Vivek Jawali

Tetralogy of Fallot with acquired coronary artery disease-An unusual presentation.

Coronary artery disease developing in tetralogy of Fallot (TOF) is rare. We report a rare case of TOF with acquired coronary artery disease, treated simultaneously with intra cardiac repair and multi vessel coronary artery bypass grafting.

Aortic root to left-atrial fistula after aortic valve replacement: A rare complication and its intraoperative management

Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement (AVR) and most of them have been diagnosed as a late complication. We present a case of this unusual complication after AVR. Intraoperative transoesophageal echocardiography identified and diagnosed this rare and potentially disastrous surgical complication and confirmed adequacy of its surgical repair.

Decrease in pulmonary artery pressure after administration of thoracic epidural anesthesia in a patient with Marfan syndrome awaiting aortic valve replacement procedure

Thoracic epidural anesthesia is an adjunct to general anesthesia in cardiac surgery. Decrease in heart rate and blood pressure are frequently seen beneficial effects. There are several other hemodynamic effects of thoracic epidural anesthesia such as decrease in systemic vascular resistance, cardiac index, left ventricular stroke work index among others. However, the effect of thoracic epidural anesthesia on pulmonary artery pressure (PAP) has not been studied extensively in humans. Thoracic epidural anes-thesia decreased pulmonary artery pressure in experimen-tally induced pulmonary hypertension in animals. The mechanisms involved in such reduction are ill understood. We describe in this report, a significant reduction in PAP in a patient with Marfan’s syndrome scheduled to under-go aortic valve replacement. The possible mechanisms of decrease in pulmonary artery pressure in the described case are, decrease in the venous return to the heart, decrease in the systemic vascular resistance, decrease in the right ventric-ular function and finally, improvement in myocardial contraction secondary to all the above. The possibility of Marfan’s syndrome contributing to the decrease in PAP appears remote. The authors present this case to generate discussion about the possible mechanisms involved in thoracic epidural anesthesia producing beneficial effects in patients with secondary pulmonary hypertension. Thoracic epidural anesthesia appears to decrease pulmonary artery pressure by a combination of several mechanisms, some unknown to us. This occurrence, if studied and understood well could be put to clinical use in pulmonary hypertensives.Thoracic epidural anesthesia is an adjunct to general anesthesia in cardiac surgery. Decrease in heart rate and blood pressure are frequently seen beneficial effects. There are several other hemodynamic effects of thoracic epidural anesthesia such as decrease in systemic vascular resistance, cardiac index, left ventricular stroke work index among others. However, the effect of thoracic epidural anesthesia on pulmonary artery pressure (PAP) has not been studied extensively in humans. Thoracic epidural anes-thesia decreased pulmonary artery pressure in experimen-tally induced pulmonary hypertension in animals. The mechanisms involved in such reduction are ill understood. We describe in this report, a significant reduction in PAP in a patient with Marfan’s syndrome scheduled to under-go aortic valve replacement. The possible mechanisms of decrease in pulmonary artery pressure in the described case are, decrease in the venous return to the heart, decrease in the systemic vascular resistance, decrease in the right ventric-ular function and finally, improvement in myocardial contraction secondary to all the above. The possibility of Marfan’s syndrome contributing to the decrease in PAP appears remote. The authors present this case to generate discussion about the possible mechanisms involved in thoracic epidural anesthesia producing beneficial effects in patients with secondary pulmonary hypertension. Thoracic epidural anesthesia appears to decrease pulmonary artery pressure by a combination of several mechanisms, some unknown to us. This occurrence, if studied and understood well could be put to clinical use in pulmonary hypertensives.

Unmasking of patent ductus arteriosus on cardiopulmonary bypass: role of intraoperative trans-esophageal echocardiography in a patient with severe pulmonary hypertension due to pulmonary vein stenosis and cor triatriatum.

venous obstruction. After induction of general anesthesia, transesophageal echocardiography (TEE) probe was inserted. TEE confirmed the diagnosis made earlier. Further, a restrictive fleshy membrane in the left atrium (cor triatriatum) contributing to pulmonary vein stenosis was observed. Surgery commenced via mid-sternotomy. Total body heparinisation was achieved with 6000 IU of heparin; the resultant activated clotting time was 450 s. The pulmonary artery (PA) pressure measured via a fine needle inserted in the main pulmonary artery revealed supra-systemic PA pressure. The systemic pressure was 73/56 and mean 63 mmHg, while the PA pressure was 98/60 mmHg. Cardiopulmonary bypass (CPB) was instituted without events after cannulation of ascending aorta and cannulation of superior and inferior vena cavae. It is our institution policy to confirm the empty status of the heart with adequate venous return and absence of aortic regurgitation after establishing CPB using TEE. During such routine examination in this patient, hitherto unreported ductal flow was detected and patent ductus arteriosus (PDA) was diagnosed [Video 1]. PDA was visualized in the upper esophageal view. As the tee probe is withdrawn gradually from the mid-esophageal position, just beyond A 15-year-old African girl, weighing 27 kilos, with a height of 148 cm was admitted to the hospital for repair of pulmonary venous obstruction and cor triatriatum. She was comfortable at rest, but had severe limitation of activities beyond those of daily living. Pulse oximetry on room air was 92%, which improved to 95% with oxygen.

Effect of thoracic epidural anesthesia on oxygen delivery and utilization in cardiac surgical patients scheduled to undergo off-pump coronary artery bypass surgery: a prospective study.

To evaluate the effect of thoracic epidural anesthesia (TEA) on tissue oxygen delivery and utilization in patients undergoing cardiac surgery. This prospective observational study was conducted in a tertiary referral heart hospital. A total of 25 patients undergoing elective off-pump coronary artery bypass surgery were enrolled in this study. All patients received thoracic epidural catheter in the most prominent inter-vertebral space between C7 and T3 on the day before operation. On the day of surgery, an arterial catheter and Swan Ganz catheter (capable of measuring cardiac index) was inserted. After administering full dose of local anesthetic in the epidural space, serial hemodynamic and oxygen transport parameters were measured for 30 minute prior to administration of general anesthesia, with which the study was culminated. A significant decrease in oxygen delivery index with insignificant changes in oxygen extraction and consumption indices was observed. We conclude that TEA does not affect tissue oxygenation despite a decrease in arterial pressures and cardiac output.

Comparison of two doses of heparin on outcome in off-pump coronary artery bypass surgery patients: A prospective randomized control study

Introduction: While off pump coronary artery bypass surgery is practiced with an intention to reduce the morbidity associated with cardiopulmonary bypass, the resultant ′hypercoagulability′ needs to be addressed. Complications such as cavitary thrombus possibly due to the hyper coagulability after off pump coronary artery bypass surgery have been described. Many clinicians use higher doses of heparin - up to 5 mg/kg in order to thwart this fear. Overall, there appears to be no consensus on the dose of heparin in off pump coronary artery bypass surgeries. Aim of the Study: The aim of the study was understand the differences in outcome of such as transfusion requirement, myocardial ischemia, and morbidity when two different doses were used for systemic heparinization. Methods: Elective patients scheduled for off pump coronary artery bypass surgery were included. Ongoing anti platelet medication was not an exclusion criteria, however, anti platelet medications were ceased about a week prior to surgery when possible. Thoracic epidural anesthesia was administered as an adjunct in patients who qualified for it. By computer generated randomization chart, patients were chosen to receive either 2 or 3 mg/kg of intravenous unfractioned heparin to achieve systemic heparinization with activated clotting time targeted at >240 secs. Intraoperative blood loss, postoperative blood loss, myocardial ischemic episodes, requirement of intraaortic balloon counter pulsation and transfusion requirement were analyzed. Results: Sixty two patients participated in the study. There was one conversion to cardiopulmonary bypass. The groups had comparable ACT at baseline (138.8 vs. 146.64 seconds, P = 0.12); 3 mg/kg group had significantly higher values after heparin, as expected. But after reversal with protamine, ACT and need for additional protamine was similar among the groups. Intraoperative (685.56 ± 241.42 ml vs. 675.15 ± 251.86 ml, P = 0.82) and postoperative blood loss (1906.29 ± 611.87 ml vs 1793.65 ± 663.54 ml , p value 0.49) were similar among the groups [Table 4]. The incidence of ECG changes of ischemia, arrhythmias, conversion to CPB, or need for intra-aortic balloon counter pulsation were not different. Conclusions: Use of either 2 or 3 mg/kg heparin for systemic heparinization in patients undergoing OPCAB did not affect the outcome.

Subxiphoid (sternal sparing) approach for minimal access coronary artery bypass grafting

BackgroundCoronary artery bypass grafting (CABG) is one of the commonest cardiothoracic surgical procedures carried out in today’s day and age. Traditionally, the midline sternotomy approach was in vogue, and CABG would be done on cardiopulmonary bypass. With further advances and expertise, various procedural modifications have been made including off-pump CABG and minimally access procedures which include minimally invasive direct coronary artery bypass (MIDCAB) grafting and partial sternotomy techniques. Subxiphoid CABG is a sparingly used novel approach but nonetheless an excellent choice in many cases.ObjectiveTo study the feasibility of minimal access subxiphoid CABG and its outcomes in patients.Materials and methodsWe used the subxiphoid approach in seven cases from June 2014 to date. Patients were followed up prospectively and evaluated for various factors which included post-op pain scores, healing and graft patency.ResultsThis technique is very useful and has various advantages. Blood loss was found to be less. Healing was found to be faster and hospital stay comparably shorter.ConclusionThe subxiphoid approach for CABG is a novel advancement in this surgery and is a true minimal access procedure which includes doing the CABG through a small incision, just starting below the xiphisternum and extending below to less than 3 inches. Direct CABG is done through this approach including multivessel grafting and gastroepiploic artery harvesting. We hereby would like to describe this advancement in the field of cardiac surgery.

Surgical retrieval of entrapped coronary angioplasty guidewire from the aorta

An entrapped or retained coronary angioplasty guidewire is a rare but serious complication of coronary interventions. A failed percutaneous transluminal coronary angioplasty attempt on the left anterior descending artery in a 35-year-old man was complicated by entrapment of the guidewire. Under cardiopulmonary bypass and cardioplegic arrest, the whole length of the entrapped guidewire was retrieved successfully from the left anterior descending artery and the aorta through an aortotomy following revascularization with left internal mammary artery.

Anesthetic implications of subxiphoid coronary artery bypass surgery

Background: Minimal invasive surgeries are carried out to benefit the patient with less pain, blood loss, mechanical ventilation and hospital stay; a smaller scar is not the aim. Minimal invasive cardiac surgeries are carried out via small sternotomy, small thoracotomy and via robotic arms. Subxiphoid route is a novel method and avoids sternotomy. Aim: This case series is an attempt to understand the anesthetic modifications required. Secondly, whether it is feasible to carry out subxiphoid coronary artery bypass surgery. Methods: Elective patients scheduled to undergo subxiphoid coronary artery bypass surgery were chosen. The surgeries were conducted under general anesthesia with left lung isolation via either endobronchial tube or bronchial blocker. Results: We conducted ten (seven males and 3 females) coronary artery bypass graft surgeries via subxiphoid technique. The mean EuroSCORE was 1.7 and the mean ejection fraction was 53.6. Eight patients underwent surgery via endobronchial tube, while, in the remaining two lung isolation was obtained using bronchial blocker. Mean blood loss intraoperatively was 300 ± 42 ml and postoperatively 2000 ± 95 ml. The pain score on the postoperative day ′0′ was 4.3 ± 0.6 and 2.3 ± 0.7 on the day of discharge. Length of stay in the hospital was 4.8 ± 0.9 days. There were no complications, blood transfusions, conversion to cardiopulmonary bypass. The modifications in the anesthetic and surgical techniques are, use of left lung isolation using either endobronchial tube or bronchial blocker, increased duration for conduit harvesting, grafting, requirement of transesophageal echocardiography monitoring in addition to hemodynamic monitoring. Other minor requirements are transcutaneous pacing and defibrillator pads, a wedge under the chest to ′lift′ up the chest, sparing right femoral artery and vein (to serve as vascular access) for an unlikely event of conversion to cardiopulmonary bypass. Any anesthesiologist wishing to start this technique must be aware of these modifications. Conclusions: Subxiphoid route is safe to carry out coronary artery bypass graft surgery using the minimal invasive cardiac surgery. It is reproducible and has undeniable benefits. We plan to conduct such surgeries in awake patients under thoracic epidural anesthesia thus making it even less invasive and amenable for fast tracking.

A Rare complication of aorto-left atrial fistula after aortic valve replacement and its management with intraoperative transoesophageal echocardiography

Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement and most of them have been diagnosed as a late complication. We present a case of this unusual complication after aortic valve replacement which was diagnosed intraoperatively and this potentially disastrous complication was corrected promptly. Early recognition and diagnosis of this rare surgical complication with intraoperative transoesophageal echocardiography (TEE) is imperative for prompt surgical repair of this lethal defect.