Rana Sandip Singh

Evaluation of closed-loop anesthesia delivery for propofol anesthesia in pediatric cardiac surgery.

The objective of this study was to compare the feasibility of closed‐loop anesthesia delivery with manual control of propofol in pediatric patients during cardiac surgery.

Major Airway Injury During Esophagectomy: Experience at a Tertiary Care Center

BackgroundTracheal laceration is a rare but life-threatening complication of esophagectomy. It is seen both with transhiatal and transthoracic esophagectomy.MethodsThree hundred eighty-two esophagectomies were performed from 1998 to 2008. The medical records of five patients with laceration of trachea during esophagectomy managed at a tertiary care center were reviewed retrospectively.ResultsThere were three males and two females with age range 18–62xa0years. The overall incidence of tracheal laceration was 1.31%. Four lacerations (1.30%) occurred during transhiatal and one (1.35%) during transthoracic resection of esophagus. Tracheal laceration was detected intraoperatively in all. Laceration was long (>3xa0cm) in three patients and short (<2xa0cm) in two. Patients with long laceration required direct suturing, while those with short laceration could be managed with gastric reinforcement. No patient required additional thoracotomy to access the lesion. Two patients had pneumonia, one had recurrent nerve palsy, while another developed anastomotic disruption. No patient died.ConclusionLaceration of trachea is a potentially morbid complication of esophagectomy. Management should be individualized based on the extent and type of laceration. The surgical strategy depends upon the index procedure. The present series describes successful management of patients with tracheal injury associated with esophagectomy.

Spontaneous double vessel coronary artery dissection : A case report and surgical management

Spontaneous coronary artery dissection is an uncommon clinical entity, its presentation and management similar to atherosclerotic coronary artery disease. We report on a young adult male who presented with myocardial infarction due to simultaneous dissection of left anterior descending and right coronary artery. He was treated with bilateral interal mammary artery grafts.

Perioperative echocardiography-derived right ventricle function parameters and early outcomes after tetralogy of Fallot repair in mid-childhood: a single-center, prospective observational study.

Right ventricular (RV) function alterations are invariably present in all patients after tetralogy of Fallot (TOF) repair. Unlike the developed world where most of the patients with TOF are corrected in infancy, average age of presentation and thus surgery for these patients in the developing world may be higher. We aimed to study the correlation between RV function parameters such as tricuspid annular peak systolic excursion (TAPSE), fractional area change (FAC), and tricuspid annular peak systolic velocity (S’) with early outcome variables after intracardiac repair for TOF.

Sinus of valsalva aneurysm associated with a left main coronary artery dissection

Sinus of Valsalva aneurysms (SVA) may become symptomatic due to rupture or compression of adjacent structures. We present images of a patient with a SVA associated with a dissection of the left main coronary artery (LMCA). A 78-year-old male was admitted with angina and dyspnea on exertion and found on coronary angiography to have a dissection of the LMCA (Figure 1). A transthoracic echocardiogram revealed a wall motion abnormality in the circumflex artery territory and thickened, calcified aortic valve leaflets associated with moderate aortic regurgitation. A computed tomography angiogram demonstrated a 4.2 × 4.5-cm SVA compressing the LMCA and the main pulmonary artery (PA) (Figure 2). A transesophageal echocardiogram showed that the SVA originated from the left coronary sinus and extended behind the PA toward the left atrium (LA) (Figure 3). At the time of surgery, following institution of cardiopulmonary bypass and cardioplegic arrest, an oblique aortotomy was performed and the aortic valve leaflets were noted to be thickened and calcified. The SVA extended from the left coronary sinus behind the PA toward the LA (Figure 4A). The opening of the SVA was 2 cm inferior to the ostium of the LMCA (Figure 4B). The opening of the SVA was closed using a expanded polytetrafluoroethylene (ePTFE) patch (IMPRA, Bard Peripheral Vascular, Inc., Tempe, AZ) using a continuous 5–0 prolene suture, avoiding the ostium of the LMCA (Figure 5). Saphenous vein bypass grafts were placed to the left anterior descending, first

Histological topography of the atrioventricular node and its extensions in relation to the cardiothoracic surgical landmarks in normal human hearts

BACKGROUNDnAtrioventricular (AV) nodal injury which results in cardiac conduction disorders is one of the potential complications of heart valve surgeries and radiofrequency catheter ablations. Understanding the topography of the AV conduction system in relation to the tricuspid and mitral valves will help in reducing these complications.nnnMETHODSnA tissue block of 3cmx4cm, which contain the AV node, bundle of His and the AV nodal extensions, was excised at the AV septal junction in 20 apparently normal human hearts. The block was divided into three equal segments through vertical incisions perpendicular to the insertion of the septal leaflet of the tricuspid valve. Each segment was processed and stained with H&E and Gomori to study the different parts of the AV conduction system.nnnRESULTSnThe lower pole of the AV node was located vertically above the tricuspid septal leaflet (TSL) in 100% (20/20) of cases and at the level of the muscular interventricular septum in 65% (13/20) of cases. The upper pole of the compact AV node was located at the level of the mitral valve leaflet (MVL) in 50% (10/20) of cases. The penetrating bundle of His was seen at the level of the TSL, while the branching bundle of His was situated 1.9±1.5 mm inferior to the TSL. The right and left posterior extensions of the AV node spanned from the MVL to 2.9±1.3 mm above the TSL.nnnCONCLUSIONSnA rectangular area (2.5 mm × 12 mm) in the Kochs triangle was devoid of AV nodal tissue and could be labeled as a safe area with no risk of conduction defects during valve surgeries. Information on the separation of AV nodal extensions from the TSL, MVL and muscular interventricular septum may play a crucial role in guiding and improving the safety of radiofrequency ablations.

Cardiovascular Causes of Pediatric Airway Compression: A Pictorial Review.

Airways compression by vascular structures is one of the important comorbidities of congenital heart disease with incidence of approximately 1%-2% in children. Airways compression is a consequence of abnormal configuration of the great vessels producing a vascular ring with enlargement of normal structures (pulmonary arteries or cardiac chambers) or because of surgery. A high index of suspicion for vascular airway compression is important in children with recurrent respiratory complaints. Early diagnosis and management are essential, as chronic airway compression causes significant morbidity. As the underlying anatomical patterns tend to be highly complex, presurgical imaging assessment is essential.

Anti-endothelial cell antibody rich sera from rheumatic heart disease patients induces proinflammatory phenotype and methylation alteration in endothelial cells

Rheumatic heart disease (RHD) is a major cause of cardiovascular morbidity and mortality in developing nations like India. RHD commonly affects the mitral valve which is lined by a single layer of endothelial cells (ECs). The role of ECs in mitral valve damage during RHD is not well elucidated. In here, anti-endothelial cell antibody from RHD patients has been used to stimulate the ECs (HUVECs and HMVECs). ECs proinflammatory phenotype with increased expression of TNFα, IL-6, IL-8, IFNγ, IL-1β, ICAM1, VCAM1, E-selectin, laminin B, and vimentin was documented in both ECs. The promoter hypomethylation of various key inflammatory cytokines (TNFα, IL-6, and IL-8), integrin (ICAM1) associated with leukocyte transendothelial migration, and extracellular matrix genes (vimentin, and laminin) were also observed. Further, the in-vitro data was in accordance with ex-vivo observations which correlated significantly with the etiological factors such as smoking, socioeconomic status, and housing. Thus, the study sheds light on the role of ECs in RHD which is a step forward in the elucidation of disease pathogenesis.

Renal function after off-pump versus on-pump coronary artery bypass grafting

Background Renal dysfunction is a well-recognized major complication after coronary artery bypass grafting. Off-pump coronary artery bypass theoretically appears to have less impact on renal function. We estimated preoperative and postoperative creatinine clearance as a marker of renal dysfunction in patients undergoing off-pump and on-pump coronary artery bypass. Methods Thirty patients undergoing coronary artery bypass were randomly allocated to undergo either on-pump (nu2009=u200915) or off-pump surgery (nu2009=u200915). The two groups had similar preoperative demographic characteristics. Serum creatinine and creatinine clearance were measured for 4 days postoperatively and the results were compared with preoperative levels. Results The rise in serum creatinine on postoperative day 1 was 0.28u2009mgċdL−1 in the on-pump group and 0.22u2009mgċdL−1 in the off-pump group (pu2009=u20090.27); on postoperative day 4 it was 0.15u2009mgċdL−1 and 0.10u2009mgċdL−1, respectively, (pu2009=u20090.28). Similarly, the fall in creatinine clearance was 17.34u2009mLċmin−1 in the on-pump group and 19.62u2009mLċmin−1 in the off-pump group on postoperative day 1 (pu2009=u20090.42), and 10.9 and 10.94u2009mLċmin−1, respectively, on postoperative day 4 (pu2009=u20090.64). Conclusion Renal function is not affected by the technique of coronary artery bypass surgery, whether with or without cardiopulmonary bypass, in spite of the theoretical advantage of off-pump surgery. Our study suggests that off-pump coronary artery bypass surgery does not confer significant protection from postoperative renal dysfunction in low-risk patients, when compared with on-pump surgery.

Vascularity of human atrioventricular valves: A myth or fact?

BACKGROUNDnKnowledge of heart valve vascularity is an important factor for understanding the valvular pathology and to develop tissue-engineered valves for repair procedures. Some investigators believe that blood vessels may exist in normal human heart valves whereas some recent publications have proposed that the presence of blood vessels in the valves is secondary to inflammation.nnnMETHODSnTissues from 60 normal formalin-fixed human hearts were examined microscopically for type, location, and number of vessels in atrioventricular valves. The age of the patient ranged from 10 to 70xa0years, and an attempt was made to study the age-related morphologic changes in atrioventricular valves.nnnRESULTSnOf the 60 tricuspid and 60 mitral valves examined, 12 tricuspid (20%) and 14 mitral (23.33%) valves were found to have vessels without the presence of an inflammatory process. In tricuspid valves the vessels were observed mainly in the fibrosa layer with a range of 1 to 4 vessels, whereas in mitral valves the vessels were situated mainly in the spongiosa layer with a range of 1 to 2 vessels. The maximum vascularity was seen in the fourth decade of life, in which the vessels were found in 40% of both tricuspid and mitral valves. The mean transverse diameter of these vessels was 0.23xa0±xa00.18xa0mm, with a range of 0.06 to 0.79xa0mm in tricuspid valves, whereas it was 0.15xa0±xa00.08xa0mm, with a range of 0.04 to 0.4xa0mm in mitral valves. The capillaries (3-11 capillaries) were found scattered in the fibrosa and spongiosa with an average lumen area of 0.39xa0±xa00.18xa0mm(2).nnnCONCLUSIONSnThe blood vessels in atrioventricular valves also can be seen in the absence of inflammation and are likely to be a necessary component of valve leaflets. Thus, when performing procedures involving in situ tissue engineering and valve repair the physician needs to be aware of the presence of these vessels in human heart valves.