Sambhunath Das

Comparison of Epsilon Aminocaproic Acid and Tranexamic Acid in Thoracic Aortic Surgery: Clinical Efficacy and Safety

OBJECTIVE To evaluate the efficacy and safety of tranexamic acid (TXA) versus epsilon aminocaproic acid (EACA) in patients undergoing thoracic aortic surgery. DESIGN A prospective randomized study. SETTING A tertiary care center. PARTICIPANT The study was conducted on 64 consecutive adult patients undergoing thoracic aortic surgery with cardiopulmonary bypass (CPB). INTERVENTIONS Group EACA received a bolus of 50 mg/kg of EACA after induction of anesthesia over 20 minutes followed by maintenance infusion of 25 mg/kg/h until chest closure. Group TXA received a bolus of 10 mg/kg of TXA after induction of anesthesia over 20 minutes followed by maintenance infusion of 1 mg/kg/h until chest closure. MEASUREMENTS AND MAIN RESULTS Cumulated mean blood loss, total packed red blood cells, and blood product requirement up to 24 h postoperatively were comparable between groups. A significant renal injury (EACA 40% v TXA 16%; p = 0.04) and increased tendency for renal failure (EACA 10% v TXA 0%, p = 0.11; relative risk 2.15) were observed with EACA compared to TXA. There was increased tendency of seizure with TXA (EACA v TXA: 3.3% v 10%; p>0.05, relative risk 1.53). There was significant increase in the D-dimer from preoperative to postoperative values in Group EACA. (p< 0.01). CONCLUSIONS Both EACA and TXA were equally effective in reducing the perioperative blood loss and transfusion requirement in patients undergoing thoracic aortic surgery. While significant renal injury was observed with EACA, there was a tendency for higher incidence of seizure with TXA. Prospective placebo-controlled trials recruiting larger sample size using sensitive biomarkers are required before any recommendations.

Efficacy of dexmedetomidine for the control of junctional ectopic tachycardia after repair of tetralogy of Fallot

Background: Junctional ectopic tachycardia occurs frequently after congenital cardiac surgery and can be a cause of increased morbidity and mortality. Dexmedetomidine (DEX) is an α2 adrenoreceptor agonist, has properties of controlling tachyarrhythmia by regulating the sympatho-adrenal system. Objective: To evaluate the efficacy of DEX for control of junctional ectopic tachycardia after repair of Tetralogy of Fallot (TOF). Materials and Methods: Two hundred and twenty pediatric cardiac patients with TOFs were enrolled in a prospective randomized control study. Patients underwent correction surgery. They were divided into two groups, i.e., Group 1 (DEX) and Group 2 (control). Heart rate, rhythm, mean arterial pressure (MAP) were recorded after the anesthetic induction (T1), after termination of bypass (T2), after 04 hours (T3), and 08 hours after transferring the patient to intensive care unit (ICU; T4). Results: Heart rate was comparable between two groups before starting the drug but statistically significant after bypass until 08 hours after transferring the patient to ICU. Junctional ectopic tachycardia occurred more in Group-2 (20%) as compared to Group-1 (9.09%; P = 0.022). Junctional ectopic tachycardia occurs early in Group-2 (0.14 ± 0.527 hours) as compared to Group 1 (0.31 ± 1.29 hours; P = 0.042). The duration of junctional ectopic tachycardia was more prolonged in Group-2 (1.63 ± 3.64 hours) as compared to Group-1 (0.382 ± 1.60 hours; P = 0.012). The time to withdraw from mechanical ventilation and ICU stay of Group 1 patient was less than of Group 2 patients (P = <0.001). Conclusion: DEX had a therapeutic role in the prevention of junctional ectopic tachycardia in patients undergoing repair for TOF.

An electron microscopic study of left ventricular regression in children with transposition of great arteries

Over the years the age limit for the arterial switch operation (ASO) is being redefined with increasing expertise and adoption of extra-corporeal membrane oxygenator (ECMO) in the surgical program. We conducted a study to see the differences in ultrastructural features in eight children with transposition of the great arteries, four with prepared and the remaining four with regressed left ventricle (LV) during the ASO. Children with prepared LV had prominent Z bands with uniform and round mitochondria, few fat vacuoles and minimal collagen in the background, whereas children with regressed LV had Z band disruption with non-uniform elliptical mitochondria and myofibrillary disarray and an abundance of fat vacuoles and collagen in the background. Children with regressed LV and abundance of collagen had a prolonged postoperative course. Collagen deposition in the LV may point to the situation where the postoperative course following ASO may be prolonged due to the increased time required for the regressed LV to increase its mass and to sustain the systemic circulation.

Perioperative management of long QT syndrome in a child with congenital heart disease

During cardiac catheterization, a 2½‐year‐old boy developed sudden cardiac arrest. The presence of a long QT interval in the electrocardiogram (ECG) along with ventricular arrhythmia and syncope at that moment enabled us to diagnose long QT syndrome (LQTS). Immediate defibrillation and beta‐blocker (metoprolol) therapy saved the life of the child. Cardiac catheterization was completed and the child was planned for Fontan operation. Beta‐blocker coverage, prevention of sympathetic stimulation and avoidance of agents which prolong the QT interval made anesthesia uneventful. There were episodes of ventricular fibrillation (VF) in the postoperative period. The child was managed with electrical defibrillation, metoprolol and magnesium.

Effect of single intraoperative dose of amiodarone in patients with rheumatic valvular heart disease and atrial fibrillation undergoing valve replacement surgery

Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone (n = 42) or control (n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% (n = 6) and remained so in 9.5% (n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% (n = 15) (p = 0.035) and remained so in 32.5% (n = 13) of patients till the end of surgery (p = 0.01). At the end of first post-operative day 21.4% (n = 9) of patients in amiodarone group and 55% (n = 22) of patients in control group were in AF (p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (+/-0.54) in amiodarone group and 2.26 (+/-0.73) in the control group (p = 0.014), and the energy needed was 22.5 (+/-8.86) joules in the amiodarone group and 40.53 (+/-16.5) in the control group (p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.

Effect of preoperative statin therapy on early postoperative memory impairment after off-pump coronary artery bypass surgery

Context: Frequent incidence of early postoperative memory impairment (POMI) after cardiac surgery remains a concern because of associated morbidity, impaired quality of life, and increased health care cost. Aim: To assess the effect of preoperative statin therapy on POMI in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Setting and Design: Prospective observational study in a tertiary level hospital. Methods: Sixty patients aged 45-65 years undergoing OPCAB surgery were allocated into two groups of 30 each. Group A patients were receiving statin and Group B patients were not receiving statins. All patients underwent memory function assessment preoperatively after admission to hospital and on the 6 th postoperative day using postgraduate institute memory scale. Statistical Analysis: Appropriate tests were applied with SPSS 20 to compare both groups. The value P < 0.05 was considered statistically significant. Multiple regression analysis was performed with confounding factors to determine the effect on memory impairment. Results: Patients in Group A showed significant postoperative deterioration in 6 of the 10 functions and in Group B showed deterioration in 9 of 10 functions tested compared to preoperative scores. Intergroup comparison detected less POMI in Group A compared to Group B and was statistically significant in 8 memory functions. Multiple regression analysis detected statin as an independent factor in preventing memory impairment. Conclusions: Preoperative statin therapy attenuates the early POMI in patients undergoing OPCAB. Future long-term studies will define the efficacy of statin on POMI.

Novel mutation detection of fibroblast growth factor receptor 1 (FGFR1) gene, FGFR2IIIa, FGFR2IIIb, FGFR2IIIc, FGFR3, FGFR4 gene for craniosynostosis: A prospective study in Asian Indian patient.

Background: Craniosynostosis (CS) syndrome is an autosomal dominant condition classically combining craniosynostosis and non-syndromic craniosynostosis with digital anomalies of the hands and feet. The majority of cases are caused by heterozygous mutations in the third immunoglobulin-like domain (IgIII) of FGFR2, whilst a larger number of cases can be attributed to mutations outside this region of the protein. Aims: To find out the FGFR1, FGFR2, FGFR3 and FGFR4 gene in craniosynostosis syndrome. Settings and Design: A hospital based prospective study. Materials and Methods: Prospective analysis of clinical records of patients registered in CS clinic from December 2007 to January 2015 was done in patients between 4 months to 13 years of age. We have performed genetic findings in a three generation Indian family with Craniosynostosis syndrome. Results: We report for the first time the clinical and genetic findings in a three generation Indian family with Craniosynostosis syndrome caused by a heterozygous missense mutation, Thr 392 Thr and ser 311 try, located in the IgII domain of FGFR2. FGFR 3 and 4 gene basis syndrome was eponymously named. Genetic analysis demonstrated that 51/56 families to be unrelated. In FGFR3 gene 10/TM location of 1172 the nucleotide changes C>A, Ala 391 Glu 19/56 and Exon-19, 5q35.2 at conserved linker region the changes occurred pro 246 Arg in 25/56 families. Conclusions: Independent genetic origins, but phenotypic similarities in the 51 families add to the evidence supporting the theory of selfish spermatogonial selective advantage for this rare gain-of-function FGFR2 mutation.

Double aortic arch as a source of airway obstruction in a child

Double aortic arch (DAA) is a congenital vascular anomaly. The diagnosis was difficult till the child was symptomatic, and other causes were ruled out. We present the interesting images of a child of respiratory distress because of tracheal compression from DAA.

Cortriatriatum With Classical Raghib Complex: A Rare Anatomic Association

Cortriatriatum with Raghib’s complex is a rarely reported entity. An 18-month-old baby who presented with tachypnea and cyanosis was diagnosed to have cortriatriatum sinistrum along with a persistant left superior caval vein draining to the left atrium through an unroofed coronary sinus. The child underwent successful surgical correction with excision of the cortriatriatum and baffling of the left superior caval vein to the right atrium.

Aortopulmonary window and double outlet right ventricle: a rare combination.

Aortopulmonary window combined with double outlet right ventricle (DORV) is a very rare congenital cardiac anomaly. We managed a 5-month-old child weighing 4.5 kg diagnosed as a case of aortopulmoary window (APW) combined with DORV with ostium secundum atrial septal defect (ASD), and bilateral confluent and adequate pulmonary arteries. The surgical correction was planned under general anesthesia. Transesophageal echocardiography (TEE; Philips pediatric S7-3t) in the upper esophageal position with slight anticlockwise rotation detected a communication between ascending aorta and main pulmonary artery [Figure 1]. The TEE images of APW with DORV are shown in Figures 1 and 2. Aortopulmonary window was arising approximately 1.0 cm above the aortic valve annulus and its diameter measured approximately 10 mm [Figure 3]. The approximate size of the pulmonary artery and aorta was 13.5 and 12 mm. Under cardiopulmonary bypass, the APW was dissected and transected. Both the openings on ascending aorta and pulmonary artery were closed by continuous suture. The DORV and ASD were corrected. Post cardiopulmonary bypass TEE examination revealed no residual ventricular septal defect (VSD), APW and left/right ventricular outflow tract obstruction [Figures 4 and 5]. The trachea was extubated after 12 h of mechanical ventilation. The subsequent course was uneventful.