Kishore C. Mukherjee

Successful Management of Potentially Fatal Vasodilator-Resistant Spasm of a Nongrafted Coronary Artery

SPASM OF THE native coronary artery is a rare but life-threatening complication after coronary artery bypass graft (CABG) surgery. Therefore, the emphasis is placed on early postoperative coronary angiography (CAG) in patients whose condition is inexplicably unstable after the surgery. There are reports in which the coronary artery spasm was relieved with intracoronary infusions of various vasodilators, but in others the spasm could not be relieved and mortalities have occurred. The authors present a case of a postoperative spasm of a nongrafted coronary artery resistant to intracoronary vasodilator administration that needed reoperation with grafting of the affected vessel. Subsequent CAG after 6 days showed relief of the spasm. CASE REPORT A 64-year-old man presented with complaints of uneasiness, chest pain, and a history of syncopal attack 1 day before admission with a history suggestive of variant angina for the last 6 months, for which he was on medical management. He had hypertension and type-2 diabetes mellitus. The patient was an occasional drinker and a nonsmoker. An electrocardiogram showed significant ST-segment depression in the inferior leads. Auscultation revealed bilateral carotid bruit. Echocardiography showed an ejection fraction of 55%. Color Doppler of the carotid arteries revealed bilateral carotid artery disease. Angiography showed 30% stenosis in the left anterior descending artery (LAD), 70% stenosis in the left circumflex artery, and 60% stenosis in the dominant right coronary artery (RCA). In addition, there were 80% and 50% stenoses of the right internal carotid artery and left external carotid artery, respectively. Because the patient was having unstable angina, he was referred for CABG surgery with right carotid artery endarterectomy. The patient underwent off-pump coronary artery bypass graft surgery with right carotid artery endarterectomy. After carotid endarterectomy, saphenous veins were grafted to the obtuse marginal branch of the left circumflex artery and the RCA on the beating heart, with proximal anastomoses to the ascending aorta. The intraoperative course remained uneventful, and the patient was shifted to the cardiac recovery room with minimal inotropic support (epinephrine, 0.01 g/kg/min). Gradual weaning from the ventilator was started, and the patient was put on a pressure support mode of ventilation after 3 hours. At that time, his heart rate was 122 beats/min, arterial blood pressure was 144/92 mmHg, temperature was 37.1°C, and the epinephrine infusion was administered at 0.01 g/kg/min. Just before extubation, the patient had an episode of ventricular fibrillation that was immediately converted with a 200 J DC shock. It was followed by significant STsegment elevation in the anterior chest leads and hypotension with a systolic blood pressure of 50 mmHg. Epinephrine infusion was stepped up, dobutamine infusion was started, and an intra-aortic balloon pump was inserted. Transesophageal echocardiography (TEE) surprisingly showed hypokinesis of the anterior wall, the area being supplied by the LAD that was not grafted. The patient was taken for urgent coronary angiography that, in accordance with the TEE findings, showed severe spasm of the proximal LAD (Fig 1) with patent vein grafts to the obtuse marginal branch and the RCA. Intracoronary vasodilators in the form of nitroglycerin, nicorandil, and diltiazem were administered in an attempt to relieve the spasm, but the spasm remained refractory. The cardiologist also tried to pass a guidewire across the lesion but was not successful. Because of persistent unstable hemodynamics, the patient was taken back to the operating room for grafting to the LAD. The left internal mammary artery (LIMA) was harvested and grafted to the LAD on the beating heart. After grafting of the LAD, the hemodynamics showed marked improvement, with a significant reduction in inotropic requirement. Electrocardiographic and echocardiographic changes also reverted back to normal. The patient was extubated after 12 hours. The IABP was removed the next day. The rest of the intraoperative course remained uneventful. Repeat angiography performed after 6 days showed relief of the LAD spasm (Fig 2). The patient was discharged from the hospital on the 7th postoperative day.

Potentially fatal tricuspid valve aspergilloma detected after laparoscopic abdominal surgery

Abstract Fungal endocarditis accounts for 1.3–6% of all cases of infective endocarditis. The most common causative organism is Candida, followed by Aspergillus and other mould fungi. Aspergillus endocarditis is usually associated with high morbidity and mortality. Establishing a definitive and timely diagnosis remains difficult and there are many reports of undetected aspergillomas leading to fatalities in the perioperative period. We present a case report of preoperatively undiagnosed large mobile tricuspid valve aspergilloma obstructing the right ventricular inlet, diagnosed incidentally on the second postoperative day after laparoscopic pancreatic abscess drainage. The patient was successfully managed with emergency open-heart surgery and systemic antifungal agents in the postoperative period.

Castleman's disease: A rare case report of unicentric type in a young female

Castlemans disease (CD), or angiofollicular lymph node hyperplasia, is a relatively rare disorder characterized by the benign proliferation of lymphoid tissue. Two clinical entities have been described: A unicentric presentation with the disease confined to a single anatomic lymph node and a multicentric presentation characterized by generalized lymphadenopathy and a more aggressive clinical course. In addition, three histopathological subtypes have been described: Hyaline-vascular (80–90%), plasma cell (10–20%), and a mixed variant. Preoperative diagnosis of CD is difficult, and the definitive result is based on postoperative pathological findings. The gold standard therapy for unicentric type is the complete surgical excision. Overall prognosis is good, particularly in the unicentric variety of disease. We report a case of 22-year-old female presenting with a large subpectoral mass on left side chest wall below clavicle. It was painless and gradually increasing since 6 months.

An Observational Comparative Study of Cardiac Index Estimated ByFloTrac and Intermittent Thermo Dilution in Off-Pump Coronary ArteryBypass Grafting

Objective: The purpose of this study was to determine the correlation between cardiac index (CI) measurements made using intermittent thermodilution (ITD) technique by pulmonary artery catheter (PAC) and arterial pulse-contour analysis by FloTrac. Design: Prospective observational study. Setting: Cardiac surgery unit in a 350 bedded tertiary care hospital in India. Participants: 31 adult patients undergoing elective off-pump coronary artery bypass grafting (OPCABG) Interventions: CI measurements performed by the two different methods at six time points during the surgery (before skin incision, during grafting of left anterior descending artery, obtuse marginal artery and right coronary/ posterior descending artery, after protamine administration and after shifting the patient to recovery room). Measurements and results: The techniques a weak correlation at all six time points during the OPCABG. The mean bias of 0.85 L/min/m2 and precision of 0.55 was found in the study population. The percentage error calculated using Critchley s criteria was found to be 46%. Conclusion: CI measurements obtained using FloTrac showed a limited correlation with those acquired by ITD technique at different stages of OPCABG. Further studies are required in other patient populations and clinical situations.

End-tidal CO2 Should not be a Parameter for Ventilatory Adjustment during Low Cardiac Output States Like Off-pump Coronary Artery Bypass Grafting

Background: Capnography is widely used as a non-invasive monitoring technique for intra-operative and postoperative mechanically ventilated patients. Aim: To study whether the EtCO2 values should be used to adjust mechanical ventilation during low cardiac output states such as off pump cardiac bypass surgery (OPCABG). Setting and design: Prospective study in 50 patients undergoing OPCABG. Material and Methods: The values of cardiac index (CI), EtCO2, PaCO2 and P(a-Et)CO2 gradient were compared at two time points during OPCABG: immediately before skin incision and during grafting of obtuse marginal artery, as usually OM grafting is considered to be associated with low cardiac output. Statistics: Data was analysed using student’s t-test. Results: There was a significant decrease in the value of CI from point A to point B (2.33 vs. 1.75 L/min/m2, p<0.001), significant decrease in EtCO2 from 25.28 to 21.88mmHg (p<0.001) and statistically significant increase in P(a-Et)CO2 gradient 4.39 at point A to 9.18 mmHg at point B (p<0.003). Conclusion: The decrease in EtCO2 had a positive correlation with the decrease in cardiac index. So during the low flow periods as found in OPCABG, EtCO2 cannot reliably estimate the adequacy of ventilation.

Isolated tear in left atrial appendage due to blunt trauma chest: A rare case report

Blunt traumatic cardiac rupture is associated with a high mortality rate. Motor vehicle accidents account for most cardiac ruptures, but crush injury is relatively rare. We describe a case of a 72-year-old man who had the left atrial appendage ruptured through blunt trauma due to a fall from scooter. Simple suture repair of the atrial appendage was achieved after clamping the base of the left atrium to control the bleeding. He recovered without complication. Traumatic injury to left atrial appendage is rarely seen and reported.