortic root underwent a Bentall procedure. Apart from the aortic pathology, no other abnormalities were detected by a preoperative transesophageal echocardiography (TEE) examination. After an otherwise uncomplicated surgical procedure, the patient’s heart was deaired using standard maneuvers, including manual cardiac agitation and conventional aspiration of the aortic root vent and left ventricular vent inserted during the operation via the superior pulmonary vein. After the de-airing, a hypoechoic structure suggestive of atrial thrombus was seen in the left atrium (LA) using TEE (Figure A). The surgeon was informed of the unusual finding, and on direct visual inspection of the heart, it was confirmed that the left atrial appendage (LAA) had become intussuscepted and inverted inside the LA. Weaning from cardiopulmonary bypass (CPB) was attempted in order to re-establish normal LA pressures and thus revert the appendage to its normal position. Nevertheless, this attempt was unsuccessful, and application of a Valsalva maneuver also failed. Accordingly, during a brief return to CPB, the tip of the LAA was grasped with Russian tissue forceps and reverted to its normal anatomic position, which was confirmed with a repeat TEE examination (Figure B).

Sutureless left pulmonary vein augmentation for primary endoluminal pulmonary vein ostial stenosis: role of pulmonary venous Doppler.

Primary PV stenosis results from an abnormal incorporation of the common PV into the left atrium. On echocardiography, it may appear as a discrete shelf, long narrow segment or as a diffuse hypoplasia of the PVs resulting in pulmonary venous hypertension secondary to an impeded pulmonary venous drainage. [2] Seen almost exclusively in young children; it is highly associated with other cardiac defects, primarily septal defects, making it imperative that echocardiographic evaluation of patients with pulmonary hypertension specifically include pulmonary venous profiling. In the sutureless marsupialization technique, any direct stitches over the cut edges of the PVs are avoided as the pericardium around the PVs is directly attached to the left atrium. According to a limited literature, an unimpeded pulmonary venous drainage is best achieved using this technique in comparison to the previous techniques that have used direct anastomosis after resection of stenotic segments or patching of the stenotic veins.[3,4] An 11-month-old girl presented with complaints of recurrent episodes of upper respiratory tract infection since birth. Transthoracic echocardiography revealed a large ostium secundum atrial septal defect (ASD), small subaortic ventricular septal defect and left superior and inferior pulmonary vein (PV) ostial stenosis. Computed tomography angiography was done to confirm the findings, and the child were subsequently planned for closure of septal defects and sutureless leftsided pulmonary venous augmentation.