Internal Jugular Vein Cannulation Using a 3-Dimensional Ultrasound Probe in Patients Undergoing Cardiac Surgery: Comparison Between Biplane View and Short-Axis View.

OBJECTIVE: To compare the clinical performance in terms of procedure time, success rate, and cannulation attempts between ultrasound biplane view (BPX) and short-axis (SAX) view for internal jugular vein cannulation (IJV) in patients undergoing cardiac surgery. DESIGN: Prospective, observational pilot study. SETTING: University level tertiary referral hospital. PATIENTS: The study comprised 100 patients between ages 18 and 75 years undergoing elective cardiac surgery. INTERVENTIONS: One hundred patients were divided into 2 groups of 50 (BPX group and SAX group) by assigning the study participants alternatively to each group. IJV cannulation was performed using a 3-dimensional ultrasound probe in all patients with either BPX view (BPX group, n = 50) or the SAX view (SAX group, n = 50) by an experienced anesthesiologist. MEASUREMENTS AND MAIN RESULTS: Time required for imaging, time for IJV puncture, time for guidewire confirmation, number of needle punctures and needle redirections, and incidence of posterior wall puncture were noted in both groups. In addition, the quality of needle visualization and the incidence of complications were recorded. The time taken for imaging was significantly greater in the BPX group than in the SAX group (9.52 ± 2.69 s v 7.94 ± 2.55 s; p = 0.0034), whereas the time taken for IJV puncture (10.39 ± 2.33 s v 23.7 ± 2.46 s; p < 0.0001), time taken for confirmation of guidewire (32.94 ± 4.50 s v 57.64 ± 7.14 s; p < 0.0001), and the incidence of posterior wall puncture (4% v 26%; p = 0.0022) were significantly less in the BPX group than in the SAX group. The total number of attempts taken to puncture the IJV was fewer in the BPX group than in the SAX group (55 v 78). Successful puncture of the IJV occurred on the first attempt in 90% of patients in the BPX group, whereas it was only 50% in the SAX group (p < 0.0001). The quality of needle visualization was good in 90% of patients in the BPX group, whereas it was only 6% in the SAX group. The number of needle redirections for IJV puncture was less in the BPX group than in the SAX group (48 v 116). The incidence of complications was not significant between the 2 groups. CONCLUSION: The results suggested that the BPX view may be a safer, feasible and more reliable method than the SAX view for IJV cannulation in cardiac surgical patients.

Taming of the Tiger: A Novel Technique to Deal With Mitral Annular Calcification -A Case Series.

BACKGROUND: Mitral valve surgery can be challenging for patients with mitral annular calcification (MAC). The prevalence of MAC in patients who undergo mitral valve replacement is 19.9%. The  treatment options for MAC include complete decalcification and annular reconstruction with valve repair/replacement or performing a surgical valve repair or replacement without decalcification, accepting the risk of paravalvular leak. We describe three cases of mitral valve prolapse with posterior annular calcification, which were repaired using a unique technique that does not require decalcification. CASE REPORTS: The mitral annular calcification was heavy and involved most of the posterior annulus just sparing the commissures in all the three cases. Leaflet prolapse was dealt with by using neochordae, closing any clefts, and leaflet plication. Since the MAC ring was not complete and there was chance of further dilatation of the annulus, a partial annuloplasty was done using a PTFE felt (cut as strip). There was trivial to no mitral regurgitation with this technique in the immediate postoperative and five-year follow-up period echocardiography in all the three cases. CONCLUSION: This technique can benefit the major subset of pure mitral valve regurgitant lesions associated with MAC, which is limited to the posterior annulus.

Outcomes of Mitral Valve Replacement after Closed Mitral Valvotomy: A Retrospective Cohort Study.

BACKGROUND: The incidence of rheumatic fever and rheumatic heart disease still remains high in the developing countries. Mitral stenosis is predominantly due to rheumatic origin and affects females more than males. Historically, closed mitral valvotomy (CMV) was the first effective intervention for mitral stenosis. We studied the immediate and early surgical outcomes of MVR in patients with history of CMV to see whether their disease behaves differently, when compared with patients without prior CMV undergoing MVR. METHODS: This single center retrospective cohort study was conducted in Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Patients who underwent MVR from January 2008 to December 2012 at our institute were studied. The hospital records of 90 patients were analyzed both in the CMV cohort and also in the non-CMV cohort. Preoperative details, intraoperative parameters, immediate postsurgery echocardiography parameters, and follow-up echocardiography details at 1 year and 5 years were studied. RESULTS: Both the cohorts were similar in age, height, weight, and BSA. In the CMV cohort, 67% were females and in the non-CMV cohort 48% were females. Most of the patients in both the cohorts presented with functional classes 2 and 3. The mean duration between onset of symptoms and MVR in the CMV cohort and the non-CMV cohort was 24.6 years and 6.25 years, respectively. Fifty-nine patients in the CMV cohort had preoperative atrial fibrillation, whereas 47 patients in the non-CMV cohort presented with atrial fibrillation. The mean left atrial (LA) size of patients with sinus rhythm and atrial fibrillation was 46.34 (SE, 0.852) and 55.21(SE, 0.808), respectively. Preoperative echocardiographic assessment revealed a mean ejection fraction of 62% and 63%, mean mitral stenosis gradient of 13 mm Hg and 14.7 mm Hg, mean LA size of 53.2 mm and 50.5 mm, and mean right ventricular systolic pressure of 47.5 mm Hg and 43.6 mm Hg in the post-CMV cohort and in the non-CMV cohort, respectively. The CMV cohort had a longer cardiopulmonary bypass time (111.5 minutes) in comparison with the non-CMV cohort (97 minutes). The aortic cross-clamp time remained similar in both the cohorts. Thirty-six percent of the post-CMV cohort patients had a valve size of 25, and 48% of patients belonging to the non-CMV cohort had a valve size of 27. The percent of moderate-to-severe subvalvar pathology was 88 in both the cohorts. Patients belonging to the post-CMV cohort had a median ventilation time of 16.35 hours, and the patients of the non-CMV cohort had a median ventilation time of 13.75 hours. The duration of ICU stay was 4.41 (SE, 0.188) days and 4.13 (SE, 0.153) days, and length of hospital stay was 8.93 (SE, 0.230) days and 9.13 (SE, 0.313) days in the CMV and the non-CMV cohorts, respectively. Inotropic requirement, measured by the vasoactive inotropic score, was higher in the post-CMV group (11.9), when compared to the other cohort (9.7). Right ventricular (RV) function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference. CONCLUSION: The percentage of females in the CMV cohort is higher. Delaying the valve replacement by performing a surgical palliative procedure like CMV, is beneficial in female patients in the child-bearing age group so that they can complete the families. The disease process started earlier in the CMV cohort, and they had a longer duration of illness before undergoing MVR. Even with the longer duration of disease, the RV function, LA size, PA pressures, and mitral stenosis gradients were comparable. Therefore, CMV prevented progression of the disease in the CMV group. The mean LA size is significantly higher in patients with atrial fibrillation. The CMV cohort had a longer cardiopulmonary bypass time. The duration of ventilation, ICU stay, and hospital stay were similar in both cohorts. Inotrope requirement was higher in the post-CMV group. RV function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference.

Intraoperative Transesophageal and Postoperative Transthoracic Echocardiographic Evaluation of a Mechanical Heart Valve Prosthesis Implanted at Aortic Position.

OBJECTIVE: The aims of this study were to evaluate the intraoperative transesophageal echocardiographic (iTEE) characteristics and Doppler flow profile of aortic Chitra heart valve prosthesis (CHVP) under stable hemodynamic and loading conditions, and to compare and correlate the iTEE data with the postoperative transthoracic echocardiography (TTE) data obtained at 48 hours (TTE1) and 3 months (TTE2) after the surgery. DESIGN: Prospective, observational study. SETTING: University-level tertiary referral hospital. PARTICIPANTS: Forty patients between 18 years and 65 years of age undergoing elective aortic valve replacement (AVR) using CHVP during the period January 2015 to August 2016. INTERVENTIONS: After obtaining permission from institutional ethics committee, 40 patients undergoing elective AVR were studied prospectively. The iTEE examination was performed in the pre-cardiopulmonary bypass (CPB) and post-CPB period in all the study subjects. CHVP was subjected to iTEE two-dimensional (2D) echo, color Doppler, and spectral Doppler evaluation under stable hemodynamic and loading condition in the post-CPB period after the administration of protamine. The CHVP were re-evaluated using TTE in all the patients 48 hours after the surgery (TTE1) and 3 months after the surgery (TTE2). The iTEE and postoperative TTE Doppler values were compared and correlated. MEASUREMENTS AND MAIN RESULTS: The CHVP could be imaged adequately and interrogated with Doppler in all the patients. None of the patients had restriction of occluder mobility or unstable seating of the valve. The intraoperative flow dependent (peak velocity [PV] and mean pressure gradient [MPG]) and less flow dependent (Doppler velocity index, acceleration time, acceleration time/ejection time, effective orifice area [EOA] and indexed EOA) Doppler parameters of CHVP were measured as per the American Society of Echocardiography recommendations. The PV and MPG of CHVP measured by iTEE showed no statistical difference (p > 0.05) and were in limits of agreement when compared with TTE1 and TTE2 data. CONCLUSION: The iTEE features of CHVP were found compliant with the criteria set by the ASE defining normal functioning of an aortic valve prosthesis. The iTEE Doppler parameters obtained under stable loading conditions strongly predicted the postoperative values of Doppler parameters on TTE examination. The iTEE Doppler values can be used as the reference values for the postoperative follow up studies.

Factors predicting difficulty in insertion of real-time-three-dimensional transesophageal echocardiography probe in adult patients undergoing cardiac surgery.

Background: Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. Methods: A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick's maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients' predictive factors such as demographic characteristics and factors related to difficult intubation. Results: Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P-value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P-value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Conclusion: Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Ectopic atrial rhythm after superior septal approach to the mitral valve - an often under-reported entity.

Purpose: Very few reports elaborate on the changes in P wave following superior septal approach to the mitral valve. We aimed to describe the changes in the P wave axis and other electrocardiographic changes following this approach among patients preoperatively in sinus rhythm. Methods: We did a retrospective review of medical records among all our patients undergoing superior septal approach for mitral valve surgery from September 2014 to September 2019. Electrocardiograms during hospital stay and until 6-month follow-up were analyzed. A deviation in P wave axis from the normal range of + 30 to + 60° was classified as ectopic atrial rhythm. Results: In the study population of 47 patients (age 16-75 years, 51.3 ± 13.6 years; M:F ratio 3.7:1), who were in normal sinus rhythm preoperatively, 34 patients (72.3%) had a visible P wave on electrocardiogram (ECG) at discharge. Among them, the P wave axes of 17 patients (36.2%) were within normal range (normal sinus rhythm), whereas 17 patients (36.2%) had ectopic atrial rhythm at discharge. The most frequent abnormal P wave axis was between 0 and - 30° (12 patients). At 6 months, 8 patients (17.0%) had a persistent ectopic atrial rhythm. These patients underwent a Holter test at 6 months and were followed up for symptomatic bradycardia for 3 years. None of the patients with ectopic atrial rhythm required pacemaker insertion. Conclusion: Persistence of ectopic atrial rhythm at 6 months is common (17%) after superior septal approach. Documentation of P wave axis after this approach will help avoid missing it. These patients may be kept on follow-up to look for symptomatic bradycardia.

Preoperative mitral annulus size - Can we get it right?

Objective: We looked for a correlation between the surgically measured mitral valve size and the cardiac dimensions (left ventricle internal diameter, left atrial size, aorta size, and body surface area) measured by preoperative and intraoperative echocardiography. We also assessed to see if we could predict the mitral prosthesis size based on the correlation data obtained. Methods: The hospital records of 180 patients who underwent mitral valve replacement (MVR) with TTK Chitra valve between January 2008 and December 2012 at our hospital, were studied. The correlation between surgically measured mitral annulus size to left ventricular internal diameter systolic (LVIDS) and diastolic (LVIDD), left atrial size (linear measurement), and aorta size on echocardiography and body surface area was calculated using Pearson correlation coefficient. Mean LVIDS was calculated for each valve prosthesis size separately and the correlation was studied. Results: The correlation between mitral valve prosthesis size and left ventricular internal diameter (systolic) showed a Pearson coefficient of 3.3 with significance at the level 0.01. Mitral valve size and left atrial size showed a correlation coefficient of 2.7 with significance at the level 0.01. The correlation coefficient for mitral valve size with left ventricular internal diameter diastolic, aorta and body surface area were 2.5, 1.9, and 1.8, respectively. There was a gradual increase in the mean LVIDS with increase in the prosthetic valve size. Box plot and scatter plot showed linear correlation between valve size and mean LVIDS.

Flexible or rigid ring in mitral annuloplasty-do the results differ?

INTRODUCTION: Mitral valve annuloplasty has evolved over the decades since its introduction and Carpentier played a major role in developing the technique. Mitral valve repair is preferred over replacement for severe primary mitral regurgitation, as it restores normal life expectancy when successful and does not require lifelong anticoagulation. There is an ongoing debate regarding the choice of ring for mitral valve annuloplasty-rigid or flexible. At present, the choice of ring is based on the availability of the ring and left to the surgeon's discretion. METHODOLOGY: This is a retrospective study conducted at a tertiary referral centre. AIM: To compare the outcomes of mitral valve repair annuloplasty with flexible and rigid rings. The hospital records of 112 patients who underwent mitral valve annuloplasty between January 2010 and December 2014 at our hospital were studied. All patients were followed up for 5 years. The rigid and flexible groups were compared for left ventricular (LV) size regression and the presence of mitral regurgitation (MR). RESULTS: One hundred and eight patients had no progression of mitral regurgitation at 5-year follow-up, compared with the immediate postoperative period. The choice of the ring (rigid and flexible) did not affect the recurrence of mitral regurgitation. At 5-year follow-up, three patients (2 patients in the rigid group and 1 patient in the flexible group) had 3+ MR. One of the two patients in the rigid group had poor functional status and underwent mitral valve replacement (MVR). The other two patients (one in the rigid group and one in the flexible group) with 3+ MR had class II NYHA symptoms and were on medical follow-up. The left ventricular internal diameter diastolic (LVIDD) measured 59.1 mm in the flexible ring group and 56.76 mm in the rigid group preoperatively and these values reduced to 48.4 mm and 47.3 mm, at 5-year follow-up respectively. The mean left ventricular internal diameter systolic (LVIDS) size regression at 5 years was 4.5 ± 6.09 mm in the flexible ring group and 3.2 ± 7.17 mm in the rigid ring group and the difference is not statistically significant (p value 0.314). The mean LVIDD size regression at 5 years was 10.62 ± 6.57 mm in the flexible ring group and 9.38 ± 9.29 mm in the rigid ring group and the difference is not statistically significant (p value 0.408). CONCLUSION: The choice of rigid or flexible ring did not have a marked difference on the outcome of mitral valve annuloplasty at midterm follow-up.

Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients.

INTRODUCTION: Patient prosthesis mismatch is known to alter post-operative remodeling of left ventricle adversely in aortic stenosis patients. An indexed orifice area of 0.85 is considered as conventional cutoff for patient prosthesis mismatch based on hemodynamic principles. Many patients have smaller annulus and annulus enlargement techniques may be required to avoid this benchmark which complicates the surgery. AIMS AND OBJECTIVES: To determine incidence of patient prosthesis mismatch (PPM) in our population, to assess left ventricle (LV) regression and impact of indexed effective orifice area on LV regression, and to determine a minimum acceptable cut off indexed orifice area that will result in LV regression. MATERIALS AND METHODS: A single-center retrospective observational study of all patients who underwent aortic valve replacement surgery for severe aortic stenosis between July 2015 and December 2015 was conducted. Patients who underwent concomitant revascularization or other valve surgery were excluded. Data regarding conventional risk factors for PPM, valve type, and indexed orifice area as well as pre-operative and late post-operative LV mass were collected. OBSERVATIONS: Thirty-seven of the 91 patients satisfied inclusion criteria. All patients had significant regression in LV mass. The incidence of PPM was 68%. Regression of indexed left ventricular mass showed a positive correlation of with indexed effective orifice area of the prosthetic valve. The correlation coefficient is + 0.48 (95% CI 0.18-0.698). Left ventricular mass regression was significantly higher in patients with indexed effective orifice area more than 0.75 (68.89 ± 29 vs 122.55 ± 58.84, p = 0.028). Relative left ventricular regression also was significantly higher in patients with an indexed effective orifice area more than 0.75 (39.53 ± 13.13 vs 49.73 ± 15.56, p = 0.022). There is a positive correlation between left ventricular regression and the reduction in mean gradient achieved by valve replacement. The correlation coefficient was + 0.35 (95% CI 0.03-0.61). CONCLUSIONS: The incidence of PPM was found to be comparable to literature. There is a positive correlation between left ventricular regression and indexed effective orifice area of the prosthetic valve. Left ventricular regression was significantly higher in patients with an indexed effective area more than 0.75. This can be considered as criteria for significant PPM in study population.

Primary modified bentall's procedure in a case of Laubry-Pezzi syndrome.

Modified Bentall's procedure done as part of the primary repair in Laubry-Pezzi syndrome is very rarely described in the literature. We present a case of a 33-year-old man with a subpulmonic venticular septal defect, aneurysmal dilatation of the aortic root and ascending aorta, with an associated patent ductus arteriosus, corrected by the incorporation of Yacoub's techique for ventricular septal defect closure with a modified Bentall's procedure and transpulmonary patent ductus arteriosus ligation. The postoperative course was unremarkable. Early follow-up reports show good biventricular function without residual ventricular septal defect or iatrogenic ventricular outflow tract obstructions.

Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience.

Sinus of Valsalva aneurysm is a rare anomaly with a higher incidence in Eastern than Western populations. Recent improvements in diagnostic techniques have resulted in more patients undergoing surgical repair. Uncorrected, the intracardiac shunts and frequently associated cardiac lesions cause a preventable deterioration in heart function. We retrospectively analyzed the data of 33 patients who underwent repair of ruptured sinus of Valsalva aneurysm from May 2000 to January 2010. The aneurysms originated from the right coronary sinus in 24 patients and from the noncoronary sinus in 9, and ruptured into the right ventricle in 21, right atrium in 10, and left ventricle in 2. Operative procedures included simple plication (1), patch repair (32), and aortic valve replacement (10). There were 3 early deaths. The 30 survivors were followed up for 5.4 ± 2.6 years; all had an improvement in functional class, with superior results in those with no aortic regurgitation. Surgical treatment of ruptured sinus of Valsalva aneurysm has an acceptably low operative risk and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening symptoms and more extensive disease.

Surgical repair of double-chambered right ventricle in adulthood.

The aim of this study was to investigate a rare subset of adult patients with double-chambered right ventricle, pertaining to clinical presentation, rhythm disturbances, surgical approach, and results of surgical repair. A retrospective review of our records revealed that 14 adults had undergone surgical repair of double-chambered right ventricle from 1990 to 2010. Their median age was 25.5 years, and their median weight was 50 kg. Patients presented with various symptoms, the most common being dyspnea on exertion. The mean systolic pressure gradient across the obstruction was 69.8 ± 23.1mm Hg. The most common associated anomaly was ventricular septal defect. Significant rhythm disturbances were present in 4 patients. Transatrial repair was undertaken in 5 patients, a combined transatrial and transpulmonary approach was used in 4, and a right ventriculotomy in 5. There was no mortality at a median follow-up of 5.1 years. A mild right ventricular outflow tract gradient was noted in 2 patients. Medical management was required for rhythm disturbances in 2 patients. Double-chambered right ventricle can present in adulthood, often with vague symptoms. The midterm results of surgical correction are satisfactory. Long-term follow-up is necessary to detect late arrhythmias.

Intra-operative assessment of biventricular function using trans-esophageal echocardiography pre/post-pulmonary thromboembolectomy in patient with chronic thromboembolic pulmonary hypertension.

Postoperative studies in patients with chronic thromboembolic pulmonary hypertension (CTPH) have shown that pulmonary thromboembolectomy (PTE) results in a rapid decrease of right ventricular (RV) size, improvement in the RV systolic function and left ventricular (LV) diastolic function. However, the extent to which the biventricular function recovers immediately after embolectomy in post-cardiopulmonary bypass period is not clear. A 45-year-old male patient was operated for retrieval of thrombus from pulmonary trunk and right pulmonary artery. Intraoperative transesophageal echocardiography (TOE) before surgery revealed signs of RV dysfunction and enlargement. The interventricular septum was seen moving paradoxically during end-systole and early-diastole. E/A ratio on transmitral Doppler flow velocity profile was about 0.63 and S/D ratio on pulmonary venous Doppler profile was 2.25, indicative of LV diastolic dysfunction. After weaning the patient from bypass, navigation on TOE showed marginal recovery of the RV systolic function and abatement of septal paradox to some extent. However, significant improvement was observed in the LV diastolic parameter (normal E/A ratio, S/D ratio of 1.08). We conclude that the geometrically altered LV recovers more than the hypertrophied and hypokinetic RV in a patient with CTPH in the post-bypass period.