Chiari network: an interesting transesophageal echocardiographic finding.
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Cardiac Catheterization↗
Biomedical subjects
N Trehan
Publications and source records attributed to N Trehan.
Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery.
BACKGROUND: Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG). METHODS: Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n = 19) and the lumbar epidural analgesia (LEA) group (n = 20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top-up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was > 3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0-10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted. RESULTS: Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for break-through pain and had comparable pulmonary functions and side effects. CONCLUSION: This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.
Adult↗
Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization.
BACKGROUND: To achieve complete myocardial revascularization in patients with diffuse coronary artery disease and patients at high risk if they undergo cardiopulmonary bypass such as severe systemic disease or diffuse arteriosclerosis of the aorta, we have adopted the technique of combining direct coronary artery bypass grafting without cardiopulmonary bypass with transmyocardial laser revascularization. METHODS: From April 1995 to September 1997 this technique was used in 77 patients. Ages ranged from 37 to 85 years with a mean of 56 +/- 17 years. Diffuse coronary artery lesions were present in 46 patients, 10 had severely deranged renal function, 7 had diffuse carotid artery lesions, and 7 had aortic arch atheromas. Liver dysfunction was present in 4 patients and severe obstructive airway disease in 3. The mean left ventricular ejection fraction was 0.45 +/- 0.05. Midsternotomy approach was used in 65 patients and anterior minithoracotomy in 12. Direct coronary artery bypass grafting without cardiopulmonary bypass was done to the left anterior descending coronary artery or right coronary artery or both. Transmyocardial laser revascularization using a 1,000-W CO2 laser machine was performed on the areas supplied by ungraftable coronary arteries or even in graftable distal targets in the posterolateral or inferior wall in patients who were at high risk if they underwent cardiopulmonary bypass. RESULTS: The mean number of vessels bypassed was 1.12. One patient died of intractable ventricular arrhythmia in the early postoperative phase. Mean follow-up was 16.6 months. At 12 months 89% of the patients were angina free. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 at baseline to 9.7 minutes at 12 months. Myocardial thallium scanning done at 3-, 6-, and 12-month intervals postoperatively revealed that myocardial perfusion in grafted segments had an exponential trend of improvement, and perfusion in transmyocardial laser revascularization segments showed a linear trend in the same period with a total gain of 28.4%. CONCLUSIONS: Transmyocardial laser revascularization is an excellent adjunct to minimally invasive coronary artery bypass grafting to achieve complete myocardial revascularization in patients with graftable vessels in the anterior wall and ungraftable vessels in the posterior and inferior wall. This achieves complete myocardial revascularization without compromising safety in patients who are at high risk if they undergo cardiopulmonary bypass. Minimal morbidity and mortality in the present series revealed that this procedure is safe, and postoperative follow-up of these patients showed significant functional improvement as well as an improvement in myocardial perfusion scan.
Adult↗
Utility of three-dimensional echocardiography during balloon mitral valvuloplasty.
OBJECTIVES: We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV). BACKGROUND: Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective. METHODS: We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed "en-face" as if looking up from the left ventricle. RESULTS: The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86+/-0.06 cm2 to 2.07+/-0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation. CONCLUSIONS: The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible.
Adolescent↗
Mammary coronary artery anastomosis without cardiopulmonary bypass through minithoracotomy: one year clinical experience.
OBJECTIVE: The recent concept of minimally invasive coronary artery surgery in selected patients has dramatically affected surgical management of coronary artery disease. We explored the possibility of coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy on beating heart. METHOD: Minithoracotomy and direct coronary artery surgery without cardiopulmonary bypass (CPB) was attempted in 116 patients. The procedure was completed in 108 cases while in eight cases minithoracotomy was converted to mid sternotomy. In 107 cases, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was done through left anterior minithoracotomy and in one case LIMA to LAD and right internal mammary artery (RIMA) to right coronary artery (RCA) anastomosis was done through bilateral minithoracotomy. Left anterior minithoracotomy through 4th intercostal space and right anterior minithoracotomy through 5th intercostal space was used for left and right internal mammary artery dissection respectively. With this approach 4-8 cm length of mammary artery was easily dissected. Mammary coronary artery anastomosis were performed on a beating heart without CPB through window pericardiotomy. Two patients also underwent left carotid endarterectomy along with LIMA to LAD anastomosis. In two patients complementary percutaneous transluminal coronary angioplasty (PTCA) to circumflex artery was done 5 days after minithoracotomy and LIMA to LAD anastomosis. RESULTS: Forty-two patients were extubated in the operating room and 66 in the intensive care unit 2-10 h after surgery. Blood transfusion was used in one case who was reexplored for postoperative bleeding due to a displaced hemoclip from the internal mammary artery branch. None of these patients required inotropic support. Postoperative predischarge check angiogram in 53 cases revealed adequate mammary coronary flow in 51 cases, the remaining two had anastomotic problems, one was subjected to PTCA and the other for redo coronary bypass grafting through mid sternotomy. Doppler flow assessment of anastomosis was done in 102 cases, of which two showed problems which was confirmed on check angiography. One-hundred and six patients are in our regular follow-up (mean follow-up 10+/-1.5 months), 98 of them are in functional class I. CONCLUSION: In our experience mammary coronary artery anastomosis without CPB through minithoracotomy is a safe, simple and minimally invasive procedure. Favorable cost/benefit ratio, has been achieved due to no early/late mortality and minimal early morbidity. Postoperative check angiogram and Doppler flow study revealed excellent mid term results.
Cardiopulmonary Bypass↗
Real-time intraoperative transesophageal echocardiography--how useful? Experience of 5,016 cases.
OBJECTIVE: To evaluate transesophageal echocardiography (TEE) as an intraoperative monitoring modality and to assess its safety, reliability, and overall utility in real-time use during cardiac surgery. DESIGN: Prospective, observational cohort study performed from January 1993 to June 1997. SETTING: Operating room of a tertiary care hospital for cardiology and cardiovascular surgery. PARTICIPANTS: Five thousand and sixteen adult patients with acquired heart disease, who underwent 1,356 valve procedures and 3,660 coronary artery bypass graftings (CABGs). INTERVENTIONS: All patients were monitored with radial artery and pulmonary artery catheters, along with continuous TEE monitoring with a multiplane transducer. MEASUREMENTS AND MAIN RESULTS: Prebypass imaging yielded unsuspected findings that either helped or modified the surgical plan in 158 of 1,356 valve procedures (11.65%) and in 993 of 3,660 CABGs (27.13%). There were 3,217 TEE-guided hemodynamic interventions in 944 patients (25.79%) in the CABG group and 629 in 142 patients (10.47%) in the valve group. TEE was the sole guiding factor in initiating therapy in 23.53% of events, whereas it was supportive to other monitoring modalities in 76.46% of events. Postbypass TEE identified the need for graft revision in 29 patients (0.8%), intra-aortic balloon pump (IABP) requirement in 29 patients (0.8%), and inadequate valve repair in 28 patients (2.08%). For the entire series, 38.78% of patients benefited from prebypass and 39.16% from postbypass use of TEE. There were no complications attributable to the use of TEE in the entire series. There was 87% concordance between online interpretation by a trained anesthesiologist and offline analysis by a cardiologist. CONCLUSION: Intraoperative TEE is useful in formulating the surgical plan, guiding various hemodynamic interventions, and assessing the immediate results of surgery. It is safe and the results are reliable in the hands of trained anesthesiologists.
Cardiac Surgical Procedures↗
Endocoronary sinus catheter--Indian experience.
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Cardiac Surgical Procedures↗
A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery.
OBJECTIVE: To compare the efficacy of thoracic epidural analgesia (TEA) and intrapleural analgesia (IPA) after minimally invasive direct coronary artery bypass (MIDCAB) surgery with regard to quality of analgesia and complications. DESIGN: A prospective, randomized study. SETTING: A specialty research hospital. PARTICIPANTS: Fifty consenting adults scheduled for MIDCAB surgery. INTERVENTIONS: All patients underwent elective MIDCAB surgery. Patients in the TEA group (n=25) had an epidural catheter inserted in the fourth to fifth thoracic interspace and those in the IPA group (n=25) had an intrapleural catheter inserted in the sixth to seventh intercostal space intraoperatively under vision. MEASUREMENTS AND MAIN RESULTS: Parameters evaluated after administration of bupivacaine (8 mL of 0.25% in the TEA group and 20 mL of 0.25% in the IPA group) on first demand included visual analog scale (VAS) pain scores, cardiovascular and respiratory (clinical, blood gases) function, wakefulness, supplemental analgesic requirement, and complications. Measurements were made at 2-hour intervals for the next 12 hours. VAS scores were significantly lower at 2, 6, 8, and 12 hours in the IPA group (TEA = 3.5, 4.5, 4.9, 4.6; IPA = 2.2, 3.6, 3.5, 3.7). There were no significant differences in hemodynamic or respiratory parameters or postoperative requirement for supplemental analgesia. In the TEA group, three patients had catheter migration and four had severe backache. CONCLUSION: IPA is a safe and effective technique for postoperative analgesia after MIDCAB surgery and has a low complication rate compared with TEA. Careful positioning, chest tube clamping, and anchoring of the catheter are mandatory for IPA to be effective.
Analgesia, Epidural↗
Case 12-2-1998. Noncardiac surgery and pacemaker cardioverter-defibrillator management.
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Anesthesia, Epidural↗
Trans-telephonic electrocardiographic monitoring--experience in India.
A centre for trans-telephonic electrocardiographic monitoring (TTEM) was established at the Escorts Heart Institute in May 1996. We have reviewed our experience in the first 398 patients. There were 321 males (81%) and 77 females (19%); their age range was 1 month to 95 years. Sixty-five per cent of patients were from New Delhi, while the remainder were from other cities in India and abroad. As well as follow-up of patients after discharge, the system was used for the evaluation of chest pain, palpitation, chronic angina, arrhythmias, and pacemaker implants. Out of 664 symptomatic transmissions, 510 (77%) were for cardiac symptoms like chest pain (309), palpitation (90), uneasiness (61), dizziness (28) and breathlessness (22); the other 154 (23) were for non-cardiac symptoms like stitch pain and backache (51), typical chest pain (39), weakness and fever (45), and sweating (19). The majority of patients with chest pain (84%), palpitation (78%) and dizziness (75%) transmitted their electrocardiograms within one hour of the onset of the symptoms. Out of 664 symptomatic transmissions, 531 required either reassurance or drug-dose adjustment by telephone and 97 were called to the outpatient department on an elective basis. Immediate hospitalization was advised for 36 patients, for acute management of their symptoms. TTEM was useful in avoiding 628 unnecessary visits to the hospital, while 36 patients were immediately hospitalized for acute care.
Adolescent↗
Trans-telephonic electro-cardiographic monitoring (TTEM)--first Indian experience.
Trans-Telephonic Electro-Cardiographic Monitoring (TTEM) centre, is an easy to use tool, now freely available in India. Between May 1996 and May 1997, 398 patients were registered at Escorts Heart Alert Centre (EHAC) for TTEM; 321 (81%) males and 77(19%) females. Age range was from 1 month to 95 years 65% patients were from New Delhi; 35% from other cities in India and abroad. Patients' clinical profile were post-CABG, post-PTCA, post-MI, patients after discharge; evaluation of chest pain, palpitation, chronic angina, arrhythmias, and pace-maker follow up. Out of 664 symptomatic transmissions, 510 (77%) were for cardiac symptoms like chest pain 309 (61%); palpitation 90 (18%); uneasiness 61(12%); dizziness 28(5%) breathlessness 22(4%). 154(23%) were for non-cardiac symptoms like stitch pain and backache (51); Atypical chest pain (39); weakness and fever (45) and sweating (19). 84%, 78% and 75% patients of chest pain, palpitation and dizziness respectively transmitted their ECGs within one hour of the onset of the symptoms. Out of 664 symptomatic transmissions, 531 required either re-assurance or drug-dose adjustment on telephone. 97 were called to OPD on elective basis. 36 patients were advised immediate hospitalization, for acute management. TTEM was useful in avoiding 628 unnecessary visits to the hospital whereas 36 patients, were immediately hospitalized, for receiving acute life-saving interventions.
Adolescent↗
Sequential external counterpulsation increases cerebral and renal blood flow.
The purpose of this study was to evaluate the effect of sequential external counterpulsation (SECP) on cerebral and renal blood flow. The effect of SECP on carotid and renal artery blood flow was studied in 35 and 18 patients, respectively. With a portable unit, cuffs were applied to the calves and thighs, sequentially inflated with air at the onset of diastole, and deflated at the onset of systole. Carotid and renal artery Duplex studies were performed during intermittent SECP. Flow velocity and flow velocity integral were measured at baseline and during SECP. Diastolic augmentation of carotid and renal artery flow velocity was observed in all patients. The mean carotid flow velocity integral increased by 22% from 27.7 +/- 1.8 cm to 33.1 +/- 2.3 cm (P = 0.001). The mean renal artery flow velocity integral increased by 19% from 21 +/- 1 cm to 25 +/- 1 cm (P = 0.0001). With SECP, a new diastolic Doppler flow velocity wave was observed, with an average peak carotid diastolic flow velocity of 56 +/- 4 cm/sec and an average peak renal artery diastolic flow velocity of 40 +/- 2.5 cm/sec. This diastolic wave was 75% (carotid) and 68% (renal) as high as the systolic wave during SECP. In addition, with SECP the systolic wave increased by 6% and 8% in the carotid and renal artery, respectively (P = 0.02 and 0.006, respectively). In conclusion, SECP significantly increases carotid and renal blood flow. This noninvasive, harmless treatment may be useful to support patients with decreased cerebral and renal perfusion.
Aged↗
Mammary-coronary artery anastomosis without cardiopulmonary bypass through a minithoracotomy.
BACKGROUND: Coronary artery bypass grafting has been based on cardiopulmonary bypass, myocardial protection, and the median sternotomy. The recent concept of minimally invasive coronary artery bypass grafting in selected patients has dramatically affected surgical management of coronary artery disease. Coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy is a procedure that is gaining acceptance. METHODS: Fifty-one patients were operated on by minithoracotomy and direct coronary artery bypass grafting without cardiopulmonary bypass. Left internal mammary artery-to-left anterior descending coronary artery anastomosis was done in 50 patients, and in 1 patient, left internal mammary artery-to-left anterior descending artery and right internal mammary artery-to-right coronary artery anastomoses were constructed through bilateral minithoracotomies. Left anterior minithoracotomy through the fourth intercostal space and right anterior minithoracotomy through the fifth intercostal space were used for left internal mammary artery and right internal mammary artery dissection, respectively. With this approach, a 4- to 6-cm length of mammary artery was easily dissected. Mammary-to-coronary anastomosis was performed on a beating heart without cardiopulmonary bypass through window pericardiotomy. RESULTS: Twenty-five patients were extubated in the operating room and 26 in the intensive care unit 4 to 6 hours after operation. None of these patients required blood transfusion or inotropic support. Postoperative predischarge angiography in 42 patients revealed adequate mammary-to-coronary flow in 40 patients. Doppler flow studies were also in accordance with angiographic findings. Forty-five patients are in our regular follow-up (mean follow-up, 6.23 +/- 1.34 months); 44 of them are in functional class I. CONCLUSION: In our experience minithoracotomy is a safe, simple, and minimally invasive procedure. Favorable cost/benefit ratio has been achieved owing to no early or late mortality and minimal early morbidity. Postoperative angiography and Doppler flow study revealed excellent predictive long-term results.
Adult↗
Significantly reduced incidence of stroke during coronary artery bypass grafting using transesophageal echocardiography.
OBJECTIVE: Protruding atheromas of thoracic aorta have been identified as a source of systemic emboli and a major cause of stroke following cardiac surgery. This prospective study used transesophageal echocardiography (TEE) to identify atherosclerosis of thoracic aorta intraoperatively. The influence of risk factors was studied. Finally the impact of modifying surgical technique on the outcome was evaluated. METHODS: Seven-hundred and ninety-two patients undergoing coronary artery bypass grafting (CABG) were evaluated with TEE. Depending on the location and extent of thoracic aortic disease various surgical modifications were carried out, e.g. hypothermic circulatory arrest with aortic arch atherectomy, CABG on beating heart and others. The stroke rate in this group of patients was determined and analysed. RESULTS: Of the 114 patients with grade II and III atheromas of aortic arch and ascending aorta in whom surgical modifications were done, none had stroke. The overall stroke rate in the study group was 0.76%, six patients had stroke. Stepwise logistic regression identified age, diabetes, serum triglycerides and VLDL as important risk factors. Associated carotid artery disease and calcium on chest X-ray (CXR) were identified as important predictors of disease. CONCLUSIONS: Intraoperative TEE is an invaluable modality for evaluating the thoracic aorta. There is significant reduction in stroke rate following identification of atheromas and modification of surgical technique.
Adult↗
Transmyocardial laser revascularisation combined with coronary artery bypass grafting without cardiopulmonary bypass.
OBJECTIVE: To achieve complete myocardial revascularisation in patients with diffuse coronary artery disease, patients with inordinately high risk of cardiopulmonary bypass (CPB) like severe systemic disease or diffuse atherosclerosis of the aorta. METHODS: We have adopted the technique of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) using 1000 W CO2 laser machine. TMLR is done to areas supplied by ungraftable arteries, while CABG without cardiopulmonary bypass is done to the left anterior descending artery (LAD) and/or right coronary artery (RCA). TMLR + CABG on beating heart without CPB has been performed on 56 patients. Age ranged from 37 to 81 years with a mean of 56.17. Four patients were in renal failure, two were redo CABG. Preoperatively 39.28% patients had angina class III and 10.71% had angina class IV. Four patients were on preoperative IABP support. RESULTS: The mean number of grafts was 1.09. Internal thoracic artery (ITA) was used in 96.4% of the patients. Five patients showed elevation of CPK-MB, while three patients had an increase in Troponin T. Mortality was 1.8% (one patient died of intractable ventricular arrhythmia). The mean follow-up is 9.2 months. Myocardial perfusion scanning showed a stepwise improvement in reversible ischemia increasing from 52% at baseline to 91% at 12 months; 90.9% of the patients were angina free at 12 months. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 min at baseline to 9.4 min at 12 months. Metabolic equivalents (METs) increased from 4.5 at baseline to 9.4 at 12 months. The average 44% Karnofsky score preoperative also increased to 86% at 12 months. CONCLUSIONS: Our results indicate that the technique is surgically feasible and safe, with excellent short term results.
Adult↗
Cardioprotective effects of diltiazem infusion in the perioperative period.
OBJECTIVE: To evaluate the perioperative effects of intravenous diltiazem infusion on left ventricular functions, hemodynamics and as an anti-ischemic and antiarrhythmic agent in patients undergoing coronary artery bypass grafting (CABG). METHODS: A double blind, randomised study was performed on 71 patients undergoing elective CABG. Infusion of diltiazem (0.1 mg/kg per h, n = 34) or nitroglycerin (1 microgram/kg per min, n = 37) was given for 24 h starting from onset of cardiopulmonary bypass. Holter monitoring, electrocardiogram and serum cardiac enzymes levels were used to diagnose myocardial ischemia. Myocardial function was assessed by perioperative transesophageal echocardiography. RESULTS: The two groups did not differ with respect to preoperative and operative data. Diltiazem had no influence on hemodynamic parameters except for significant reduction in post operative heart rate and pulse pressure rate. Transient ischemic events (dilitiazem 10.2% versus nitroglycerin 33.3%, P = 0.15) and transient coronary spasm (diltiazem-6.8% versus nitroglycerin 25.9%, P = 0.15) were reduced in the diltiazem group as compared with the nitroglycerin group. The postoperative incidence of atrial fibrillation (diltiazem 3% versus nitroglycerin 22%, P = 0.03), supra ventricular tachycardia (diltiazem-3% versus nitroglycerin-22%, P = 0.03) and average ventricular premature contraction per h (diltiazem-40.2 +/- 10.2 versus nitroglycerin 53.8 +/- 12.3, P < 0.01) were significantly lower in the diltiazem group. Transesophageal echocardiography showed no significant difference in left ventricular functions and better preservation of left ventricular diastolic functions in post cardiopulmonary bypass period in diltiazem group. In addition mean deceleration time for the E wave on a 12 h post cardiopulmonary bypass period was significantly lower in the diltiazem group as compared with nitroglycerin (diltiazem 131 +/- 6 versus nitroglycerin 171 +/- 6, P < 0.01). CONCLUSION: The present study demonstrates that diltiazem infusion provides superior anti-ischemic protection and control of supraventricular arrhythmias as compared to nitroglycerin and does not produce any negative inotropic effect, as demonstrated by transesophageal echocardiography.
Aged↗
Minimally invasive coronary artery surgery: anesthetic considerations.
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Adult↗