Annals of Cardiac Anaesthesia
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Item Evaluation of Perioperative Major Adverse Cardiac Events in Patients with Coronary Artery Disease Undergoing Carotid Endarterectomy(Wolters Kluwer – Medknow, 2025-09) Nayanar, V Krishna Narayanan; Prakashbabu, U Abinaya; Babu, MS Saravana; Sukesan, Subin; Koniparambil, P Unnikrishnan; Dash, Prasanta K.Background: Major adverse cardiac events (MACE) are the leading cause of morbidity and mortality during carotid endarterectomy (CEA). The primary outcome of the study was to assess the incidence of perioperative MACE and non?MACE in patients with coronary artery disease (CAD) undergoing CEA. The secondary objectives were to analyze the incidence of MACE and non?MACE based on various perioperative risk factors. Methods: This retrospective study included patients with CAD who underwent CEA for carotid artery disease from July 2013 to June 2023. We analyzed the incidence of perioperative MACE and non-MACE and its association with revised cardiac risk index (RCRI) score, previous coronary revascularization, beta?blocker therapy, previous myocardial infarction (MI), the time interval from stroke to CEA, and multivessel CAD. Results: Medical records of 101 patients were studied. The incidence rates of perioperative MACE and non?MACE were around 18.8% and 15.8%, respectively. A preoperative coronary revascularized patient to develop patient’s odds of developing a MACE(OR: 0.184, CI: 0.0398–0.8497) and non-MACE (OR: 0.051, CI: 0.0132–8.331) were lower than a non-revascularized patient. There were no significant differences in the incidence of perioperative MACE and non?MACE concerning RCRI score, beta?blocker therapy, previous MI, varying time intervals from stroke to surgery, and severity of CAD. Conclusion: There was a higher incidence of perioperative MACE and non?MACE in patients with CAD undergoing CEA. Preoperative coronary revascularization reduced the incidence of perioperative cardiovascular events in these subsets of patients.Item Intraoperative Course of Left Ventricular Diastolic Strain in Surgical Valve Replacement for Severe Aortic Valve Stenosis(Wolters Kluwer – Medknow, 2025-09) Seuthe, Katharina; Gerwin, Eva; Rahmanian, Parwis; Böttiger, Bernd W.; Borde, Deepak; Labus, JakobPurpose: Assessment of LV diastolic dysfunction (LVDD) poses challenges due to the dynamic changes of loading conditions in the perioperative course. Diastolic strain-based measures showed to be less load dependent, but data in aortic valve replacement (AVR) surgery remains sparse to date. Therefore, we aimed to explore the feasibility to assess these measurements and to describe the intraoperative course in this patient population. Methods: Prospective observational study including 30 adult patients. Intraoperative transesophageal echocardiography (TEE) was performed after induction of anesthesia [T1], after termination of cardiopulmonary bypass [T2], and after sternal closure [T3]. TEE assessment included the evaluation of peak longitudinal strain rate during isovolumetric relaxation (SR-IVR), early (SR-E) and late (SR-A) LV filling, as well as of conventional echocardiographic measurements and LVDD grading algorithms. Results: Diastolic strain analysis was feasible in 27 (90%) AVR patients at all time points of assessment. LV diastolic strain improved significantly after AVR [T1 vs T3] as measured by SR-IVR (0.31 s?1 (IQR 0.22; 0.38) vs. 0.4 s?1 (IQR 0.33; 0.43); P = 0.01), SR?E (1.13 s?1 (IQR 0.89;1.28) vs. 1.35 s?1 (IQR 1.10;1.52); P = 0.035), and E/SR-IVR (2.2 m (IQR 1.7;2.8) vs. 1.6 m (IQR 1.3;2.2); P = 0.013). In contrast, conventional echocardiographic measurements and grading algorithms were not able to detect these changes in the same period. Conclusion: Assessment of LV diastolic strain was feasible in our group of selected AVR patients. LV relaxation and filling improved during the intraoperative course of AVR as measured by diastolic strain, while most conventional grading algorithms were not able to detect these alterations.Item The Role of Acetaminophen Use in Acute Kidney Injury Prevention in Cardiac Surgery: A Systematic Review and Meta-Analysis(Wolters Kluwer – Medknow, 2025-09) Ciconini, Luis E.; Perim, Victor; Beck, Theodoro; Carbonar, Mauren F.; Ejikem, Mazpa M.; Zaky, Ahmed; Neyra, Javier; Gosling, Andre F.Acute kidney injury (AKI) is a common complication following cardiac surgery, often leading to increased morbidity and mortality. Despite its prevalence, the role of acetaminophen in preventing AKI after cardiac surgery remains uncertain. This meta?analysis sought to clarify whether perioperative administration of acetaminophen could reduce the risk of postoperative AKI in adult patients undergoing cardiac procedures. To address this question, a systematic review and meta?analysis were performed by searching the MEDLINE, Cochrane, and Embase databases. Studies comparing the effects of perioperative acetaminophen to those of no acetaminophen in adult cardiac surgery patients were evaluated, with risk of bias assessed for each study. Sensitivity analyses were also conducted to strengthen the reliability of the findings. In total, 13 studies, including nine randomized controlled trials and four observational studies, involving 11,583 patients, were analyzed. The results showed that acetaminophen administration was associated with a lower incidence of AKI [OR 0.62 (95% CI 0.40–0.97), P = 0.04]. Additionally, acetaminophen use was linked to reduced in?hospital mortality, delirium rates, and shorter ICU stays, though it had no significant effect on overall hospital length of stay. These findings suggest that perioperative acetaminophen administration may play a protective role in reducing both AKI incidence and in?hospital mortality in patients undergoing cardiac surgery. Until large multicenter randomized controlled trials confirm these results, acetaminophen may still be considered as a preventive measure for patients both before cardiopulmonary bypass initiation and in the postoperative period.Item Palpation versus Ultrasound-Guided Dynamic Needle Tip Positioning Technique for Radial Artery Cannulation(Wolters Kluwer – Medknow, 2025-09) Dhakal, Sujan; Shrestha, Gentle S.; Lamsal, Ritesh; Bastola, Priska; Gautam, Elija; Shrestha, AnilIntroduction: Invasive blood pressure monitoring is the clinical reference during perioperative patient management. It is usually performed by cannulating the radial artery. Different clinical conditions make arterial cannulation difficult using the conventional palpation (CP) method. This study compares the ultrasonography (USG)?guided dynamic needle tip positioning (DNTP) technique with the CP method to assess the first?pass success rate of radial artery cannulation. Methods: In the operation theater of a university hospital, a total of 52 adult patients requiring arterial cannulation were randomized into two equal groups. Arterial cannulation was performed using the CP method in one group and the ultrasound?guided DNTP method in the other group. The first?pass success rate was the primary objective. The 5?minute success rate, the time required for successful cannulation, the number of skin punctures, and the number of cannulae used were also compared using the Chi?square test, an independent sample t?test, and the Mann–Whitney U test. Results: The first?pass success rate was significantly higher in the USG?guided DNTP method (88.5%) compared to the CP method (46.2%) ( P 0.001). The overall 5?minute success rate was 96.2% in the USG?guided DNTP and 65.4% ( P 0.005) in the CP method. The median time for successful cannulation was significantly lesser in the USG-guided DNTP group [44 s (IQR: 35–72)] compared to the CP group [134 s (IQR: 28–378)] (P 0.007). The mean number of skin punctures in the USG-guided DNTP group was 1.15 ± 0.46 and 2.04 ± 1.18 in the CP group ( P 0.001). Conclusion: USG?guided DNTP method of radial artery cannulation increased the first?pass success rate.Item The Effect of Continuous Magnesium Infusion to Prevent Postoperative Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting(Wolters Kluwer – Medknow, 2025-09) George, Robin; Rajmohan, Nisha; Lobo, Rolita Prathima; Nair, Suresh Gangadharan; Govind, J Lekshmipriya; Menon, Lakshmi PriyaIntroduction: Postoperative atrial fibrillation (POAF), which occurs in almost 20?40% of cardiac surgeries, is associated with life?threatening complications. Serum hypomagnesemia, a frequent finding after cardiac surgeries, is a predictor for POAF. In this study, we investigated the effect of continuous magnesium infusion to prevent POAF in patients undergoing off?pump coronary artery bypass grafting (OP?CABG). Materials and Methods: A prospective, randomized controlled study was conducted on 110 patients undergoing OP?CABG. Patients were classified into two groups after reaching the intensive care unit (ICU). Group M was started on magnesium (Mg) infusion at 750 mg/h for 3 days after an initial bolus dose of 1.5 g of magnesium sulfate, to target a serum magnesium level of 1.5 to 2 mmol/L. The control group (Group C) did not receive any infusion. The incidence of POAF, magnesium values, duration of ICU stay, number of patients who required pharmacotherapy and cardioversion, and maximum vasoactive-inotropic score (VIS max) were recorded. A P <.05 was taken as statistically significant. Results: 104 patients were analyzed. The incidence of POAF (19.2% vs 1.9%, P = .008) and the number of patients requiring pharmacotherapy other than magnesium (15.4% vs 1.9%, P = .0310) were significantly higher in group C. Mean of peak magnesium values (1.624 ± 0.136 vs 0.710 ± 0.147, P < .001) was significantly higher in Group M. The number of patients requiring cardioversion ( P = .618), duration of ICU stay (P = .121), and the VIS max ( P = .360) were not significantly different between groups. Conclusion: Postoperative continuous magnesium infusion after a bolus was effective in preventing POAF in patients undergoing OP?CABG by maintaining serum magnesium levels (1.5?2 mmol/).Item A Comparative Study of the Efficacy and Safety Profile of Topical Application of Tranexamic Acid in the Form of Mist to Reduce Postoperative Bleeding in on-Pump CABG Procedures(Wolters Kluwer – Medknow, 2025-09) Jagadish, Chandrika; Kumara, Vijaya; Aspari, Mahammad A.; Rai, D Guruprasad; Sumanth, RBackground: Postoperative bleeding is a major concern in cardiovascular surgery, leading to an increased need for blood transfusions and a longer hospital stay. Between 30% and 70% of open?heart surgery patients will require blood product transfusion. The use of the cardiopulmonary bypass machine (CPB) often leads to bleeding due to complement activation, platelet activation, and hyperfibrinolysis. Antifibrinolytic drugs, like ?-aminocaproic acid, aprotinin, and tranexamic acid (TXA) are used to decrease postoperative bleeding in cardiac surgery. According to the Society of Thoracic Surgeons guidelines, TXA is class I recommendation to reduce the risk of bleeding. Aims: Compare the efficacy and safety of TXA in the mist form to reduce postoperative bleeding. Settings and Design: Prospective, Randomized, Single?Centre, Interventional Study. Material and Methods: The study included sixty participants undergoing on?pump CABG randomized into two groups. Group T and Group C received topical TXA and 20 mL NS in mist form, respectively. The mist was blown over the pericardium, LIMA bed, and sternotomy sites before chest closure. The primary objectives were to compare the 48th hour drain collection and need for blood transfusion. Statistical Analysis Used: Simple t-test, Chi-square test and Mann–Whitney U test. Results: The experimental group had significantly less 48?hour drain ( P value 0.001), reduced need of blood and blood products ( P value 0.001) and less duration of postoperative ventilation ( P value 0.001). Conclusion: The topical application of TXA in mist form significantly reduced postoperative bleeding, the necessity for blood transfusion, and the duration of mechanical ventilation in on?pump CABG procedures.Item Analysis of First 50 Robotic-Assisted Thoracic Surgeries in a University Teaching Hospital: Anesthetic Considerations and Postoperative Outcomes(Wolters Kluwer – Medknow, 2025-09) Granell, Manuel; Martínez-Plumed, Ruth; García del Olmo, Eva; Pastor Martínez, Enrique; Grynovska, Marta; Biosca Pérez, Elena; Cervera Puchades, Alvaro; De Andrés, José; Guijarro Jorge, RicardoIntroduction: Robotic?assisted thoracic surgery (RATS), due to its multiple advantages, has revolutionized the medical field in recent years. Yet, its implementation has been slower compared to other surgical fields. More data on the benefits of RATS regarding patient outcomes are required to justify the high costs of equipment. This study aimed to expand our understanding of anesthetic management of RATS and to analyze the postoperative patient outcomes. Materials and Methods: The r–retrospective descriptive study of the clinical history of 50 patients who underwent RATS using Da Vinci dVX® between 2018 and 2021 in the Thoracic Surgery Department of a single-center university teaching hospital. Statistical analyses of the clinical–demographic variables and those related to airway management, mechanical ventilation, intraoperative hemodynamics, and postoperative outcomes were carried out. Subgroup analysis of patient cases was performed based on the date of surgical intervention to compare the operating time, length of hospital stay, and postoperative complications as surrogates of the learning curve. Results: 92% of patients were easily intubated with double-lumen tubes (76% were VivaSight-DL and 12% standard double-lumen tubes) following the usual protocol, while in 8% of patients, a difficult airway was detected and lung isolation using bronchial blockers was performed. During the one-lung ventilation (OLV) period, 24.4% of patients suffered arterial hypotension and 19.5% required intravenous vasoconstrictors probably due to the capnothorax. The mean duration of the interventions was 135.4 minutes. The average hospital stay was 5.4 days on average, and the mean number of complications was 0.48% per person. No statistically significant difference was found between early and late patient subgroups in terms of operating time, length of hospital stay, and postoperative complications. Conclusions: RATS is a safe intervention which is well managed anesthetically by the use of double?lumen tubes with embedded camera. The use of protective ventilation strategy, including optimal PEEP and lung recruitment maneuver, during one?lung ventilation is effective and hemodynamically well?tolerated in the majority of the patients (80%). The RATS approach is associated with short hospital stay and low postoperative complication incidence. Further studies are warranted to explore new anesthetic management techniques and compare the benefit of robot?assisted thoracic surgery with conventional surgical approaches.Item Aortic Transvalvular Gradient Mis-Quantification(Wolters Kluwer – Medknow, 2025-09) Modestini, Marco; Krikken, Jan A.; Jansma, Geertje; Bouma, Wobbe; Jainandunsing, Jayant S.Mitral regurgitation (MR) can occasionally mimic aortic stenosis (AS) on echocardiographic Doppler imaging, leading to diagnostic challenges. We present the case of a 55-year-old man undergoing minimally invasive mitral valve surgery for severe MR caused by posterior mitral valve leaflet prolapse. Preoperative transthoracic echocardiography revealed severe MR with no significant aortic valve abnormalities. Intraoperative transesophageal echocardiography (TEE) initially showed a high transvalvular aortic gradient (3 m/s) in the transgastric long?axis view, suggestive of mild?to?moderate AS. However, detailed Doppler analysis revealed a double envelope signal, representing both eccentric MR and true aortic valve flow. The closer evaluation showed the MR signal occurred earlier in the cardiac cycle, aligning with its hemodynamic timing, while the true aortic flow followed isovolumetric contraction. Subsequent three?dimensional TEE confirmed normal aortic valve morphology and function. This case highlights the importance of correlating preoperative findings, Doppler signal timing, and imaging data to avoid misdiagnosis. Systematic echocardiographic evaluation, including signal timing analysis, can differentiate between MR and AS, ensuring accurate intraoperative decision?making and preventing unnecessary interventions.Item Multimodal Analgesia in Cardiothoracic Procedure: Opioid and Non-opioid Pharmacology for Pain Management: Part 1(Wolters Kluwer – Medknow, 2025-09) Bhatt, Himani V.; Patel, Dhruv; Rogando, Dillon; Abrams, Jordan; Shariat, AliPain in the context of cardiothoracic surgery can be attributed to multiple factors. Furthermore, cardiothoracic procedure?related pain can be significant and can lead to multiple morbidities including chronic pain syndromes when left undertreated. Even though opioids remain mainstay of treatment for these procedures, opioid?sparing techniques utilizing a well?developed multimodal regimen can be important in the proper pain management of this patient population. It is imperative for the anesthesiologist to understand the multiple pharmacological and non?pharmacological modalities available, the benefits and adverse effects, and the literature supporting the utility of these methods.Item Pulmonary Thromboendarterectomy in a Jehovah’s Witness Patient, Case Report(Wolters Kluwer – Medknow, 2025-09) Leal, Luz J. Pacheco; Salamanca, Fabio A. Garcia; Parada, Julián M.; Pardo, Gianmarco Camelo; Manrique-Hernandez, Edgar F.This study describes the perioperative management of a 68-year-old Jehovah’s Witness patient with chronic pulmonary thromboembolism, multiple comorbidities, and undergoing pulmonary thromboendarterectomy. The patient had a satisfactory perioperative evolution, demonstrating the feasibility of this complex procedure in this population with a comprehensive and timely approach, complemented by an evaluation from a multidisciplinary team.Item WATCHMAN Gone Astray, Catastrophic Mitral Regurgitation Following Device Dislodgement(Wolters Kluwer – Medknow, 2025-09) Jouryyeh, Basil; Beshara, MichaelWATCHMAN (Boston Scientific, Plymouth, MN, USA) is the most commonly utilized left atrial appendage occlusion device. Although increased operator experience has led to a significant decline in reported complications, serious and potentially fatal events can still occur. We present a case of WATCHMAN device embolization that was identified using transesophageal echocardiography shortly after device deployment, along with the subsequent management and retrieval of the device.Item Paradoxical Increase in Left Ventricular Outflow Tract Gradient in a Patient Undergoing Mitral Valve Repair and Septal Myectomy(Wolters Kluwer – Medknow, 2025-09) Poduval, Devika; Madathil, Thushara; Nagarjuna, P; Joseph, Tony; Varma, Praveen; Neema, PKThe Doppler?derived gradient depends on the magnitude of the flow across a narrowed orifice and the alignment of the Doppler with the flow. Septal myectomy is indicated in symptomatic obstructive hypertrophic cardiomyopathy (HCM) patients with peak instantaneous gradient > 50 mmHg. Chordal rupture has been reported infrequently in obstructive HCM patients, which may hide left ventricular outflow tract (LVOT) gradient because of a decreased forward flow across the LVOT, posterior shift of the coaptation point due to flail posterior mitral leaflet widening the LVOT, or absence of systolic anterior motion (SAM). An increase in the flow across the LVOT will occur after mitral valve repair, which may manifest as an increased LVOT gradient. In a clinical scenario of the simultaneous presence of severe mitral regurgitation, severe septal hypertrophy, and low gradient across the LVOT, the dilemma is whether to perform a septal myectomy in addition to MV repair. An unexpected increase in the LVOT gradient occurred despite septal myectomy in a patient with mitral regurgitation after mitral valve repair. We discuss the necessity of septal myectomy in the presence of a low LVOT gradient, severe mitral regurgitation, and posterior shift of the coaptation point due to posterior leaflet flail and chordal rupture.Item Intraoperative Plasma Exchange for Sensitized Lung Transplantation Candidate Leads to Significant Perioperative Coagulopathy(Wolters Kluwer – Medknow, 2025-09) Landolt, Luke; Goldstein, Joseph C.; Weir, William; Rackauskas, Mindaugas; AbuRahma, JosephSensitized lung transplantation recipients are at an increased risk for complications. Therapies such as plasma exchange (PLEX) exist to lessen the antibody burden in hopes of mitigating acute and chronic complications. Although the use of PLEX has been shown to be an effective immunomodulation for many diseases, its benefit in lung transplantation has been debated, and the fear of PLEX-induced coagulopathy has curtailed its use more broadly. Although the type of fluid used for exchange can determine the severity of coagulopathy, even the use of fresh frozen plasma (FFP) can disrupt the coagulation cascade. We present the case of severe perioperative coagulopathy following PLEX with FFP during bilateral lung transplantation.Item EVLW by Lung Ultrasound to Predict Short-Term Post Operative Outcomes in Pediatric Cardiac Surgery - A Prospective Observational Study(Wolters Kluwer – Medknow, 2025-09) Diwakar, Anitha; Punetha, Pankaj; Kamat, Anuradha; Chalam, Kolli S.Background: Extravascular lung water (EVLW) in children undergoing cardiac surgery may affect the outcomes after surgery. The study aimed to evaluate if extravascular lung water assessed by ultrasound could serve as a predictor of short?term postoperative outcomes in pediatric cardiac surgery. Material and Methods: This is a prospective observational study conducted at a tertiary care facility involving children aged 6 months to 12 years who were scheduled for cardiac surgery. A lung ultrasound assessment was carried out before the operation (T0), immediately after the surgery (T1), 6 to 8 hours after surgery (T2), and 18 to 24 hours postoperatively (T3). A score was assigned based on the presence of extravascular lung water indicated by B lines. Pearson’s correlation analysis was performed to examine the relationship between the lung ultrasound score of extravascular lung water and the duration of mechanical ventilation and the length of stay in the intensive care unit, with fluid balance, inotrope score, and oxygenation status being analyzed secondarily. Results: The EVLW score demonstrated a positive relationship with the duration of mechanical ventilation across all time points, with correlation coefficients of r = 0.56 at T0, r = 0.70 at T1, r = 0.40 at T2, and r = 0.52 at T3. The most pronounced correlation occurred at T1, where r = 0.7 was observed. A moderate positive correlation with the duration of ICU stay was noted at the time points T0, T1, and T3. The EVLW score at T1 proved to be significant in linear regression analysis for prediction of both the duration of mechanical ventilation and the length of stay in the ICU. Conclusions: The EVLW score measured at T1, which is immediately after surgery, can serve as an indicator of short-term postoperative outcomes in pediatric cardiac surgery related to the duration of mechanical ventilation.Item Frequency of Fast Track Extubation and Factors Affecting its Success in Adult Cardiac Surgery Patients: A Retrospective Analysis(Wolters Kluwer – Medknow, 2025-09) Zahid, Muhammad Arslan; Yousuf, Muhammad Saad; Ahmed, Syed Shabbir; Hamid, MohammadObjective: The primary objective is to identify how often do adult patients, who undergo elective open?heart surgeries are fast track extubated. Secondary objectives are to identify the causes of delayed extubation and to quantify the frequency of re?intubation and hospital stay in fast?track patients. Study design: Retrospective cross?sectional study. Place and duration of the study: The Cardiovascular Intensive Care Unit (CICU) at Department of Anesthesia, Aga Khan University Hospital, Karachi, Pakistan, where data was collected from January 2021 to December 2022. Methodology: Data of 419 adult patients admitted to the CICU and who underwent elective open?heart surgery, during the study period were included. Demographic and clinical information of the patients was collected using proforma eliciting details keeping anonymity and confidentiality of patients. Statistical analysis was conducted by RStudio (version 4.1.2, Boston, USA). Results: There were 58.4% ( n = 245) of 419 patients extubated within the FastTrack window. No significant differences were seen in demographic and clinical characteristics (except surgery type, P < 0.001). There was significant difference in intraoperative outcomes (CICU arrival time, temperature, Vasoactive-Inotropic Score [VIS], and hospital stay) between groups ( P < 0.001). High inotropic support, late night cases, bleeding and hypothermia were the major causes of delayed extubation. Conclusion: In patients undergoing elective open heart surgeries including elective CABG, fast track extubation is a feasible, safe, and effective option in improving resource utilization and patient outcome. Early extubation and prevention of postoperative complication can be facilitated by optimizing perioperative care protocols. Fast?track protocols should be standardized to protect patient safety. Fast track extubation requires careful patient selection and individual patient characteristics need to be considered.Item Effectiveness of Pecto-Intercostal Fascia Plane Block in Reducing Total Postoperative Opioid Consumption in Cardiac Surgery Involving Sternotomy: A Meta-Analysis(Wolters Kluwer – Medknow, 2025-09) Wardhana, Ardyan; Sudono, Halim; Kurniawaty, JuniThe pecto?intercostal fascia plane block (PIFB) is gaining recognition for its potential to reduce postoperative opioid use after cardiac surgery. This study aimed to evaluate the effectiveness of PIFB compared with conventional intravenous regimens in reducing total postoperative opioid consumption in patients undergoing cardiac surgery involving sternotomy. A meta?analysis of relevant studies, published up to August 13, 2024, retrieved from the PubMed and CENTRAL databases was performed. The inclusion criteria were studies involving a superficial parasternal block or PIFB for patients undergoing cardiac surgery involving sternotomy. Studies comparing PIFB with other blocks or local anesthetic regimens were excluded. Data analysis was performed using an inverse variance random?effects model using RevMan 5.4.1 software, with the effect measure expressed as standardized mean difference (SMD) to account for the different opioids used. Of 88 studies retrieved in the literature search, 16 fulfilled the inclusion criteria [ten ultrasound (US)?guided and six non?US?guided]. PIFB significantly reduced total opioid consumption [SMD ?1.55 (95% CI ?2.15 to ?0.95); P < 0.001] and time to extubation [SMD ?1.22 (95% CI ?2.05 to ?0.38); P < 0.001]. A subgroup analysis of multiple? versus single?shot injections yielded consistent results. Analyses including only US?guided PIFB revealed consistent reductions in total opioid consumption [SMD ?1.18 (95% CI ?1.79 to ?0.56); P < 0.001] and time to extubation [SMD ?0.82 (95% CI ?1.01 to ?0.63); P < 0.001]. PIFB effectively reduced opioid consumption and shortened postoperative time to extubation in cardiac surgery involving sternotomy.Item Intravenous Levosimendan versus Milrinone: Coronary Sinus Lactate and PA Catheter Derived Parameters in Patients with Pulmonary Hypertension Undergoing Elective Mitral Valve Replacement(Wolters Kluwer – Medknow, 2025-09) Virmani, Sanjula; Garg, Sukhdev; Malik, Indira; Dash, Abhas Chandra; Naqvi, Sayyed Ehtesham Hussain; Wadhwa, Rachna; Singh, HarpreetBackground: Coronary sinus (CS) lactate level has been shown to corroborate with changes in myocardial metabolism induced by ischaemia and reperfusion, and hence can be used to indicate the effect on myocardial metabolism. In patients with mitral stenosis (MS) undergoing valvuloplasty or valve replacement, presence of severe pulmonary hypertension (PH), indicates advanced disease state and development of right ventricular (RV) failure, an important hallmark of bad prognosis. Levosimendan and milrinone are increasingly being used as inodilators to treat PH and improve RV function to varying degrees, but their effect on myocardial metabolism awaits precise validation. Methods: Thirty patients were randomized into two groups of 15 patients each. Group L (received levosimendan) and Group M (received milrinone). All the patients received fentanyl (8–10 ?g/kg), rocuronium bromide 0.8 mg/Kg for induction and maintenance of anaesthesia. In addition to the routine intravenous and invasive arterial access, a Cavafix? (Certo? 257, 45 cm, B Braun Melsungen AG, Germany) was inserted via right IJV and positioned in the right atrium (RA) to be later re-positioned in the CS before coming off cardiopulmonary bypass (CPB), to obtain blood samples for measuring the CS lactate levels postoperatively. At the commencement of rewarming, group L received levosimendan 10 ?/kg bolus over 10 min, followed by an infusion (0.1 ?/kg/min) and group M received 50 ?g/kg bolus over 10 min, followed by infusion (0.5 ?g/kg/min), till 24 hours post?operatively. CS lactate, heart rate (HR), mean arterial pressure (MAP) and PA catheter derived data [Cardiac index (CI), cardiac output (CO), PA pressure, systemic and pulmonary vascular resistance indices (SVRI/PVRI)] and mixed venous oxygen saturations (SvO2) were recorded at predetermined time points. Results: In both the groups the CS lactate levels increased gradually till 6 hours after surgery followed by a decrease at 24 hours. Comparison of CS lactate between the two groups revealed that the CS lactate levels were significantly lower in group L at various time points till 24 hours after surgery with a P value of < 0.05. HR and MAP were comparable in both the groups at all time points. MAP was significantly lower in the two groups, both after induction of anaesthesia and after CPB. 7 patients in group M (46.7%) developed hypotension (MAP decreased by > 20% of baseline) that was treated with norepinephrine. CO increased significantly in both group M and group L, post CPB 10 min after surgery. Patients in group L had a significantly higher CO and CI, compared to group M, P < 0.05. PAP was significantly reduced compared to baseline valuesafter valve replacement in both the groups being lower in group L compared to group M, but the difference was statistically not significant. After valve replacement, SVRI decreased significantly in both the group the decrease being significantly more in group L ( P < 0.05). Conclusion: This study revealed that, in comparison to milrinone, levosimendan was associated with comparable reduction in systolic and mean pulmonary artery pressure, lesser incidence of hypotension, lesser requirement of inotropic support and better myocardial performance.Item A Comprehensive Clinical Acumen Enhanced by Point-of-Care Ultrasonography in Managing Acute Life-Threatening Massive Pulmonary Thromboembolism in a Peripheral Setting: A Case Report(Wolters Kluwer – Medknow, 2025-03) Chhaperwal, Prabhav; Kumar, Sudhir; Suri, Gurbinder; Garg, Uma; Kapoor, Suraj; Devarakonda, BhargavaAcute massive pulmonary thromboembolism (PTE) is a potentially life?threatening condition requiring urgent management to decrease mortality. However, in the peripheral setting, managing the emergency can be challenging. We report a case of massive PTE presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, early initiation of anticoagulants (heparin), and thrombolytics. This case report explores the successful management of a critically ill patient presenting with massive pulmonary embolism in a peripheral healthcare facility, emphasizing the importance of a well?coordinated approach in such challenging environments. The approach in the case included recognizing the challenge with timely provisional diagnosis, initial stabilization, hemodynamic support, early consideration for anticoagulants, and thrombolysis after supporting provisional diagnosis with point?of?care ultrasonography (POCUS), team effort, and administrative support in Cas Evac to the tertiary care center. Timely administration of heparin and thrombolytics may serve as potential life?saving measures in peripheral settings, along with the availability of an ultrasound machine. Managing acute life?threatening massive PTE in peripheral settings requires a strategic and resourceful approach. Timely administration of heparin and thrombolytics may serve as potential life?saving measures. However, the administration of thrombolytics in PTE needs the support of POCUS to make quick decisions in peripheral settings. Collaboration between peripheral and advanced tertiary care healthcare facilities is crucial to ensure optimal outcomes for patients experiencing this critical condition.Item Accuracy of Intraoperative Transesophageal Echocardiographic Doppler Parameters in Assessing the Right Ventricular Diastolic Function After Repair of Tetralogy of Fallot in Pediatric Patients(Wolters Kluwer – Medknow, 2025-03) Panidapu, Nagarjuna; Babu, Saravana; Dharan, Baiju S.; Sen, Barsha; Koshy, ThomasBackground: This study aimed to assess the accuracy of tricuspid spectral Doppler (E/A) and tissue Doppler parameters (E/E’) to diagnose right ventricular diastolic dysfunction (RVDD) in comparison to American Society of Echocardiography (ASE criteria) in pediatric tetralogy of Fallot (TOF) patients after surgical repair. Methods: This prospective, observational study was done at a tertiary care hospital involving 40 pediatric TOF patients aged less than 2 years who underwent complete intracardiac repair with cardiopulmonary bypass (CPB). Echocardiographic observations were made using a pediatric transesophageal echocardiography probe after surgical repair in the post?CPB period. The ASE?described parameters (late diastolic forward flow in the main pulmonary artery, right atrial dilatation, inferior vena cava dilatation, and hepatic venous flow reversal) were acquired to diagnose the RVDD. The tricuspid Doppler parameters (E/A and E/E’) were measured, and its predictive ability to diagnose RVDD was analyzed and compared with the ASE criteria. Results: Based on the ASE criteria, 13 patients (32.5%) were diagnosed to have RVDD. We found that an E/E’ ratio of ? 6.26 and an E/A ratio of >1.34 can be taken as the cutoff for diagnosing the RVDD. Based on the tricuspid Doppler parameters (E/A > 1.34 and E/E’ >6.26), 17 patients (42.5%) were diagnosed to have RVDD, which was comparable to that of the diagnosis by ASE criteria ( P > 0.05). Conclusion: The results suggested that the use of tricuspid Doppler parameters can be equally accurate and reproducible to the current ASE?described echocardiographic parameters for diagnosing RVDD after surgical repair of TOF.Item Assessment of Right Ventricle Function in Patients with Mitral Repair: Case Series(Wolters Kluwer – Medknow, 2025-03) Amador, Yannis; Garijo, Jacobo Moreno; Mashari, Azad; Gadotti, Giovanni; Hopman, Wilma M.; David, Tirone E; Meineri, MassimilianoObjectives: We aim to assess right ventricular function in patients undergoing mitral valve repair using trans-esophageal echocardiography, focusing on the predictive value of right ventricular longitudinal strain compared to other echocardiographic measures. Design: Retrospective analysis. Setting: Toronto General Hospital. Participants: Thirty elective patients undergoing mitral valve repair. Interventions: Quantitative assessment of right ventricular function using transesophageal echocardiography images pre- and post-mitral valve repair, including right ventricular longitudinal strain, fractional area change, tricuspid annular plane systolic excursion, and systolic peak velocity (S'). Measurements and Main Results: 3 patterns of RV strain were identified with right ventricular longitudinal strain emerging as the most significant discriminator among right ventricular functional subgroups, with 43% of cases showing worsening, 20% showing no change, and 37% showing improvement. No correlation was found between right ventricular performance parameters and the need for vasopressors post-cardiopulmonary bypass. There was also no association between initial right ventricular longitudinal strain and difficulty in weaning off bypass or increased demand for pressors. Changes in tricuspid annular plane systolic excursion across all cases warrant further investigation with a larger cohort. Conclusions: Right ventricular longitudinal strain is a valuable tool for assessing right ventricular function post-mitral valve repair, offering insights into immediate postoperative outcomes and long-term right ventricular remodeling. Despite limitations like single-surgeon experience and institution-specific choice of pressors, our study provides useful insights into right ventricular function post-mitral repair surgery, paving the way for future research in larger patient populations.