Comparative Study of 0.5% Bupivacaine, 0.5% Ropivacaine, and 0.75% Ropivacaine With Fentanyl as a Continuous Intraoperative Epidural Infusion on Post-operative Analgesia.

Introduction Persistent postoperative pain leads to impaired patient recovery and delays in discharge of patients. The aim was to compare the efficacy of 0.5% bupivacaine to two varying concentrations of ropivacaine, specifically 0.5% and 0.75%, along with fentanyl as a continuous epidural infusion in providing adequate pain relief for patients subjected to infraumbilical surgeries. Materials and methods A prospective randomized comparative study was carried out on 150 patients and was divided into three groups, namely group B, group R, and group RP. Group B indicates (0.5% bupivacaine), group R means (0.5% ropivacaine), and finally, group RP means (0.75% ropivacaine); the three groups had 50 patients each. Group B was administered an epidural infusion of bupivacaine at a concentration of 0.5%, group R was given 0.5% ropivacaine, and group RP was treated with 0.75% ropivacaine; all three groups included 40 mcg fentanyl. The duration of the motor and sensory blockade and the time needed for the first rescue analgesia after the stoppage of epidural infusion were assessed in all three groups. The data were statistically analyzed using the ANOVA, "post hoc Tukey," and chi-square tests. Results Comparison of the duration of motor and sensory blockade among all three groups showed that group RP (0.75% ropivacaine with 2 mcg/cc fentanyl) had the longest duration of 328.8 and 406 minutes, and the difference was statistically significant (p < 0.001). Comparison of the time of stoppage of epidural infusion to the requirement of first rescue analgesia showed that the group that received 0.75% ropivacaine with 40 mcg fentanyl had the highest value of 258.6 minutes and was statistically significant (p < 0.001). Conclusion Epidural intraoperative infusion of 0.75% ropivacaine with fentanyl offers better postoperative pain relief as compared to both 0.5% bupivacaine and 0.5% ropivacaine with fentanyl.

A case report of left circumflex stent infection and mycotic aneurysm: a rare but life-threatening complication of percutaneous coronary intervention.

BACKGROUND: Coronary stent infections are an uncommon but deadly complication of percutaneous coronary intervention. Mortality remains as high as 40-60% even with adequate treatment. We report such an interesting case of left circumflex stent (LCX) infection and mycotic aneurysm that was successfully managed with antibiotics and surgery. CASE PRESENTATION: A middle-aged man who underwent percutaneous coronary intervention (PCI) to the left circumflex artery four weeks prior was referred as a case of pyrexia of unknown origin, not responding to antibiotics, and colchicine started for suspected Dressler syndrome. Although the inflammatory markers were elevated, the results of the blood culture did not show any growth. Echocardiography showed a doubtful echogenic structure in the left atrioventricular groove and mild pericardial effusion, and a stent infection was suspected. PET scan showed focal metabolic activity in the region of the LCX stent, with metabolically active supraclavicular and paratracheal lymph nodes, and a coronary angiogram revealed an aneurysm arising distal to the stented LCX. A diagnosis of stent infection and associated mycotic aneurysm was made, and the patient underwent surgery which included aneurysm repair, stent retrieval, and coronary artery bypass graft (CABG) to the major and terminal OM. The postoperative course was uneventful, and the patient was discharged without complications. CONCLUSIONS: It is important to investigate the possibility of coronary stent infection in individuals experiencing prolonged fever following PCI. PET scans and coronary angiograms can aid in diagnosis when echocardiograms are inconclusive. Adequate antibiotic therapy and timely surgery are crucial for successfully managing coronary stent infections.

Atrial septal defect occluder device embolization: Experience of a tertiary care cardiac center.

Background: Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life-threatening complications such as device embolization. Objective: To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Settings and Design: A retrospective study was performed at a tertiary referral center for cardiac services. Material and Methods: Pre-procedure, intra-procedure, and post-procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re-exploration for bleeding, while another had an air embolism and succumbed. Conclusions: Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Distinguishing Competing Mechanistic Manifolds for C(acyl)-N Functionalization by a Ni/N-Heterocyclic Carbene Catalyst System.

Carboxylic acid derivatives are appealing alternatives to organohalides as cross-coupling electrophiles for fine chemical synthesis due to their prevalence in biomass and bioactive small molecules as well as their ease of preparation and handling. Within this family, carboxamides comprise a versatile electrophile class for nickel-catalyzed coupling with carbon and heteroatom nucleophiles. However, even state-of-the-art C(acyl)-N functionalization and cross-coupling reactions typically require high catalyst loadings and specific substitution patterns. These challenges have proven difficult to overcome, in large part due to limited experimental mechanistic insight. In this work, we describe a detailed mechanistic case study of acylative coupling reactions catalyzed by the commonly employed Ni/SIPr catalyst system (SIPr = 1,3-bis(2,6-di-isopropylphenyl)-4,5-dihydroimidazol-2-ylidine). Stoichiometric organometallic studies, in situ spectroscopic measurements, and crossover experiments demonstrate the accessibility of Ni(0), Ni(I), and Ni(II) resting states. Although in situ precatalyst activation limits reaction efficiency, the low concentrations of active, SIPr-supported Ni(0) select for electrophile-first (closed-shell) over competing nucleophile-first (open-shell) mechanistic manifolds. We anticipate that the experimental insights into the nature and controlling features of these distinct pathways will accelerate rational improvements to cross-coupling methodologies involving pervasive carboxamide substrate motifs.

Left ventricular mass regression after aortic valve replacement with the TTK Chitra™ monoleaflet tilting disc valve.

Objective: To study the extent of left ventricular (LV) mass regression in aortic stenosis after aortic valve replacement with the TTK Chitra™ tilting disc valve. Methods and materials: This study included patients with severe isolated aortic stenosis (AS), admitted in our department. They had aortic valve replacement (AVR) with the TTK Chitra™ tilting disc valve, between January 2008 and December 2010. Data were collected from consecutive forty-eight patients. LV mass and diametric and functional parameters were recorded preoperatively and compared with echocardiography after 3 months, 6 months, then yearly, up to 3 years. Results: 70.8% of the patients were males and 29.2% were females. The mean duration of illness was 37.92 ± 25.87 months. The mean LV ejection fraction increased 3 months after surgery (61.56 ± 10.10% to 69.31 ± 9.34%) with a sustained increase for the next 3 years. The mean LV end-diastolic diameter decreased (50.16 ± 6.05 mm to 45.69 ± 5.93 mm) after 3 months of surgery, with a sustained decrease for the next 3 years. The mean LV end-systolic diameter decreased (32.84 ± 6.96 mm to 29.41 ± 5.86 mm) after 3 months of surgery and then showed a sustained decrease for the next 3 years. The LV mass assessed with echocardiography regressed from 324.65 ± 97.77 g before surgery to 252.64 ± 71.12 g after 3 months and then showed a sustained decrease over the next 3 years. Conclusion: Significant LV mass regression occurred after AVR with the TTK Chitra™ valve. The maximum reversal was found to be within the first 3 months after surgery with sustained beneficial improvement for the next 3 years.

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.

Clinical outcomes of bileaflet St. Jude Medical and tilting disc TTK Chitra mechanical heart valve prosthesis: A comparative study.

BACKGROUND: Comparative data on the clinical outcomes of TTK Chitra mechanical heart valve prosthesis (CHVP), an indigenously developed low-cost tilting disc valve and commonly used bileaflet valve, the St. Jude medical (SJM) prosthesis are sparse. METHODS: We conducted a retrospective follow-up study of consecutive patients undergoing mitral (MVR) and aortic valve replacement (AVR) with SJM or CHVP mechanical prostheses over a 6-year period at our institution. RESULTS: Seven hundred and thirty-five patients who underwent isolated MVR (n = 510) or AVR (n = 225) were included in the study. Patients with CHVP were younger and belonged to a lower socioeconomic class. The study cohort was followed-up for 2836 patient-years (SJM: 1865.1, CHVP: 971.0). All-cause mortality (p = 0.894), valve-related mortality (p = 0.681), prosthetic valve thrombosis (p = 0.155), embolism (p = 0.210), hemorrhage (p = 0.959) and infective endocarditis (IE, p = 0.084) were similar between both valve on follow-up. Estimated event free survival was 2302 ± 1 days in SJM as compared to 2484 ± 65 days in CHVP group (p = 0.393). Valve type was not an independent predictor of adverse events after adjusting for baseline data, time in therapeutic range and aspirin use. Subgroup analysis of patients who underwent MVR and AVR showed similar functional improvement and outcomes, except for a higher incidence of IE with SJM at the aortic position (p = 0.041). CONCLUSION: The indigenously developed, low-cost CHVP has comparable midterm clinical performance as SJM in aortic or mitral positions.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection

Abstract Introduction: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. Methods: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. Results: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. Conclusion: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection.

INTRODUCTION: Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients. METHODS: Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up. RESULTS: Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively. CONCLUSION: SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Clinical Profile of Prosthetic Valve Endocarditis due to Candida parapsilosis: An 11-year Retrospective Observational Study from a Quaternary Cardiac Referral Institute in India.

Background: Recent changes in the diagnostic criteria and the introduction of newer technologies like prosthetic valve replacement require the need to identify the changing epidemiology of prosthetic valve endocarditis (PVE). Materials and methods: This is a retrospective, cross-sectional, observational study. Patients diagnosed with Candida parapsilosis definite and possible PVE as per modified Duke's criteria for a period of 11 years from January 2010 to December 2020 were included for the analysis. Results: Twelve of the 47 PVE cases (25.5%) were caused by C. parapsilosis. The median age of the patients was 52 years. Males were predominantly affected (58%). Based on the modified Duke's criteria, eight (67%) were definite infective endocarditis (IE) cases. The single valve was affected in 11 cases (92%) with the mitral valve being the commonest (n = 8, 67%). The type of valve commonly involved was mechanical [n = 10, 83%]. The mean size of the vegetation was 13.15 mm. Most cases (n = 7, 58%) were late-onset PVE. The mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) levels for C. parapsilosis PVE were 70.2 mg/L, 51.08 mm/hour, and 0.3 ng/mL, respectively. The rates of complications and in-hospital mortality were 75% each. The most common observed complication was embolic events (n = 8, 67%). Statistical significance (p ≤ 0.05) was observed for mean vegetation size, overall complications, embolic events, and mortality for C. parapsilosis PVE when compared with bacterial PVE. Conclusion: C. parapsilosis was the commonest etiological agent causing PVE. Predominant mitral valve involvement, higher rates of late-onset presentation, complications, and mortality were key differential characteristics observed. Highlights: The manuscript throws light on the changing epidemiology, clinical, and microbiological profile of PVE due to Candida sp., which are scarcely studied and reported in low- and middle-income countries like India. How to cite this article: Ponnambath DK, Gopalakrishnan A, Pillai VV, Kaviyil JE, Raja K. Clinical Profile of Prosthetic Valve Endocarditis due to Candida parapsilosis: An 11-year Retrospective Observational Study from a Quaternary Cardiac Referral Institute in India. Indian J Crit Care Med 2021;25(8):860-865.

Intracardiac extension of intravenous leiomyomatosis in a patient with vascular pelvic tumor and prior hysterectomy: A case report.

Uterine leiomyoma (UL) is the most common benign smooth muscle tumour of the premenopausal women. Rarely it shows malignant behaviour by metastasizing through the pelvic veins into systemic veins, inferior vena cava (IVC), there it is termed as intravenous leiomyomatosis (IVL). IVL may restrict itself within the IVC or it may extend into right heart chambers reaching up to pulmonary arteries. Here we report a case of single staged excision of intracardiac(IC) extension of IVL of a 45 -year -old premenopausal women, who have undergone abdominal hysterectomy five years ago, with the complaints of shortness of breath aggravated on bending forward for the past two years.

Computed tomography validated right ventricular mid-septal lead implantation using right ventricular angiography.

BACKGROUND: Right ventricular (RV) mid-septal pacing has been proposed as an alternative to RV apical pacing. Fluoroscopic and electrocardiogram criteria are unreliable for predicting the RV mid-septal lead position. This study aimed to define the optimal RV mid-septal pacing site using RV angiography. METHODS: We randomized patients undergoing pacemaker implantation (PPM) to the RV angiography-guided group (Group A) or conventional fluoroscopy-guided group (Group F). In Group A, we performed an angiogram in right anterior oblique (RAO 30°), left anterior oblique (LAO 40°), and left lateral (LL) views. We made a 5-segment grid in RAO 30° and LL views and a 3-segment grid in LAO 40° on the angiographic silhouette to define the lead position. Computed tomography (CT) was used to validate the lead tip position in both groups. RESULTS: We enrolled 53 patients (Group A: 26, Group F: 27) with a mean age of 55.9 ± 12.2 years. CT images validated the lead position in the mid-septum (Group A, 23 [88.5%]; Group F, 11 [40.7%], P = .0003) and anteroseptal (Group A, 3 [11.5%]; Group F, 5 [18.5%], P = .24). In Group F, the lead was in the anterior wall in 9 patients (33.3%) and the right ventricular outflow tract in 2 (7.4%) patients and none in these two positions in Group A. The lead tip in segment one on the angiographic 5-segment grid in RAO 30° and LL views indicated a mid-septal lead position on CT. CONCLUSIONS: RV angiography is safe and may be used to confirm the mid-septal lead position during PPM.

Comparison of multiple risk scores in assessing medium-to long-term clinical outcomes in unstable angina / non-ST-elevation myocardial infarction patients undergoing multi vessel percutaneous coronary intervention: An observational, registry-based study in India.

OBJECTIVE: Post-revascularization mortality in multivessel coronary artery disease (MVCAD) has been explored via several risk scores. Here, we assessed and compared various risk scores in predicting medium to long-term clinical outcomes in unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients with MVCAD undergoing percutaneous coronary intervention (PCI). METHODS: We analyzed a cohort of a tertiary care center registry enrolling patients in South India, Kerala, with MVCAD (N = 200) who had undergone PCI between 2010 and 2018. The outcomes evaluated were all-cause mortality and major adverse cardiac events (MACE). The risk scores assessed included SYNTAX score (SS), residual SYNTAX score (rSS), SYNTAX revascularization index (SRI), age, creatinine, and ejection fraction (ACEF) score, clinical SYNTAX score (cSS), and SYNTAX score II (SSII). RESULTS: Of the analyzed risk scores, SSII had the best predictive capability with the area under the curve (AUC) of 0.79 in c-statistics, followed by ACEF score and cSS with AUCs of 0.74 and 0.65, respectively for all-cause mortality (p < 0.01). Kaplan-Meier survival curves and multivariate analysis by Cox regression showed SSII with cut-offs of >35.15 and > 29.55 to be the only score associated with higher mortality and MACE, respectively. CONCLUSIONS: In UA/NSTEMI patients with relatively less complex MVCAD treated by PCI, the SSII, ACEF and cSS risk scores could predict the outcomes better. The SSII showed the best predictive performance for all-cause mortality and MACE. Scores based on baseline and residual atherosclerotic burden (SS, rSS, and SRI) performed poorly in predicting the mortality and MACE.

Preoperative screening for obstructive sleep apnea in cardiovascular patients - How useful is STOP-BANG questionnaire in the Indian context?

Background: Obstructive sleep apnea (OSA) is reported in a high proportion of cardiac surgical patients, up to 73%. STOP-BANG is a validated questionnaire for screening of outpatients for OSA with high sensitivity. There is sparse literature from India regarding the prevalence of OSA in preoperative cardiovascular patients and the utility of screening tools. Aims: We sought to study the utility of the STOP-BANG questionnaire as a screening tool for OSA in cardiovascular patients validating it with ambulatory level 3 polysomnography. Materials and Methods: It was a prospective study where consecutive patients getting admitted for coronary artery bypass surgery (CABG) from August 2017-February 2019 were recruited. All the patients were screened with the STOP-BANG questionnaire. 53 patients underwent overnight level 3 polysomnography using Apnea-Link. Correlations were made between clinical symptoms, STOP-BANG score, and OSA severity, measured using Apnea hypopnea index (AHI). Results: We had 120 patients(103 males) with a mean age 60 years. Snoring was the most common sleep complaint. Our cohort had a high prevalence of vascular risk factors (DM 72.3%, hypertension 59.2%, dyslipidemia 60%) and 11.7% were obese (BMI >30). The median STOP-BANG score was 3 (IQR 2) with 83 having scores ≥3. Median AHI was 5.6 with AHI ≥5 in 28 patients and AHI 15 or above in 14 patients. Among the clinical parameters, arousals with respiratory difficulty at night, higher neck circumference, and tonsillar hypertrophy showed a significant association with PSG-proven OSA.STOP-BANG scores 3 or above had a sensitivity of 75% in predicting OSA. Conclusions: Our study shows that in cardiovascular patients less symptomatic for sleep complaints, the STOP-BANG questionnaire is a useful screening tool for OSA in outpatient settings. Among clinical parameters, airway narrowing and neck circumference can predict OSA.

Pericardial pseudocyst along atrioventricular groove.

Cystic lesions in relation to the pericardium are a rare congenital lesion with an estimated incidence of 1 per 100,,000. Pericardial cysts may be classified as congenital or acquired. Here, we present a case of a pericardial pseudocyst having a horseshoe configuration along the atrioventricular groove in a middle-aged subject with no previous relevant medical history. The patient underwent open surgery for the same with histopathological diagnosis being established. This paper highlights the differentials for a cystic pericardial lesion in imaging in addition to the histopathological entity of a pericardial pseudocyst.

Intraoperative comparison of 2D versus 3D transesophageal echocardiography for quantitative assessment of mitral regurgitation.

Background: Effective regurgitant orifice area (EROA) can be represented by 3D echocardiographic vena contracta cross-sectional area (3D-VCA) as a reference method for the quantification of mitral regurgitation (MR) without making any geometrical assumptions. EROA can also be derived from 3D PISA technique with a hemispherical (HS) or hemielliptical (HE) assumption of the proximal flow convergence. However, it is not clear whether HS-PISA and HE-PISA has better agreement with 3D-VCA. Aims: This study was conducted to compare the EROA and Rvol obtained from 3D-VCA with those obtained from 2D-VC, 2D-HS-PISA, 3D-HS-PISA, and 3D-HE-PISA. Setting: Tertiary care hospital. Design: Prospective observational study. Materials and Methods: After anesthesia induction, 43 consecutive patients were evaluated with RT-3D-TEE after acquiring images from midesophegeal views and performing the offline analysis of volume dataset. 3D-VCA was measured using multiplanar reconstruction mode and EROA and regurgitant volume were estimated using HS-PISA and HE-PISA methods. The HE-PISA was calculated by using the Knud Thomsen formula. Statistical Analysis: Agreement between methods to estimate EROA and regurgitant volumes were tested using Bland-Altman analysis. The interobserver variability and intraobserver variability were assessed using an intraclass correlation coefficient. Results: The EROA estimated by 3D-VCA was larger than EROA obtained by 2D-HS-PISA and 3D-HS-PISA, which were significantly greater than 3D-HE-PISA. 3D-HS-PISA-EROA showed the best agreement with 3D-VCA (bias: 0.21; limits of agreement: -0.01 to 0.41; SD: 0.1). Correlation between various methods as compared to 3D-VCA was better in the organic MR group than functional MR group. Conclusion: 3D-HS-PISA showed the best agreement with 3D-VCA compared to other PISA methods. Better correlation between PISA-EROA and 3D-VCA was observed in patients with organic MR than functional MR.

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study.

OBJECTIVES: The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods. DESIGN: A prospective observational study. SETTING: A tertiary referral center and a university level teaching hospital. PARTICIPANTS: The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions. MEASUREMENTS AND MAIN RESULTS: Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71). CONCLUSIONS: Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Extracardiac Intrapericardial Mass Impersonating as Left Atrial Mass: Echocardiographic Perspectives.

Extracardiac intrapericardial masses arising posterior to left atrium (LA) often mimic an intracardiac LA mass on echocardiography. Although transthoracic echocardiography (TTE) is the primary screening tool to detect any cardiac mass, transesophageal echocardiography (TEE) is proven superior to TTE in delineating the size, morphology, and exact site of origin of LA masses. We report a case, where the preoperative TTE diagnosed an LA mass which was later confirmed to be an extracardiac intrapericardial mass by cardiac magnetic resonance imaging and intraoperative TEE. The mass was compressing the LA, and the timely diagnosis avoided the opening of the LA for mass excision.