Monish S Raut

Stuck suction catheter in endotracheal tube

Endotracheal tube (ETT) suction is essential to clear secretions so that airway patency can be maintained. Stuck suction catheter in ETT is an uncommon event, and it can be dangerous in patients with difficult airway cases.

Left ventricular mass: myxoma or thrombus?

Patient with embolic episode should always be evaluated for cardiac mass. Mass in left ventricular can be a myxoma or thrombus even in a normal functioning heart. In either case, mobile mass with embolic potential should be surgically resected.

Difficult venous catheterization in internal jugular vein

Valve in IJV is seen in 90% of the individuals.[1] IJV valve is mostly located in the distal portion of the IJV, just proximal to the jugular bulb in the retroclavicular space.[2] This site makes the ultrasound assessment of the valve difficult with large ultrasound probes. The valve leaflet is commonly bicuspid (77–98%), but tricuspid W(0–7%) or unicuspid (1.4–16%) valves have also been observed.[3] Competent IJV valve is important in maintaining the transcranial blood pressure gradient during chest compression in cardiopulmonary resuscitation.[4] Central venous catheterization of the IJV can cause persistent incompetence of the IJV valve and thrombus formation on damaged valve.[1,5] In the present case, we found the large unicuspid valve in IJV that itself an uncommon observation. Such a large valve could potentially have caused difficult passage of the guide wire of venous catheter. Any forceful attempt to overcome resistance could have damaged the valve. Ultrasound examination helped us to visualize IJV and find out the cause for difficult central venous catheterization.

Malposition of a nasogastric tube

Failure to identify a malpositioned NGT may lead to fatal pulmonary complications. Hence, it is essential to confirm radiographically before starting enteral feeding or medications. Mostly narrow lumen tubes with stiff inner guide wire have been reported in the malposition complication.[6] In the present case, we had a malposition of large bore 14 French gauge nasogastric tube without guide wire. Inadequately inflated ETT cuff may have been the reason for the passage of NGT in trachea as cuff pressure was not monitored. While inserting NGT, confirm cuff of ETT adequately inflated and NGT can be directed to esophagus under direct laryngoscopic vision with the help of Magill’s forcep (Manufacturer ‐ Anaesthetics). After placing NGT, epigastric auscultation can mislead about the positioning as, in this case. However, checking for the air coming out of the outer end of NGT and confirming it by seeing air bubbles with every expiration of the patient when outer end of The Editor,

Anterior tracheal injury during sternotomy.

on CPB, a consumptive coagulopathy, and formation of thrombi within the CPB circuit or the patients end organs. Therapeutic approaches to address the issue of altered heparin responsiveness include administering additional heparin, supplementing AT with either FFP or AT concentrate, or to accept the ACT and proceed with CPB without any additional treatment. Since the AT concentrate was not available, we had no option other than to administer additional doses of heparin and FFP. Presently, the US FDA recommends use of FFP to treat altered heparin responsiveness if AT concentrate is not available. Compared to the AT concentrate, transfusion of FFP may be associated with more problems like transmission of infection, volume overload and acute lung injury, although it remains beneficial in terms of easy availability and lower cost. Transfusing FFP is an accepted method of AT supplementation and contains approximately 1 IU of AT per 1 mL of FFP. Thus, 1200 mL of FFP should have provided a dose of 1200 IU of AT to our patient. Avidan et al reported that 2 units of FFP were insufficient to improve heparin responsiveness in the majority of patients with heparin resistance. Large doses of AT (≥50 IU/kg or ≥3500 IU of AT concentrate for a 70 kg patient) resulted in normalizing AT levels throughout the entire CPB time. The AT levels decrease below baseline soon after commencing CPB with the standard dose (500–1000 IU) commonly given for heparin resistance. Heparin, 1200 units/kg, and FFP, 800 mL, failed to raise the ACT value above 400 seconds in our patient. In that situation, establishing CPB was a big challenge because features of volume overload had become apparent, and additional infusion of FFP would have precipitated overt heart failure. Commencing inotropic infusion to improve contractility was fraught with the risk of precipitating high ventricular rates in a patient with severe MS with atrial fibrillation. Establishment of CPB, the quickest way to support the circulation in the presence of hemodynamic instability, was not possible due to inadequate anticoagulation. Other laboratory investigations to assess the heparin activity like APTT, serum heparin PF-4 antibodies, and AT levels are time consuming and were not practical in the intraoperative period. Backing out from the surgery after sternotomy in a patient with severe valvular heart disease and chronic heart failure was not the appropriate option, as postoperative weaning from the ventilator would have been difficult without corrective surgery. The PET was a very useful technique in this situation. It is similar to the PET that can be used for the removal of serum antibodies. Successful use of pre-CPB PET to reduce heparin/PF4 antibody titers has been reported in patients with heparin-induced thrombocytopenia, who subsequently underwent CPB with heparin anticoagulation. The PET in our patient would have replenished depleted plasma AT levels without causing volume overload in the scenario of cardiac failure.

Intraoperative detection of stuck leaflet of prosthetic mitral valve

[50_TD

Empagliflozin: Novel antidiabetes and pro-cardiac drug

DIFF]Bileaflet prosthesis valves are the most commonly used mechanical valves. Dysfunction of bileaflet prosthesis valve is rarely observed. Pannus and thrombus can obstruct prosthesis valve in postoperative period over a period of time. Here we present a rare case of intraoperatively diagnosed prosthesis valve dysfunction along with review of different mechanism causing such complication. 50 years male presented with severe shortness of breath at rest and fever since 15days. He was already on antibiotics when he was referred to our center for further management.He was thoroughly evaluatedandechocardiographyshowedseveremitral regurgitation with vegetation on posterior mitral leaflet bouncing in left atrium. Considering high embolic potential of the lesion, patient was urgently scheduled for open heart surgery for removal of lesion and correction of mitral regurgitation. After smooth anaesthesia induction, transesophageal echocardiography (TEE)was performed and it revealed 1.2 square cm mobile mass on the posterior mitral leaflet. (Fig. 1, clip 1) Severe mitral regurgitation was observed due to noncoaptation of mitral leaflets. (Fig. 2, clip 2) After instituting cardiopulmonary bypass, mass with mitral leaflets were resected and sent for bacterial and fungal cultures. OnX 25mm bileaflet prosthetic mechanical mitral valve was inserted. While weaning frombypass, TEE revealedone stuck leafletof prostheticmitral valve in semiclosed position, where as other leafletwasmoving normally. (Fig. 3, Clip 3,4) As the cardiac outputwas low even after optimizing loading conditions, it was decided to reinstitute cardiopulmonary bypass again. After achieving cardioplegic arrest of the heart, prosthetic valvewas examined. Both leaflets could be easily opened with cotton tipped swab. We assume that subvalvular tissue might be obstructing themovement of one leaflet. So, prosthetic valvewas rotated by 90 with the rotator. TEE showed normal movements of both leaflets of prosthetic valve. (Fig. 4, Clip 5) Hemodynamicswere stable and patient was easily weaned from bypass. Postoperative course of the patient was uneventful. Bileaflet prosthetic valves are most commonly used mechanical valves due to their good hemodynamic performance and low incidence of valve complications.[51_TD

Awareness of Kounis Syndrome, a Takotsubo-Like Syndrome, by a Cardiovascular Anesthesiologist.

DIFF] Thrombosis and pannus can causeprostheticvalvedysfunctioninpostoperativeperiodoveradue course of time.[52_TD

Left atrial myxoma with biventricular dysfunction

DIFF] –4 However, Intraoperative mechanical valve dysfunction is rare event with potentially fatal complication.[53_TD

Eustachian valve - Masquerading ASD rim

DIFF] –8 Such complication has been reported more commonly with metallic prosthetic valves than bioprosthetic valves. Obstruction causing stuck valve can be intrinsic or extrinsic. Intrinsic obstruction is caused by inherent defects in manufacturing of the valve or defects due to wear. [54_TD