Tuesday, April 14, 2015

Rational Interpretation Of Tee Haemodynamics In The ICU

Case study

A 66 year old male underwent Tissue-AVR. Post op,he required high inotropic supportand high antibiotic support-- his heart rate was 120/min and blood pressure was 90/60mmHg. His TEE-ECHO report reveals-------


  • Thus the intelligent interpretation of non-invasively derived haemodynamic by TEE could be extremely useful in the appropriate diagnosis and management of critically ill patients.
  • The data derived from TEE should not be interpreted in isolation but must always be interpreted in context to the clinical scenario


Read Full Article at:  http://www.annals.in/article.asp?issn=0971-9784;year=2015;volume=18;issue=2;spage=225;epage=226;aulast=Kapur

Transcatheter, Valve-In-Valve Transapical Aortic And Mitral Valve Implantation, In A High Risk Patient With Aortic And Mitral Prosthetic Valve Stenosis

Intimo-intimal Intussusception (III) Teaching Points 

III is rare and is caused by circumferential detachment of the intima of the ascending or descending aorta, which then prolapses into the lumen of the aorta.

Complications caused by III can vary based on location of the intussusception.

III must be considered when a patient with suspected aortic dissection acutely develops cardiovascular and concomitant acute neurologic symptoms.

III might not be revealed on CT or MRI, based on anatomic location of the flap, intraoperative TEE exam might be the first and only method of diagnosis; aortography has been used in the limited literature available.

Patients with “ pseudocoarctation” symptoms in the setting of thoracic aneurysmal disease must be carefully assessed for III.

Intraoperative TEE may show the unique features of the intussusception, with a thick, undulating flap that may prolapse retrograde into the LVOT and back through the aortic valve as noted in this patient, coronary ostial occlusion is an associated complication.Antegrade prolapse of an ascending aortic III may lead to occlusion of the ostia as well as extension of dissection into the great vessels (innominate, left common carotid, left subclavian arteries).

Absence of a flap in the ascending aorta does not rule out III, the arch and descending aorta must be carefully imaged with TEE in multiple orthogonal planes.

Read Full Article at:  http://www.annals.in/article.asp?issn=0971-9784;year=2015;volume=18;issue=2;spage=246;epage=251;aulast=Ramakrishna

Single Lumen Tube As Endobronchialstent To Manage Left Bronchial Compression Post Total Anomalous Pulmonary Venous Connection Repair

Case History:

A 6-month-old female child presented to emergency department with respiratorydistress. On examination, the child was found to have tachycardia, tachypnea, subcostalretractions and peripheral oxygen saturation of 85% on oxygen (5 l/min) with no fever. On transthoracic echocardiography, a diagnosis of obstructed supracardiac total anomalous pulmonary venous connection (TAPVC) with atrial septal defect (ASD) and severe pulmonary artery hypertension was made. The child was managed for congestive heart failure and intubated and mechanically ventilated. On preoperative chest X-ray, a homogenous opacity was seen on the left side [Figure 1]. Therefore, endotracheal (ET) secretions were sent for culture, and empirical antibiotic therapy was started. On 3rdday Acinetobacterspp. was reported in the ET secretions and the child was treated with antibiotics for 5 days before being taken for surgery. A TAPVC repair was done by anastomosing the common chamber with the left atrium, ligating the vertical vein and closing the ASD. The child was stable in the immediate postoperative period with stable hemodynamics and arterial blood gases.


  • Bronchial stenosis should be considered in difficult to wean children with congenital heart disease.
  • Is short term stenting is useful in relieving bronchial stenosis after congenital heart surgeries?
  • Bronchial Stenosis can be repaired in a single setting with congenital heart surgery, with appropriate planning.
  • What is most appropriate line of management if tracheobronchial stenosis is diagnosed preoperatively? Can both stenting and corrective cardiac surgery be done in same setting?


Read Full Article at:  http://www.annals.in/article.asp?issn=0971-9784;year=2015;volume=18;issue=2;spage=217;epage=220;aulast=Singh

Is It Really Ruptured Sinus Of Valsava? The Crucial Role Of Comprehensive Transesophageal Echocardiography In Clinical Decision-Making

Case History:

A 49 years old NYHA grade III male patient presented with orthopnea and grade III dyspnea. His electrocardiogram showed left axis deviation and evidence of left ventricular hypertrophy. The chest X-ray except for cardiomegaly with left ventricular apex was inconclusive. Upon TTE patient was diagnosed with RSOVA draining into left ventricle. Cardiac catheterization and angiography further showed- normal coronaries, right coronary cusp (RCC) aneurysm with rupture into left ventricle causing severe regurgitation [Figure 1], normal left ventricle function, absence of any VSD, no gradient across left ventricle and aorta and Qp/Qs=1. Patient was scheduled for RSOVA repair with aortic valve repair / replacement.


  • TEE should be considered routine monitoring in Sinus of Valsalva aneurysm cases.
  • Transesophageal echocardiography is more useful when compared to transthoracic echocardiography in detecting: a) the fistula; b) the sinus involved; c) the right chamber affected; d) congenital aneurysms morphology and size; e) aneurysm prolapse through a ventricular septal defect, f) the identification of other cardiac congenital or acquired anomalies. (Rev Esp Cardiol 2002;55(1):29-36)
  • TTE can miss diagnosis of RSOV in about 10% cases. (International Journal of Cardiology ; 2014, 173:Pages 33–9)
  • Anatomical details available on TEE should be used to improvise on the surgical plans and strategies.


Read Full Article at:  http://www.annals.in/article.asp?issn=0971-9784;year=2015;volume=18;issue=2;spage=221;epage=224;aulast=Jain

A Novel Technique Of Anesthesia Induction In Supine Position With Impaled Knife In The Back

Case History:

A 35years old male presented with a knife in the back (Figure 1). Computerized tomography of chest was performed in prone position (Figure2), which revealed knife inside the right chest with partial collapse of lung and right hemopneumothorax.

Putting patient in supine position by simple and reproducible method by authors has distinct advantages:

  • After the patient was put on supine position, the anesthesia induction procedure can be routine.
  • In supine position rapid sequence induction can be done more effectively.
  • Even though authors have not used lung isolation, bronchial blockers in case of torrential bleeding can rapidly institute it.
  • Insertion of central venous lines and in case required arterial line could be inserted rapidly.
  • In case of need of resuscitation during induction, can be given effectively.
  • Table height should not be varied once fixed at the level of the trolley.
  • Team effort is the key to success.


This kind of out of the box thinking is life saving in emergency challenging clinical scenarios.

Read Full Article at:  http://www.annals.in/article.asp?issn=0971-9784;year=2015;volume=18;issue=2;spage=231;epage=233;aulast=Kumar

Welcome To ACA Blog

Welcome to the Annals of Cardiac Anaesthesia Blog (Padharo Mhare Blog). The ACA Blog is created for Heart to Heart Blog (Interesting Images) at http://blog.annals.in. The idea of having a blog linked to the journal is to have an interactive forum with the readers wherein the editorial board members and the Annals of Cardiac Anaesthesia readers can exchange ideas and better their practice. It would be nice if these articles initiate a serious exercise of introspection on how to achieve the best images in different clinical situations and eventually lead to new directions in which the cardiac anaesthesia community will surge ahead in the years to come. This ACA is a journal by all for all – kindly contribute in enhancing scientific publishing in cardiac anaestheaia.

Poonam Malhotra Kapoor
Chief – Editor
Annals of Cardiac Anaesthesia