Prabhat Tewari

Combined left-sided recurrent laryngeal and phrenic nerve palsy after coronary artery operation

BACKGROUND Ice/saline slush used along with cold cardioplegia for heart arrest in cardiac operations can cause hypothermic damage to certain structures, an important one being the left phrenic nerve, damage of which results in raised left hemidiaphragm and delayed recovery of the patient. In coronary artery bypass grafting, opening of the pleura and collection of the ice/saline slush in the pleural cavity increases the incidence of injury. METHODS Three of our nonconsecutive patients underwent coronary artery bypass grafting with cold cardioplegia and open pleura, with collection of ice/saline slush in the pleural cavity for a sufficiently long time. RESULTS Simultaneous involvement of left recurrent laryngeal nerve along with left phrenic nerve was found in all patients without any concurrent topical injury around the larynx. the recurrent laryngeal nerve took 8 to 10 months to recover. CONCLUSIONS The left recurrent nerve as it arches around aorta lies in the thorax very close to the parietal pleura and may be prone to hypothermic injury by ice/slush collecting in the pleural cavity during cardiac operations. Judicious use of ice/saline slush had helped in eliminating the problem to some extent.

Emergency cardiopulmonary bypass for impassable airway.

INTRODUCTION Some medical emergencies need compromised airway management as the first measure. Most of these cases are first seen by an ENT surgeon, whose proper evaluation and timely intervention can prove decisive. Knowledge of alternatives for airway management can prove life-saving, although these may require the active involvement of other specialities. CASE REPORTS Two patients, a 27-year-old man and a 31-year-old woman, presented in respiratory distress with cyanosis. Each had a pedunculated mass in the lower trachea above the carina, with about 90 per cent tracheal lumen obstruction. They were managed successfully with femorofemoral cardiopulmonary bypass and restoration of airway. CONCLUSION Femorofemoral cardiopulmonary bypass can be a relatively safe option which gains time for airway management in such conditions. Knowledge of this procedure among ENT surgeons can lead to timely intervention, in properly selected cases, which can save valuable time.

Management of difficult airway in intratracheal tumor surgery

BackgroundTracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach.Case PresentationWe are presenting a case of tracheal adenoid cystic carcinoma (cylindroma) occupying about 90% of the tracheal lumen. It was successfully managed by surgical excision of mass by sternotomy and tracheotomy under femorofemoral cardiopulmonary bypass (CPB).ConclusionAny patient with recurrent respiratory symptoms should be evaluated by radiological and endoscopic means earlier to avoid delay in diagnosis of such conditions. Femorofemoral cardiopulmonary bypass is a relatively safe way of managing certain airway obstructions.

A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass.

Introduction: Although the level of inferior vena cava (IVC) thrombus governs the type of surgical approach, there is no consistency in reporting the levels of IVC thrombus in the literature. This prospective study illustrates a simple three-level classification based on the need for clamping hepatoduodenal ligament and venovenous or cardiopulmonary bypass. Materials and Methods: Between January 2010 and June 2014, 30 patients of renal mass with renal vein and/or IVC thrombus were treated after classifying the IVC thrombus into three levels on the basis of need for clamping the hepatoduodenal ligament. After excluding renal vein thrombi, level I was described as thrombus located caudal to the hepatic vein. Level II included all retrohepatic, suprahepatic infradiaphragmatic or supradiaphragmatic thrombi reaching till the right atrium. Atrial thrombi were categorized as level III. Level I and II thrombi were managed without venovenous or cardiopulmonary bypass. Level III thrombus required cardiopulmonary bypass. Results: Of 26 patients with thrombus, 13 had level I thrombus. Of eight cases with level II thrombus, three were retrohepatic, three were suprahepatic infradiaphragmatic and two were supradiaphragmatic. All were removed successfully. Of five patients with level III thrombus, three were operated with cardiopulmonary bypass while the remaining two patients were too sick to be taken up for surgery. The median hepatoduodenal ligament clamp time was 10 min. One patient with level II thrombus had transient liver enzyme elevation. Conclusion: Renal vein thrombus should not be categorized as level I thrombus. Level II thrombus, irrespective of its relation to the diaphragm, could be managed without venovenous or cardiopulmonary bypass.

Left ventricular outflow tract obstruction after mitral valve replacement.

A 68-yr-old man presented with a 1-yr history of exertional dyspnea. Five years previously he had contracted endocarditis for which he underwent mitral valve replacement (MVR) with the native leaflet preservation technique. During his current hospitalization, preoperative transthoracic echocardiography demonstrated a gradient of 50 mm Hg across the left ventricular (LV) outflow tract (LVOT) with no evidence of aortic valve disease. There appeared to be a mobile strand attached to the subvalvular aspect of his mitral valve prosthesis (29 mm Carpentier–Edwards pericardial stented valve). Suspecting a healed endocarditis strand, he was scheduled for a redo MVR via a transeptal approach. In the operating room a transesophageal echocardiography (TEE) examination was done before cardiopulmonary bypass. Two-dimensional midesophageal (2D ME) five chamber (Fig. 1) and 2D ME long axis views revealed a long anterior mitral leaflet (AML)-like structure (2.71 cm in 2D ME five chamber view) attached to the base of the mitral valve prosthesis. On further interrogation this structure seemed to be attached to the papillary muscles with chordae-like strands (please see videos clip available at www.anesthesia-analgesia.org). The structure extended well into the LVOT during systole, causing a gradient of 40 mm Hg with continuous wave Doppler (CWD) and showing turbulence on color flow Doppler (please see videos clip available at www.anesthesia-analgesia.org). The prosthetic valve was seated well, had good leaflet excursion, sharp margins, and minimal transvalvular gradient. There was no paravalvular or significant transvalvular regurgitation. On the basis of the TEE findings, the surgical team changed its plan to cut this structure out through an aortotomy leaving the prosthetic valve untouched. At surgery, the structure was confirmed to be a redundant AML with elongated chordae. The postcardiopulmonary bypass TEE gradient across the LVOT was 6 mm Hg (Fig. 2). The patient made an uneventful recovery. Elevated LVOT gradients after MVR can occur for a variety of reasons. Fixed LVOT obstruction (LVOTO) is sometimes found with high profile bioprosthetic valves, like the Carpentier–Edwards used in this patient. This occurs because of incorrect orientation resulting in the strut impinging on the LVOT. Dynamic LVOTO, after MVR, can occur with a narrowed mitral-aortic angle, thickened interventricular septum, systolic anterior motion of the preserved AML, small hyper contractile LV and also with atrial fibrillation. Pharmacological attenuation of dynamic obstruction with the use of -blockers and vasoconstrictors along with adequate fluid therapy is sometimes successful in providing symptomatic relief. In addition to measuring the gradient across the LVOT, the shape of the CWD flow profile can be useful in differentiating a dynamic LVOTO from a This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Stroke associated with left atrial mass: Association of cerebral aneurysm with left atrial myxoma!

Association of LA myxoma with cerebral aneurysm is rare. We describe a patient who had LA mass and cerebral aneurysm and developed stroke. The patient underwent clipping of the cerebral aneurysm. We discuss the pathology of the association and the anesthetic management.

Pericardial Monocusp for Pulmonary Valve Reconstruction: A New Technique

Enhancing the pulmonary annulus renders the pulmonary valve incompetent in cases of tetralogy of Fallot. A pressure-loaded right ventricle may change to a volume-loaded ventricle, which may dilate and eventually dysfunction. This study evaluated a new technique of fashioning a monocusp valve from untreated autologous pericardium suspended on a transannular patch. It was assessed in 40 children undergoing complete repair of tetralogy of Fallot between January 2005 and December 2007. 24 patients had a transannular patch alone (group A) and 16 received a transannular patch with the autologous pericardial monocusp valve (group B). All patients were followed up for 1 year with transthoracic echocardiography to determine pulmonary insufficiency. There was no significant difference in cardiopulmonary bypass or aortic crossclamp times, postoperative chest tube drainage, duration of inotropic usage, intensive care unit or hospital stay between groups. Univariate analysis showed significantly lower grades of pulmonary insufficiency in group B. This technique for creating an autologous pericardial monocusp valve is an inexpensive, simple, and reliable procedure that effectively reduces pulmonary insufficiency at the 1-year follow-up.

Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

Toe thumb: a musculoskeletal disorder related to transesophageal echocardiography.

The musculoskeletal disorders (MSD) are common in healthcare providers and those who are doing sonography are also affected. There are reports of MSD in healthcare providers who do transthoracic echocardiography. Transesophageal echocardiography (TEE) is being regularly used in peri-operative setting. We describe MSD of hand in a cardiovascular and thoracic anesthesiologist who has been performing TEE scanning for 10% of his work-time in operating room and critical care area for the last 8 years. As the role of TEE is increasing and many doctors are doing it on a routine basis, the knowledge of association of MSD with TEE and measures to prevent it is important.

Hypertension and tachycardia during adrenal manipulation.

The purpose of this report is to draw attention to haemodynamic changes during intraoperative adrenal gland manipulation. Severe hypertension, ventricular tachycardia and subendocardial ischaemia occurred during the manipulation of adrenal gland in a patient who underwent live related donor nephrectomy. The patient responded well to intravenous lidocaine. Plasma norepinephrine concentration was elevated at the time of event. Further investigations after surgery excluded the possibility of phaeochromocytoma. In two years follow-up patient remains well. Suspicion for the cause of the event remains the excessive release of catecholamines with manipulation of a normal adrenal gland. The presence of halothane might have contributed to the arrythmia.RésuméCette observation vise a attirer l’attention sur les répercussions hémodynamiques provoquées par la manipulation peropératoire de la glande surrénale. De l’hypertension grave, de la tachycardie ventriculaire et de l’ischémie sous-endocardique surviennent pendant la manipulation de la surrénale chez un patient soumis une néphrectomie pour don d’organe. Le patient réagit favorablement à la lidocaïne intraveineuse. Au moment de l’incident, la concentration de norépinéphrine plasmatique est élevée. L’investigation postchirurgicale exclut la possibilité d’un phéochromocytome. Après deux ans, le patient est toujours en bonne santé. L’explication de cette complication la plus plausible demeure la libération excessive de catécholamine par manipulation d’une glande surrénale normale. L’halothane pourrait avoir exagéré l’arythmie.