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.

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.

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.

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.

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.