Feasibility and Utility of Adenosine Stress Echocardiography in Children Following Post-Arterial Switch Operation: A Comparison with Technetium 99m-Sestamibi Myocardial Perfusion SPECT (MPS).

There is a need for a sensitive, safe, and cost-effective tool for coronary assessment among asymptomatic post-operative children who have undergone arterial switch operation (ASO) for transposition of great arteries (TGA). Adenosine stress echocardiography may be useful in assessing major structures as well for coronary functional assessment. Twenty-six children [median age 6.0 years; IQR 4.9-7.1 years, (22 boys)], who had undergone ASO at a median age of 40 days (IQR 30-75 days), were prospectively included. Left ventricular ejection fraction (LVEF) was calculated in both rest and stress studies (140 µg/kg/min of adenosine IV over 4 min), along with assessment of regional myocardial wall motion. Coronary flow reserve (CFR) was also measured in the left anterior descending artery (LAD). Technetium 99m-MIBI [0.2mCi/kg] was injected after 2 min of adenosine infusion. Adenosine infusion had to be stopped in two children, due to transient atrioventricular (AV) block. The LVEF increased from 55.87 ± 7.27 to 61.20 ± 7.70% (p < 0.001) with adenosine stress. No significant regional wall motion abnormality was seen in rest or stress. Distal LAD could not be visualized in four patients. Basal and peak coronary flow velocities were 41.51 ± 14.12 and 74.18 ± 6.01 cm/s. Mean CFR was 1.91 ± 0.51. Myocardial perfusion scintigraphy (MPS) was normal in all the patients. Four patients were lost to follow-up and remaining children did not develop any adverse events in the follow-up period of 64.5 ± 7.19 months. Adenosine stress echocardiography is feasible as the initial screening test in the assessment of asymptomatic post-operative children with ASO, at minimal to no inconvenience to the patient. The findings concurred with stress MPS.

Benevolent Renal Angiomyolipoma with Intra-cardiac Extension-A Challenge in Diagnosis and Management.

While intra-caval and intra-cardiac extension of retroperitoneal tumors is extremely rare, it is almost unheard-of in benign tumors. We report the challenges in diagnosis and management of the first case of a renal angiomyolipoma (AML) with intra-ventricular extension in a young man who presented with pain and a lump in the abdomen.

Prevalence of carotid artery stenosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting for coronary artery disease: Role of anesthesiologist in preoperative assessment and intraoperative management.

OBJECTIVE(S): This study aimed to determine the prevalence of carotid artery stenosis (CAS) due to atherosclerosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD). It contemplated a greater role for the cardiac anesthesiologist in the perioperative management of such patients with either previously undiagnosed carotid artery disease or towards re-assessment of severity of CAS. DESIGN: Prospective, observational clinical study. SETTING: Operation room of a cardiac surgery centre of a tertiary teaching hospital. PARTICIPANTS: A hundred adult patients with New York Heart Association (NYHA) classification I to III presenting electively for CABG. INTERVENTIONS: All patients included in this study were subjected to ultrasonic examination by means of acarotid doppler scan to access for presence of CAS just prior to induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: Based on parameters measured using carotid doppler, the presence of CAS was defined using standard criteria. The prevalence of CAS was found to be as high as 38% amongst the patients included in our study. The risk factors for CAS were identified to be advanced age, history of smoking, diabetes mellitus, dyslipidaemia and presence of a carotid bruit. CONCLUSION: This study points towards the relatively wide prevalence of carotid artery disease in neurologically asymptomatic patients undergoing CABG for CAD in the elective setting. It highlights the need to routinely incorporate carotid ultrasonography in the armamentarium of the cardiac anesthesiologist as standard of care for all patients presenting for CABG.

Lactate clearance for initiating and weaning off extracorporeal membrane oxygenation in a child with regressed left ventricle after arterial switch operation.

We hereby report a child with transposition of great arteries and regressed ventricle who underwent arterial switch operation (ASO) with the aid of cardiopulmonary bypass and "integrated" extracorporeal membrane oxygenation (ECMO) circuit. The significance of lactate clearance as a guide to initiate and terminate veno-arterial ECMO in a post ASO child with regressed left ventricle is discussed.

Use of dexmedetomidine as an adjunct in the treatment of paradoxical hypertension after surgical repair of coarctation of the aorta in infants.

Severe persistent hypertension is seen infrequently in newborns and infants, but we came across two infants who developed severe paradoxical hypertension after successful coarctation repair. Treatment of systemic hypertension following repair of coarctation of the aorta is always challenging particularly in infants. Dexmedetomidine was used successfully as an adjunct to the established anti-hypertensive drugs in the immediate postoperative period in our cases to treat postoperative paradoxical hypertension.

Extra corporeal membrane oxygenation after pediatric cardiac surgery: a 10 year experience.

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author's institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.

An unusual case of dissecting aneurysms involving both coronary sinuses of valsalva.

A 16-year-old boy with a progressive history of dyspnea and palpitations was diagnosed to have rupture of the right and left coronary sinuses on transthoracic echocardiography. The right coronary sinus had ruptured and dissected into the interventricular septum from its base up to the left ventricular apex and all around the lateral wall of the left ventricle up to the base of the papillary muscles. The left coronary sinus was also ruptured, and the rupture was contained by a false aneurysm that dissected into the roof of the left atrium from the aortomitral intervalvular fibrosa. The involvement of multiple coronary sinuses is extremely rare.

Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery.

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy offentanyl and sufentanil in controlling pain due to chest tube removal. One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 microg/Kg fentanyl IV or 0.2 microg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals. Mean pain intensity scores 10 minutes before removal of chest tubes infentanyl, sufentanil and control groups were 23.88+/-5.2, 25.10+/-5.39 and 23.64+/-6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11+/-6.9 (p<0.05) in the fentanyl group and 13.60+/-6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97+/-8.39 (p

Subaortic membrane excision: mid-term results.

BACKGROUND: Subaortic membrane (SAM) is a form of fixed subaortic obstruction in which a fibrous membrane is located below the aortic valve. AIM: To determine the role of surgical treatment for patients with a discrete SAM. PATIENTS AND METHODS: The hospital records of 45 patients (age range: 2-23 years; median 8 years) undergoing surgery for SAM between 1990 and 1998 at the All India Institute of Medical Sciences, New Delhi, India, were analysed. Preoperative echocardiographically calculated gradients across the left ventricular outflow tract ranged from 50 to 154 mmHg (mean: 86.5 +/- 33.2 mmHg). Nine patients had trivial aortic regurgitation (AR), 10 had mild AR and five had moderate-severe AR. The left ventricular ejection fraction (LVEF) ranged from 20 to 68% (mean 48 +/- 15%). Nineteen patients had significant left ventricular dysfunction (LVEF <50%). Transaortic resection of SAM was done in all patients along with excision of a wedge-shaped segment of septal muscle underlying the membrane. RESULTS: There were no early or late postoperative deaths. On follow up (up to 113 months), only four patients had gradients >30 mmHg. LVEF improved to 45-70% (mean 58 +/- 7.7%). AR reduced to mild in four patients and trivial in four patients, and did not progress further. CONCLUSION: Resection of SAM carries long-term benefits. Routine septal myectomy appears to be associated with a low risk of recurrence.

Epsilon aminocaproic acid in paediatric cardiac surgery to reduce postoperative blood loss.

We have studied the efficacy of epsilon aminocaproic acid in reducing postoperative blood loss in infants and children with congenital cyanotic cardiac anomalies undergoing corrective operative procedures. This prospective study was carried out on 170 infants and children randomly divided into two equal groups. Group A acted as the control group and received normal saline as placebo while group B patients received epsilon aminocaproic acid (100 mg/kg body wt) intravenously slowly soon after anaesthetic induction followed by 100 mg/kg in the cardiopulmonary bypass pump at the time of starting of cardiopulmonary bypass and 100 mg/kg after weaning from bypass over a period of 3 h. In group A the time for sternal closure after separation from bypass and administration of protamine was 75.18 +/- 5.5 min and in group B 50.7 +/- 5.2, (P < 0.001). Blood loss at 24 h in group A was 42.6 +/- 6.9 ml/kg/24 h and in group B 23.7 +/- 5.8 ml/kg/24 h, (P < 0.001). The need for packed red cells in group A was 21.8 +/- 7.1 ml/kg/24 h and in group B 10.7 +/- 7.8 ml/kg/24 h, (P < 0.001). The need for platelet concentrate in group A was 22.0 +/- 6.7 ml/kg/24 h and group B 6.2 +/- 3.2 ml/kg/24 h, (P < 0.001). Fibrin degradation products (split) in group A was 8.2 +/- 0.8 micrograms/ml, and group B 3.8 +/- 1.3 micrograms/ml, (P < 0.001). Reexploration rate was also considerably reduced in group B, 5 of 85 (6%) compared to group A, 13 of 85 (15%), (P < 0.001). It was found that epsilon aminocaproic acid is effective in reducing postoperative blood loss, packed red cells and plasma product requirements in paediatric patients undergoing corrective surgical procedures for congenital cyanotic heart diseases.