Laparoscopic excision of normotensive variant pheochromocytoma in a case of triple vessel coronary artery disease: The anaesthesia challenge.

Pheochromocytomas are catecholamine-secreting tumours arising mostly from the adrenal medulla. With the advancement in surgical and anaesthetic techniques, the incidence of severe morbidity and mortality associated with surgery is low. However, concurrent coronary artery disease and pheochromocytoma continue to be a challenge due to the risk of adverse cardiovascular events. We describe the successful management of pheochromocytoma excision in a patient with coronary artery disease.

Pulsatile flow in descending aorta: Can coarctation of aorta be ruled out by transesophageal echocardiography?

A 5-year-old child with L posed great arteries, large subpulmonic ventricular septal defect (VSD), atrial septal defect (ASD), and a large patent ductus arteriosus (PDA) with mild isthmic narrowing was scheduled for surgical correction. Intraoperatively, it was a case of anatomically corrected malposition of great arteries. Due to abnormal positioning of great vessels, the isthmus was ligated instead of the large PDA. The postoperative transesophageal echocardiography showed pulsatile flow in descending aorta as it was being filled by large PDA, and thus iatrogenic coarctation (CoA) was missed. It was detected in the intensive care unit due to the onset of acidosis on blood gas analysis and the presence of gradient between radial and femoral arterial line pressures. The patient was taken for redo surgery, the PDA was then ligated, resection of the isthmic narrowing and repair by end-to-end anastomosis was done.

Aorto-left ventricular tunnel - A case report.

Aorto-left ventricular tunnel (ALVT) is a rare congenital anomaly with extracardiac channel connecting ascending aorta to the ventricle. It presents early in life due to congestive cardiac failure. We present a case of ALVT with unusual morphology in an 11-year-old male child with palpitations and dyspnea. We also describe the transesophageal echocardiography evaluation of ALVT.

A calcified amorphous tumour in a patient with coronary artery disease: an atypical entity.

We describe a case of a 46-year-old man with calcified amorphous tumour in the right atrium and significant coronary artery disease. Preoperative investigations revealed a polypoid oscillating mass arising from the interatrial septum and attached to the tricuspid valve annulus. On-pump complete extirpation of the tumour with concomitant coronary artery bypass grafting was performed successfully. The patient's postoperative course was uneventful.

Rupture of sinus of valsalva - A 15 years single institutional retrospective review: Preoperative heart failure has an impact on post operative outcome?

Background: We reviewed our experience with ruptured sinus of Valsalva aneurysms (RSOV) to determine a correlation with preexisting heart failure (HF) and coexisting cardiac lesions (aortic regurgitation [AR] and ventricular septal defect [VSD]) to postoperative left ventricular (LV) dysfunction and postoperative outcomes. Materials and Methods: Retrospective review of RSOV cases over 15 years showed that RSOV repair was done in 87 patients. We looked for patients who presented with HF and patients having AR and/or VSDs. Statistical analysis was done to see if the coexisting lesions and preoperative HF were associated with postoperative LV dysfunction. Chi-square test was used on contingency table for statistical analysis. Complications in the postoperative period and prolonged Intensive Care Unit stay were noted. Results: 17% (15/87) presented with HF. Fifty-two patients had moderate to severe AR and 50 patients had VSD. Seventeen patients had postoperative LV dysfunction. The correlation of preoperative HF and coexisting lesions with postoperative LV dysfunction was not statistically significant. Two patients underwent redo surgery for residual RSOV and AR. Two patients had arrhythmias. One patient had cerebrovascular accident. No mortality was seen in the study. Conclusion: Preoperative HF and the presence of VSD and/or AR have no statistical significant correlation with postoperative LV dysfunction. As the outcome of RSOV repair is good, all patients need to undergo early repair to avoid complications.

Absent superior vena cava in tetralogy of fallot.

Absent superior vena cava (SVC) is an asymptomatic congenital systemic venous anomaly which is rarely detected and compatible with normal life. Undiagnosed absent SVC may cause problems during cardiac catheterization or cardiac surgery. We present our surgical experience in a patient with tetralogy of Fallot who had undiagnosed absent SVC.

Comparison of hemodynamic responses to laryngoscopy and intubation with Truview PCD™, McGrath® and Macintosh laryngoscope in patients undergoing coronary artery bypass grafting: A randomized prospective study.

CONTEXT: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation. AIM: Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope. SETTING AND DESIGN: Superspecialty tertiary care public hospital; prospective, randomized control study. METHODS: Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview™. Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra-/post-operative complications were also recorded and compared between groups. STATISTICAL ANALYSIS: SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant. RESULTS: Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively). CONCLUSIONS: Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.

Perioperative management of a patient with Dandy Walker malformation with tetralogy of Fallot undergoing total correction and fresh homologous pericardial pulmonary valve conduit implantation: Report of a rare case.

Perioperative management of a patient with Dandy-Walker malformation (DWM) with tetralogy of Fallot (TOF), patent ductus arteriosus, and pulmonary artery stenosis is a great challenge to the anesthesiologist. Anesthetic management in such patients can trigger tet spells that might rapidly increase intracranial pressure (ICP), conning and even death. The increase in ICP can precipitate tet spells and further brain hypoxia. To avoid an increase in ICP during TOF corrective surgery ventriculo-peritoneal (VP) shunt should be performed before cardiac surgery. We present the first case report of a 11-month-old male baby afflicted with DWM and TOF who underwent successful TOF total corrective surgery and fresh autologous pericardial pulmonary valve conduit implantation under cardiopulmonary bypass after 1 week of VP shunt insertion.

Healed perivalvular abscess: Incidental finding on transesophageal echocardiography [corrected].

A 36-year-old male patient presented with the complaints of palpitations and breathlessness. Preoperative transthoracic echocardiography (TTE) revealed a bicuspid aortic valve; severe aortic regurgitation with dilated left ventricle (LV) and mild LV systolic dysfunction (ejection fraction 50%). He was scheduled to undergo aortic valve replacement. History was not suggestive of infective endocarditis (IE). Preoperative TTE did not demonstrate any aortic perivalvular abscess. Intraoperative transesophageal echocardiography (TEE) examination using the mid-esophageal (ME) long-axis view, showed an abscess cavity affecting the aortic valve, which initially was assumed to be a dissection flap, but later confirmed to be an abscess cavity by color Doppler examination. The ME aortic valve short-axis view showed two abscesses; one was at the junction of the non-coronary and left coronary commissure and the other one above the right coronary cusp. Intraoperatively, these findings were confirmed by the surgeons. The case report demonstrates the superiority of TEE over TTE in diagnosing perivalvular abscesses.

Low-grade myofibroblastic sarcoma of the tongue.

Low-grade myofibroblastic sarcoma is a neoplasm of atypical myofibroblasts with fibromatoseslike features and a predilection for head and neck sites, including the oral cavity. These lesions have only been characterized in the last 2 decades, and controversies in the concept of neoplastic myofibroblasts still exist. Lack of obvious cytological atypia may result in their being mistaken for reactive fascitislike lesions or fibromatosis and architectural similarities to fibrosarcoma or leiomyosarcoma may complicate the diagnostic process. This paper describes a spindle cell neoplasm in a 40-year-old man that was diagnosed 9 years ago as an unclassifiable myofibroblastic proliferation. The recurrent tumor, which presented 6 years following excision of the original tumor, was subsequently classified as a low-grade myofibroblastic sarcoma. The morphological, immunohistochemical, and electron microscopic features of this unusual sarcoma and the most likely differential diagnoses are discussed.