047423   KUNIGO T, NAWA Y, YOSHIKAWA Y, YAMAKAGE M (Anesthesiology Dep, Hokkaido P.W.F.A.C. Obihiro Kosei General Hospital, Hokkaido 080-0024, Japan, Email: tatsuya_9250@yahoo. co.jp) : Tracheal extubation of anesthetized pediatric patients with heart disease decreases the incidence of emergence agitation: A retrospective study . Ann. Card. Anaesth 2020, 23 (4), 433 - 8.

Emergence agitation for pediatric patients after general anesthesia is one of the postoperative complications. The relationship between consciousness at tracheal extubation and emergence agitation is not clear. The aim of the present study was to determine whether tracheal extubation of anesthetized pediatric patients with heart disease by propofol decreases the incidence of emergence agitation. This was a retrospective case-control study conducted at a children?s hospital. Pediatric patients with heart disease aged 0-14 years who underwent cardiac catheterization under general anesthesia by propofol between October 2014 and September 2018 were enrolled. The incidence of emergence agitation by anesthetized extubation was compared with that by awake extubation. Logistic regression analysis was performed. Anesthetized extubation was performed in 202 patients and awake extubation was performed in 56 patients. The incidence of emergence agitation was significantly lower in patients who underwent anesthetized extubation than in patients who underwent awake extubation (25.2 % vs. 69.6 %, P = 0.000). In logistic regression analysis, anesthetized extubation [odds ratio (OR): 0.075, 95 % confidence interval (CI): 0.034-0.165, P = 0.000] and older age (OR: 0.808, 95 % CI: 0.728-0.897, P = 0.000) were associated with a decreased incidence of emergence agitation, and preoperative anxiety (OR: 2.220, 95 % CI: 1.060-4.660, P = 0.03) was associated with an increased incidence of emergence agitation. Tracheal extubation under anesthesia by propofol decreases the incidence of emergence agitation in pediatric patients with heart disease.

2 illus, 3 tables, 25 ref

047422   KUNDRA T S, THIMMARAYAPPA A, SUBASH S S, KAUR P (Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, Email: tanveerashwini@yahoo. Com) : Monitoring of limb perfusion after vascular surgery in critical limb ischemia using near-infrared spectroscopy: A prospective observational study . Ann. Card. Anaesth 2020, 23 (4), 429 - 32.

Intra and postoperative perfusion monitoring should be used in critical limb ischemia patients undergoing vascular surgery to improve outcomes and reduce costs. While a pulse oximeter can be applied on the affected limb to monitor the arterial saturation of the limb, thus reflecting flow in that limb, we need to focus on other important parameters like muscle oxygen consumption and regional blood flow for a good outcome. Near-infrared spectroscopy (NIRS) can be used in such patients to monitor regional and tissue oxygenation. In this prospective observational study, 30 adult patients undergoing infra-inguinal bypass were recruited. All these patients were given combined spinal-epidural anesthesia. In addition to routine monitoring, a pulse oximeter and NIRS electrodes were applied on the affected limb. rsO2, limb spO2, and Doppler signals were noted before the induction of anesthesia (baseline) and postoperatively at 0, 6, and 12 h. Improvement in rsO2 and limb spO2 values after surgery was noted and fall in these values was evaluated. Pearson correlation between rsO2 and limb spO2 was assessed. The data was analyzed using repeated-measures ANOVA. Pearson correlation between rsO2 and limb spO2 was r > 0.8. Two patients had a fall in rsO2 in postoperative period, which co-related with a fall in limb spO2 and decreased/absent Doppler signals. NIRS represents a noninvasive and reliable means to monitor limb perfusion in patients undergoing vascular surgery for rest pain.

3 tables, 10 ref

047421   NANDITHA S, MALIK V (Cardiac Anesthesia Dep, AIIMS, Ansari Nagar, New Delhi, Email: dr.vishwasmalik@gmail. Com) : Comparison of flow-independent parameters for grading severity of aortic stenosis using intraoperative transesophageal echocardiography ? a prospective observational study . Ann. Card. Anaesth 2020, 23 (4), 425 - 8.

Discrepancies have been reported in grading of severity of aortic stenosis. We propose to compare Aortic valve area by continuity equation, Dimensionless Index and Acceleration time/ Ejection time in patients with documented severe aortic stenosis with normal left ventricular function by TEE after induction of anesthesia. This might give use insight about the best parameter we can rely on intra-operatively for decision making. 60 patients with severe AS undergoing elective cardiac surgery were enrolled in our study. Post intubation trans-thoracic echocardiography (TEE) was performed and above mentioned parameters was noted. 96.7 % of patients continued in severe AS category when AS was measured using AVA as echo parameter. So there is 3.3 % disparity. There was disparity in 13.3 % of cases when DI was considered. And there was 43.3 % disparity when AT/ET was considered. Perioperative grading of aortic stenosis continues to be a challenge for cardiac anesthesiologists. Multiple echocardiographic parameters have to be considered. We have found AVA and DI to have less disparity compared to AT/ET.

1 illus, 3 tables, 18 ref

047420   SABZI F, ASADMOBINI A (Cardiovascular Research Centre, Kermanshah - 6715847145, Iran, Email: a.asadmobini@gmail. Com) : Gender difference in long-.and short-term outcomes of off-pump coronary endarterectomy . Ann. Card. Anaesth 2020, 23 (4), 419 - 24.

The role of gender in the selection of the most effective method for treatment of patients with diffused coronary artery diseases remains a matter of debate. This study thus evaluated the effect of gender on long- and short-term outcomes of off-pump coronary endarterectomy (CE). This was a single-center retrospective study of patients who had undergone coronary artery bypass graft (CABG). The patients were divided into two groups, the CABG and the CABG + CE group, and further stratified into male and female. Long-term survival for each group was estimated by Kaplan?Meier analysis with log-rank testing. In addition, Cox regression analyses of each gender were also carried out to identify the predictors of the primary and secondary endpoints. Overall, 25.8 % of the patients were female. Diseased vessels were not statistically different in the two groups ? men and women. There was no significant difference in postoperative outcomes between males and females in the CABG and CABG + CE groups. There was no significant difference in hospital mortality in the two groups between males and females. Kaplan?Meier curves show that there was no significant difference in the 5-year cardiac mortality between males and females belonging to the CABG and CABG + CE groups. The results of this study show that there was no significant difference in the short- and long-term outcomes of off-pump CABG and CE in both genders although women tend to carry a greater risk.

2 illus, 4 tables, 30 ref

047419   PILLAI V V, SREEKANTHAN R, KARUNAKARAN J (Cardiothoracic Surgery Dep, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, Email: drvivekpillai@ yahoo.co.in) : Quantitative estimation of LIMA blood flow between extraluminal papavarine vs extraluminal papavarine plus intraluminal vasodilator cocktail in CABG patients . Ann. Card. Anaesth 2020, 23 (4), 414 - 8.

In this study, we aimed at a comparative quantitative estimation of the difference in LIMA blood flow between LIMAs treated with topical papaverine alone and LIMAs treated with a combination of topical papaverine plus an intraluminal cocktail of papaverine, nitroglycerine, and milrinone. Nearly 50 consecutive patients with similar demographics undergoing elective on-pump CABG were recruited for the study. After pedicled LIMA harvest, topical papaverine was sprayed on the pedicle and kept enveloped in papaverine soaked gauze. LIMA flow was then estimated. Later, intraluminal vasodilator solution of papaverine, NTG, milrinone, and heparinized blood were instilled in LIMA, and LIMA flows were estimated. The mean LIMA flows with topical papaverine alone was 47.19 mL/min whereas the mean LIMA flows with topical papaverine plus intraluminal cocktail was 104 mL/min. There was a significant difference between the two flows as their mean was 56.815 mL/min and the paired t-test for significance had a P value of 0.0001. There was a significant difference in the LIMA flow when the LIMA had been treated with the intraluminal instillation of the vasodilator cocktail in addition to the topical application of papaverine solution. Therefore, intraluminal vasodilator cocktail of milrinone, NTG, and papaverine mixed with heparinized blood in addition to topical papaverine is a simple and effective method for LIMA preparation in CABG.

1 illus, 3 tables, 25 ref

047418   MAISAT W, SAWASDIWIPACHAI P, AROONRAT W, LAPMAHAPAISAN S (Anesthesiology Dep, Faculty of Medicine Siriraj Hospital, Bangkok - 10700, Thailand, Email: saowaphak.lap@gmail. Com) : Measurement of aortic root dimensions by transesophageal echocardiography in adult patients undergoing cardiac surgery . Ann. Card. Anaesth 2020, 23 (4), 409 - 13.

Normal aortic root dimensions were established from studies from Western countries. As the body size is significantly associated with the aortic root dimensions, Thai populations may have smaller aortic root diameters. To elucidate the aortic root dimensions using transesophageal echocardiography (TEE) in adult patients undergoing cardiac surgery. A retrospective cohort study including 150 patients aged >18 years undergoing cardiac surgery. Aortic root dimensions (annulus, sinus of Valsalva, sinotubular junction (STJ), and proximal ascending aorta) were measured using two-dimensional TEE. Patients with aortic-root related pathology were excluded. Men constituted 60% of the study population; the mean age was 61.9 ? 12.6 years, and mean body surface area (BSA) was 1.7 ? 0.2 m2. The absolute dimensions for the annulus, sinus of Valsalva, STJ, and proximal ascending aorta were 22.3 ? 3.4, 32.6 ? 3.9, 26.4 ? 3.3, and 29.3 ? 3.1 mm, respectively, in men (12.9 ? 1.6, 18.8 ? 2.6, 15.2 ? 2.1, and 17.9 ? 2.7 mm, respectively, after adjusting for BSA) and 20.3 ? 2.2, 29.8 ? 3.6, 23.8 ? 2.6, and 27.1 ? 3.1 mm, respectively, in women (13.5 ? 2.0, 19.8 ? 2.3, 15.8 ? 2.5, and 17.0 ? 2.1 mm, respectively, after adjusting for BSA). The absolute aortic root diameters were significantly greater in men at all levels (P < 0.001). The BSA-adjusted diameters were similar for both sexes at the annulus (P = 0.076) and STJ (P = 0.076), except for the sinus of Valsalva (P = 0.010) and proximal ascending aorta (P = 0.006). This study reports reference values of aortic root dimensions by TEE. The body size should be considered when comparing the aortic root dimensions of Thai populations with the standard normal values.

1 illus, 2 tables, 13 ref

047417   KAPOOR M C (Anaesthesia, Max Smart Super Specialty Hospital, Delhi - 110 092, Email: mukulanjali@gmail.com) : Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical Illness; Potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction . Ann. Card. Anaesth 2020, 23 (4), 391 - 400.

Severe cognitive decline and cognitive dysfunction has been attributed to patient?s stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.

3 illus, 3 tables, 115 ref

047416   RASTOGI A, TEWARI P (Anaesthesiology Dep, SGPGI, Lucknow, Uttar Pradesh, Email: amit.rastogi.sgpgi@ gmail.com) : Covid 19 and its cardiovascular effects. Ann. Card. Anaesth 2020, 23 (4), 401 - 8.

COVID-19 pandemic is mainly related with the pulmonary problems initially but now as the pandemic is growing it is observed that almost all organ systems of the body are affected. Up to 20-30 % patients who are admitted in Covid hospitals are showing cardiovascular involvement. Severity of cardiovascular disease in a COVID-19 patient depends whether a patient is having pre-existing cardiac disease or not. Patients with pre-existing cardiac disease have more severe infection and associated mortality. Severe COVID-19 infection shows close association with myocardial damage and various arrythmias. The cardiovascular involvement occurs by either engagement directly with the angiotensin converting enzyme 2 or indirectly by the effect of inflammatory mediators which are generated as a result of viral-host response to infection. The COVID-19 disease is said to produce a wide spectrum of affliction ranging between even asymptomatic patient to Cardiovascular syndrome. Even after recovering from COVID-19 patients can reappear in the hospital with cardiomyopathies and arrythmias.

7 illus, 1 table, 66 ref

047415   KAPOOR M C (Anaesthesia Dep, Max Smart Super Specialty Hospital, Delhi - 110 092, Email: mukulanjali@gmail.com) : Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 1: The problem; nomenclature; delirium and postoperative neurocognitive disorder; and the role of cardiac surgery and anesthesia . Ann. Card. Anaesth 2020, 23 (4), 383 - 90.

The association with cardiac surgery with cognitive decline was first reported in the 1960s after the introduction of coronary artery surgery. The incidence in cognitive decline was thought to be more after cardiac surgery, especially with the use of the cardiopulmonary bypass. Anesthesia and surgery are both associated with cognitive decline but many other factors appear to contribute its genesis. On-pump surgery, microembolization during manipulation of the heart and great vessels, temperature changes, pH changes, and altered cerebral perfusion, during cardiac surgery, have all been blamed for this. Postoperative cognitive decline is associated with poor clinical outcomes and higher mortality. Several studies have been conducted in the last decade to determine the genesis of this malady. Current evidence is absolving cardiac surgery and anesthesia to be the primary causes per se of cognitive dysfunction.

3 tables, 74 ref

047414   SURACI N, PRESTI S L, CONCEPCION G G, SANTANA O (Anesthesiology Dep, , Florida 33140, United States, Email: nicholas.suraci@gmail. Com) : Left ventricular pacemaker wire through patent foramen ovale. Ann. Card. Anaesth 2020, 23 (4), 528 - 9.

A 53-year-old male status post pacemaker placement three months prior for sinus bradycardia presented with worsening dyspnea, holosystolic murmur, and a ventricular-paced right bundle branch block on electrocardiogram. Transesophageal echocardiography demonstrated a pacer wire in the right atrium coursing into the left atrium and ventricle through an undiagnosed patent foramen ovale. The patient underwent surgical repair and repositioning of the pacemaker lead without complication. Although rare, it should be suspected after recent lead placement.

3 illus, 3 ref

047413   PRUTHI G, SINGH N G, NAGARAJA P S, BALAJI R M, THA N M, CHOUDHARY P K, KURINCHI R M (Cardiac Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru - 560 069, Karnataka, Email: docnag10@gmail.com) : Pharmacological preconditioning with intralipid in patients undergoing off-pump coronary artery bypass surgery . Ann. Card. Anaesth 2020, 23 (3), 327 - 31.

The objective of the study was to determine the preconditioning myocardial protective effects of intralipid (IL) in off-pump coronary artery bypass (OPCAB) surgery by measuring highly sensitive troponin T (hsTnT) and cardiac-specific creatine kinase (CK-MB) as markers of myocardial injury. Thirty patients, scheduled to undergo elective OPCAB surgery, were randomly assigned to the IL group (n = 15) or control (C) group (n = 15); the IL group received an infusion of 20 % IL 2 ml/kg, 30 min prior to revascularization and the control group received an equivalent volume of normal saline. Serum levels of hsTnT and CK-MB were measured before surgery and at 6 h, 24 h, 48 h, and 72 h postoperatively. Also, intraoperative hemodynamic parameters, inotrope use, ventilatory hours, ICU stay, postoperative left ventricular ejection fraction, postoperative lipid profile, renal and hepatic function tests were measured. The hsTnT values at the 24 h, 48 h, and 72 h in IL group were significantly lower as compared with the control group. The decline in plasma levels of CK-MB mirrored the hsTnT levels post revascularization at 24 h and 48 h in the IL group compared with the control group; however, at 72 h, level was comparable in both the groups. None of the treated patients had abnormal lipid metabolism, deranged renal, and hepatic function. The study revealed Intralipid as a safe pharmacological preconditioning agent for OPCAB surgeries which can reduce the postischemic myocardial injury indicated by the reduction in postischemic cardiac enzymes hsTnT and CK-MB.

1 illus, 3 tables, 17 ref

047412   DIPROSE P, FOGG K J, PITTARELLO D, GAMMIE J S, D?AMBRA M N (Univ Hospital Southampton NHS Trust, Southampton, UK, Email: drpdiprose@gmail.com) : Intensive care and anesthesia management for harpoon beating heart mitral valve repair . Ann. Card. Anaesth 2020, 23 (3), 321 - 6.

Patients with severe mitral valve regurgitation secondary to degenerative disease are known to benefit from mitral valve repair surgery. Novel techniques for achieving mitral valve repair on the beating heart have been developed and are being introduced into clinical practice. The HARPOON Beating Heart Mitral Valve Repair System (MVRS) in recent studies has demonstrated efficacy and safety for the repair of degenerative mitral valve disease on the beating heart. The device uses transoesophageal echocardiographic guidance to implant artificial expanded polytetrafluoroethylene (ePTFE) cords on prolapsed mitral valve leaflets in the beating heart. It requires general anaesthesia and there are specific intensive care and anaesthesia considerations for the safe management of these cases. This article describes the general principles of intensive care and anaesthesia management employed for the initial patients treated with the HARPOON Beating Heart MVRS, the outcomes for these patients, and the potential challenges for the future management of these cases.

3 illus, 2 tables, 11 ref

047411   GOVIL N, PARAG K, KUMAR B, KHANDELWAL H, DUA R, SIVAJI P (Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun - 248 001, Uttarakhand, Email: dr_parag1@yahoo.com) : Translation, cultural adaptation, and validation of the duke activity status index in the hindi language . Ann. Card. Anaesth 2020, 23 (3), 315 - 20.

The Duke Activity Status Index (DASI) is a validated questionnaire in English to assess the functional capacity (FC) of patients with cardiovascular disease (CVD). The aim of the study is to translate, cross-culturally adapt, and validate the DASI in Hindi. Observational validation study. Different translators translated the DASI into Hindi and then back-translated it into English. Validation for feasibility and psychometric properties of translated questionnaire was done on 200 adults, Hindi-speaking patients with CVD, who were advised exercise testing by a cardiologist. Internal consistency (Cronbach?s ?) and test?retest reliability (Pearson?s correlation coefficient) were calculated. Construct (correlation with the Canadian Cardiovascular Society Classification [CCSC] for angina and exercise capacity with treadmill testing [TMT]) and content validity (time taken to fill the questionnaire, ease of understanding the questionnaire items, and comprehensibility) were calculated. P < 0.05 was considered significant. The Cronbach?s ? for internal consistency was 0.78, which indicates adequate relatedness among the items of questionnaire, and the test?retest reliability was 0.65 (P < 0.05). A significant correlation between CCSC (r = ?0.60) and TMT (r = 0.56) was found. The median time taken by the respondents to fill the questionnaire was 4 min. Of all the respondents, 95.74 % of the respondents agreed that the Hindi questionnaire was easy to comprehend and 97.87 % patients correlated the translated items to their daily physical activity. The Hindi translated and culturally adapted version of the DASI is reliable, valid, and feasible to assess the FC in the Hindi-speaking CVD patients.

1 illus, 1 table, 24 ref

047410   YUHE K, CHEW S T H, ANG A S, NG R R G, BOONKIANGWONG N, LIU W, TOH A H H, CALEB M G, HO R C M, TI L K (Anesthesia Dep, National Univ Health System, Singapore, Email: lian_kah_ti@nuhs.edu.sg) : Comparison of postoperative cognitive decline in patients undergoing conventional vs miniaturized cardiopulmonary bypass: A randomized, controlled trial . Ann. Card. Anaesth 2020, 23 (3), 309 - 14.

Neurocognitive dysfunction is a common complication of coronary artery bypass grafting (CABG) with incidence of 19?38 %. The miniaturized cardiopulmonary bypass (MCPB) system was developed to reduce hemodilution and inflammation and provides better cerebral protection than conventional cardiopulmonary bypass (CCPB). In a meta-analysis, MCPB was associated with a 10-fold reduction in the incidence of strokes. However, its effect on postoperative cognitive decline (POCD) is unknown. We assessed if MCPB decreases POCD after CABG and compared the risk factors. A total of 71 Asian patients presenting for elective CABG at a tertiary center were enrolled. They were randomly assigned to MCPB (n = 36) or CCPB group (n = 35) and followed up in a single-blinded, prospective, randomized controlled trial. The primary outcome was POCD as measured by the repeatable battery of neuropsychological status (RBANS). Inflammatory markers (tumor necrosis factor-alpha and interleukin-6), hematocrit levels, and neutron-specific enolase (NSE) levels were studied. Overall, the incidence of POCD at 3 months was 50 %, and this was not significantly different between both groups (51.4 vs 50.0 %, P = 0.90). Having <6 years of formal education [risk ratio (RR) = 3.014, 95 % confidence interval (CI) = 1.054?8.618, P = 0.040] was significantly associated with POCD in the CCPB group, while the lowest hematocrit during cardiopulmonary bypass was independently associated with POCD in the MCPB group (RR = 0.931, 95% CI = 0.868?0.998, P = 0.044). The postoperative inflammatory markers and NSE levels were similar between the two groups. This study shows that the MCPB was not superior to CCPB with cell salvage and biocompatible tubing with regard to the neurocognitive outcomes measured by the RBANS.

1 illus, 3 tables, 27 ref

047409   FRANCHI F, BALDINI G, MAUTONE M, TACCONE F S, SANTIS P D, ROCCO A S, MARCHETTI L, SCOLLETTA S (Medicine Dep, Univ of Siena, Siena , Italy, Email: sabino.scolletta@ dbm.unisi.it) : Evaluation of arterial stiffness in cardiac surgical patients using applanation tonometry . Ann. Card. Anaesth 2020, 23 (3), 302- 8.

Applanation tonometry enables the noninvasive analysis of arterial pressure wave morphology. Applanation tonometry provides the augmentation index (AIx, %), an index of arterial stiffness that partially reflects arterial-ventricular (A-V) coupling. In addition, applanation tonometry provides the dP/dt (rate of intraventricular pressure variation over time), which reflects myocardial contractility, and the sub-endocardial viability ratio (SEVR, %), which is an indicator of myocardial oxygen supply and demand. There are no data on how cardiac surgery can modify these tonometry-derived indexes. The aim was to assess changes in AIx, dP/dt, and SEVR in patients undergoing cardiac surgery. This observational study was conducted at the University Hospital of Siena. We studied 32 patients before cardiac surgery in intensive care unit (ICU) on admission and at ICU discharge. We measured AIx, dP/dt, and SEVR using applanation tonometry (SphygmoCor). Changes in variables over time were evaluated by analysis of variance for repeated measurements. AIx decreased significantly from T1 [28.8 %, interquartile range (IQR) 21.6?36.6 %] to T2 (16.2 % IQR 8.1?22.4 %) and T3 (14.5 % IQR 7.9?23.6 %) (P = 0.01). dP/dt increased significantly from T1 (635 mmHg/ms, IQR 534?756 mmHg/ms) to T3 (751 mmHg/ms, IQR 651?1013 mmHg/ms; P = 0.03). The SEVR was lower at T2 than at T1, but returned toward T1 values by T3. Cardiac surgery was associated with an improvement in arterial stiffness, A-V coupling, and myocardial contractility as assessed using applanation tonometry. The results suggest, however, a transient imbalance between myocardial oxygen supply and demand in the immediate postoperative period.

4 illus, 2 tables, 23 ref

047408   CHAKRAVARTHY M, PRABHAKUMAR D T, SHIVALINGAPPA B, RAO S, PADGAONKAR S, HOSUR R, HARIVELAM C, JAWALI V (Anesthesia Dep, Fortis Hospitals, Bengaluru -?560 076, Email: mailchakravarthy@ gmail.com) : Routine preoperative doppler ultrasound examination of arterial system in patients undergoing cardiac surgery is beneficial: A retrospective study . Ann. Card. Anaesth 2020, 23 (3), 298 - 301.

Presence of peripheral vascular disease enhances surgical risk in cardiac surgical patients. Prior knowledge of peripheral arterial disease may help the physician make changes in the monitoring and cardiopulmonary bypass cannulation plans. It is claimed that the incidence of peripheral vascular disease in cardiac surgical patients ranges from 11 to 30 %. This study was conducted to understand the characteristics of peripheral vascular disease and their implication on cardiac surgery. This was a prospective study undertaken in a tertiary referral hospital. All adult patients who underwent cardiac surgery during the period of six months were included. A Doppler examination of the neck, upper limb, abdomen and lower limb was carried out by our inhouse radiologist. The incidence of peripheral vascular disease, the implication on invasive pressure monitoring site and cannulation for cardiopulmonary bypass or intraaortic balloon pump or extracorporeal membrane oxygenation were made note of. During the said period, six hundred twenty eight patients underwent cardiac surgery, of whom five hundred and sixty-one patients who underwent CABG surgery. All these were subjected to Doppler examination. We observed peripheral arterial disease in 105 patients (20 %). In general men suffered from PAD more often than women. Monitoring site of invasive arterial pressure, the choice of beating heart surgery, insertion of intraaortic balloon pump, femoral arterial route for cardiopulmonary bypass were some of the decision that were altered. Performing Doppler examination in cardiac surgical patients may yield important data that might prevent complications and support patient safety.

5 illus, 3 tables, 12 ref

047407   HEMPEL C, TURTON E, HASHEMINEJAD E, BEVILACQUA C, HEMPEL G, ENDER J, ROTZOLL D (Anaesthesiology and Intensive Care Medicine Dep, Heart Center Leipzig, Leipzig, Germany, Email: J?rg.ender@medizin. uni-leipzig.de) : Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students . Ann. Card. Anaesth 2020, 23 (3), 293 - 7.

Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination. A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the HeartworksTM, (Cardiff, UK) and the CAE Vimedix?, (Qu?bec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSSTM 24, IBM, USA) using the Mann-Whitney-Test to compare both groups. Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students. Both teaching methods are effective and lead to the intended level of knowledge and skills.

1 illus, 1 table, 22 ref

047406   ELGEBALY A S, ANWAR A G, FATHY S M, SALLAM A, ELBARBARY Y (Anesthesiology Dep, Surgical Intensive Care and Pain Medicine, Elgharbia, Egypt, Email: elgebaly_13@hotmail. Com) : The accuracy of electrical cardiometry for the noninvasive determination of cardiac output before and after lung surgeries compared to transthoracic echocardiography . Ann. Card. Anaesth 2020, 23 (3), 288 - 92.

The anatomical changes associated with lung surgeries may decrease cardiac output and heart function. Therefore, monitoring of cardiac output (CO) is of significant value in these patients for clinical decision-making. This study is to evaluate the reliability of electrical cardiometry (EC) for the noninvasive continuous determination of CO after lobectomy or pneumonectomy compared to transthoracic echocardiography (TTE). This study was carried out on 60 patients, age ?18 years scheduled for elective lung surgery (lobectomy or pneumonectomy). All patients underwent simultaneous measurement by EC using the ICON_ device and by TTE by measuring left ventricle outflow tract diameter (LVOT) and velocity time integral (VTI). Heart rate (HR), systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), stroke volume index (SVI), CO, and cardiac index (CI) were measured 1 day before the surgery and 7 days after the surgery. There was no significant difference between TTE and EC regarding preoperative and postoperative HR, SV, SVI, CO, and CI. There was a strong positive correlation between TTE and EC as regard preoperative and postoperative HR, SV, SVI, CO, and CI. Bland and Altman analysis showed low bias with accepted limits of agreement of HR, SV, SVI, CO, and CI. Postoperative readings showed a significant increase in HR and a significant decrease in SV and CO (either by TTE or EC), SBP, and DBP as compared to preoperative reading. Compared to the TTE, EC provides accurate and reliable CO, SV, and HR measurements before and even after lung surgeries.

2 illus, 6 tables, 15 ref

047405   HEMAMALINI P, DUTTA P T, ATTAWAR S (Cardiac Anesthesia Dep, Institute of Heart and Lung Transplantation, Chennai, Tamil Nadu, Email: drhema07@yahoo.com) : Transesophageal echocardiography compared to fluoroscopy for avalon bicaval dual-lumen cannula positioning for venovenous ECMO . Ann. Card. Anaesth 2020, 23 (3), 283 - 7.

The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80 %) placed under fluoroscopy required repositioning whereas one cannula (20 %) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.

3 illus, 2 tables, 25 ref

047404   GUILLET L, MOURY P H, BEDAGUE D, DURAND M, MARTIN C, PAYEN J F, CHAVANON O, ALBALADEJO P (Hopital Michallon, Grenoble, France, Email: MDurand@ chu-grenoble.fr) : Comparison of the additive, logistic european system for cardiac operative risk (EuroSCORE) with the EuroSCORE 2 to predict mortality in high-risk cardiac surgery . Ann. Card. Anaesth 2020, 23 (3), 277 - 82.

The aim of this study was to compare the new EuroSCORE (ES) 2 prediction model in high-risk patients with the 2 other oldest additive ES (aES) and logistic ES (lES). Consecutive adult patients undergoing all cardiac surgery except heart transplantation and left ventricular assist device were included. The 3 risk scores were collected before surgery. We defined 4 high-risk groups of patients, patients ?80 years, combined cardiac surgery, surgery of the thoracic aorta, and emergency cardiac surgery, and 2 low-risk groups, valve surgery and coronary artery bypass surgery. The predicted value of each score has been assessed by the area under the receiver operating characteristics curve (AUC). The study had included 3301 patients. Thirty-day mortality was 3.9 % (95 % confidence interval (CI), 3.3 ? 4.6 %). The AUC of ES2 was 0.81 (0.77 ? 0.84), 0.82 (0.78 ? 0.85), 0.70 (0.64 ? 0.76), 0.79 (0.74 ? 0.83), 0.85 (0.83 ? 0.87), and 0.88 (0.86 ? 0.90) for octogenarians, thoracic aortic surgery, combined surgery, emergency surgery, coronary surgery, and valve surgery, respectively. These ES2 AUC values were higher than those obtained with the aES for octogenarians, and with the lES for octogenarians and valve surgery. The ES2 calibration was better than the aES and lES calibration for the whole population, and low-risk groups. The ES2 calibration was superior to aES and lES in high-risk groups, except for octogenarians and thoracic aortic surgery compared to lES. In high-risk cardiac surgery patients, ES2 only marginally improve the predicted 30-day mortality in comparison to other ES.

1 illus, 4 tables, 29 ref

047403   ELGEBALY A S, MOURAD M B E, FATHY S M (naesthesia and SICUD Dep, , Tanta, Egypt, Email: elgebaly_13@hotmail. Com) : The role of entropy monitoring in reducing propofol requirements during open heart surgeries. a prospective randomized study . Ann. Card. Anaesth 2020, 23 (3), 272 - 6.

Hypotension, which is commonly associated with propofol induction of general anesthesia in coronary artery bypass grafting (CABG) surgery, may cause adverse consequences in patients with coronary artery diseases undergoing this type of surgeries. The clinical absence of verbal response and eyelash reflex was used as an endpoint for hypnosis. Spectral entropy, as a novel monitoring method for the endpoint of hypnosis, affect the dose of required anesthetic agents for induction as well as the hemodynamic profile during general anesthesia in CABG surgery. We hypothesized that entropy monitoring might reduce the dose of propofol required for induction of anesthesia during CABG surgery and could maintain hemodynamic stability when compared with the conventional clinical monitoring. Sixty adult patients of both sexes, aged 30?60 years, ASA II and III, and scheduled for CABG surgery were enrolled in this prospective, controlled, randomized, double-blind study. These patients were randomly divided into two equal groups to receive intravenous propofol for induction of anesthesia guided by either the patients? clinical response (Group I) or by entropy monitoring (Group II). The total dose of propofol used for induction of anesthesia was recorded. Hemodynamic parameters and entropy values were also recorded. Propofol consumption was significantly reduced in Group II than Group I (P = 0.000*). Heart rate showed no statistical significance between the two groups, whereas the mean arterial pressure significantly decreased at induction in group I compared to Group II (P = 0.000*). The entropy values were significantly lower in Group I than Group II at induction (P = 0.036* for state entropy; 0.002* for response entropy). However, during intubation, and after 1 and 5 min, entropy indices displayed a significant increase in Group I than Group II. Entropy monitoring significantly reduced the dose of propofol required for induction of anesthesia and maintained hemodynamic stability compared to the conventional clinical monitoring during CABG surgeries.

3 illus, 2 tables, 21 ref

047402   SURACI N, HOYOS J, BARUQUI D, SANTANA O (Anesthesiology Dep, Mount Sinai Medical Center, Florida 33140, USA, Email: nicholas.suraci@gmail. Com) : Right ventricular outflow tract obstruction due to a leiomyosarcoma. Ann. Card. Anaesth 2020, 23 (3), 338 - 9.

A 65-year-old female presenting with worsening dyspnea and notable weight loss were found to have a systolic murmur on physical examination. On workup with computed tomography (CT) angiogram, a solid mass was found extending from the inferior vena cava into the right ventricle. Transesophageal echocardiography demonstrated this mass extension causing right ventricular outflow tract obstruction. After surgical removal, the pathology of the mass was endometrial leiomyosarcoma.

3 illus, 4 ref

047401   SHASHIKANTH M, NICOLA S, CHEN YI, JULIAN S (Casey Hospital, Victoria, Australia, Email: smanikappa@gmail.com) : Right atrial cavernous hemangioma. Ann. Card. Anaesth 2020, 23 (3), 335 - 7.

Benign cardiac hemangiomas are rare tumors that may present in or out side of the heart, epicardium being the most common site. Echocardiography is the method of choice in diagnosing cardiac masses and though 3D TEE may seem to add exact information about the location, the time constraint in doing a comprehensive examination along with 3D rendering inside operation room may become an hindrance.

5 illus, 4 ref

047400   SHABADI R, DESAI P, CHENGODE S (Anesthesia and Intensive Care Dep, Sultan Qaboos Univ Hospital, Muscat, Sultanate of Oman, Email: drrahool@yahoo.com) : Intraoperative 2D and 3D transesophageal echocardiographic assessment of cor triatriatum with ostium secundum atrial septal defect in an adult patient . Ann. Card. Anaesth 2020, 23 (3), 332 - 4.

Cor triatriatum is a rare congenital cardiac anomaly. Majority of the cases present in the childhood with an incidence of 0.4 %. However, we report a case of cor triatrium sinister with ostium secundum atrial septal defect (ASD) in a 39-year-old female. The intraoperative 3D transesophageal echocardiography (TEE) offers an advantage over 2D TEE in visualizing the interatrial septum and the attachments of the fibromuscular accessory membrane in the left atrium (LA), which could help in surgical decision-making in this patient.

5 illus, 4 ref

047399   ORA M, GAMBHIR S (Nuclear Medicine Dep, SGPGIMS, Lucknow -?226 014, Uttar Pradesh, Email: gaambhir@yahoo.com) : Nuclear investigative techniques and their interpretation in the heart and vascular disease . Ann. Card. Anaesth 2020, 23 (3), 262 - 71.

Over the last several decades, myocardial perfusion imaging with single photon emission tomography and positron emission tomography has been a mainstay for the evaluation of patients with known or suspected coronary artery disease non-invasively. Technical advances in imaging modalities and radiopharmaceutical have revolutionaries the understanding of pathogenesis and management of various diseases. In this article, we shall discuss the various available imaging nuclear medicine techniques, radiopharmaceutical, and common indications. In the era of ?precision medicine,? imaging has to be patient centered. We will briefly review the upcoming areas of nuclear medicine imaging apart from perfusion imaging, such as advances in myocardial blood flow quantitation and molecular imaging.

7 illus, 1 table, 43 ref

047398   KAR P, RAMACHANDRAN G (Anesthesia and Intensive Care Dep, Nizams Institute of Medical Sciences, Hyderabad - 500 082, Telangana, Email: prachikar@yahoo.co.in) : Pain relief following sternotomy in conventional cardiac surgery: a review of non neuraxial regional nerve blocks . Ann. Card. Anaesth 2020, 23 (2), 200 - 8.

Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques.

6 illus, 2 tables, 30 ref

047397   AGGARWAL N K, SUBRAMANIAN A (Cardiac Anesthesia Dep, Manipal Hospitals, Dwarka, New Delhi - 110 075, Email: aruncardiac@live.com) : Antifibrinolytics and cardiac surgery: the past, the present, and the future . Ann. Card. Anaesth 2020, 23 (2), 193 - 9.

Cardiac surgery is usually associated with significant blood loss, which often necessitates blood transfusion. In order to decrease the risks associated with the latter, pharmacological as well as nonpharmacological strategies have been used to reduce blood loss. Among the pharmacological approaches, antifibrinolytic drugs are the mainstay. Aprotinin, which was the first ubiquitously used drug, fell into disrepute only to re-emerge after much debate. The decline of aprotinin paved the way for the lysine analogs. However, we must be aware with the side effects of these drugs as well as the dose modification required in special situations. Nonsaccharide glycosaminoglycans have been under investigation to overcome the drawbacks of the lysine analogs. It remains to be seen whether these drugs can replace the traditional antifibrinolytics.

90 ref

047396   BHAVYA G, NAGARAJA P S, SINGH N G, RAGAVENDRAN S, SATHISH N, MANJUNATH N, KUMAR K A, NAYAK V B (Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore - 560 069, Karnataka, Email: naveengsingh@hotmail. Com) : Comparison of continuous cardiac output monitoring derived from regional impedance cardiography with continuous thermodilution technique in cardiac surgical patients . Ann. Card. Anaesth 2020, 23 (2), 189 - 92.

Cardiac output (CO) assessment is a corner stone in advanced haemodynamic management, especially in critical ill patients. The present study was conducted to validate cardiac index and cardiac output by NICaS? with the thermodilution technique using pulmonary artery catheter in post-operative cardiac surgical patients. This was a prospective observational clinical study conducted at a tertiary care hospital. 23 adult patients in the age range of 18-65 years who had undergone for elective coronary artery bypass grafting were included in the study. Spearman?s correlation coefficient of cardiac index between continuous Thermodilution (cTD) and Non-Invasive Cardiac System (NICaS?) showed a good correlation (r = 0.765, 95 % confidence interval 0.70 to 0.82, P < 0.0001). There was a good correlation between cTD and NICaS? for cardiac output (r = 0.759, 95 % confidence interval 0.69 to 0.81, P < 0.0001), Bland-Altman plot for cardiac index between cTD and NICaS? showed a mean bias of ?0.66 ? 0.6919 with limits of agreement being ?2.02 to 0.6936. Bland-Altman plot for cardiac output between cTD and NICaS? showed a mean bias of ?1.0386 ? 1.17 with limits of agreement being ?3.34 to + 1.26. Percentage error for cardiac index and cardiac output were 64.78 % and 64 % respectively. Polar plot analysis showed an angular bias of 6.32? with radial limits of agreement being ?8.114? to 20.75? for cardiac index and angular bias of 5.6682? with radial limits of agreement being ?9.1422? to 20.4784? for cardiac output. NICaS? demonstrated a good trending ability for both CI and CO. However, NICaS? derived parameters are not interchangeable with the values derived from continuous thermodilution technique.

5 illus, 11 ref

047395   ASAI O G, PRABHAKAR V, MANJUNATHA N (Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore - 560 069, Karnataka , Email: omshubham.asai@ gmail.com) : Comparison of upper thoracic epidural analgesia versus low thoracic epidural analgesia in off-pump coronary artery bypass graft for perioperative pain management and fast tracking . Ann. Card. Anaesth 2020, 23 (2), 183 - 8.

Upper thoracic epidural analgesia (TEA) is compared with lower thoracic epidural analgesia for the perioperative pain management and fast tracking in patients undergoing off pump coronary artery bypass grafting (OPCAB) surgery for the intraoperative hemodynamic, quality of analgesia, incentive spirometry, time to awakening & extubation and intensive care unit (ICU) duration. A prospective, randomized comparative clinical study was conducted with total of 60 patients randomized to either Group U: Upper TEA (n = 30) or Group L: Lower TEA (n = 30). Visual analog scale (VAS) was recorded in both the groups during rest and deep breathing at the various time intervals postextubation. Both the groups were also compared for intraoperative hemodynamics, incentive spirometry, time to awakening, and extubation and ICU duration. Statistical analysis was performed using the independent Student?s t-test. A value of P < 0.05 was considered statistically significant. Postextubation VAS score at rest and deep breathing at 0, 3, 6, 12, 24, 36, and 48 h were statistically significant in both groups (P ? 0.05). Incentive spirometry, time to awakening and extubation and duration of ICU stay were also statistically significant (P ? 0.05) between the groups. Lower thoracic epidural was better than upper thoracic epidural in perioperative pain management and fast tracking in OPCAB surgery.

4 illus, 5 tables, 15 ref

047394   DASTAN F, LANGARI Z M, SALAMZADEH J, KHALILI A, AQAJANI S, JAHANGIRIFARD A (Shahid Beheshti Univ of Medical Sciences, Tehran, Iran, Email: alirezajahangiri@sbmu. ac.ir) : A comparative study of the analgesic effects of intravenous ketorolac, paracetamol, and morphine in patients undergoing video-assisted thoracoscopic surgery: a double-blind, active-controlled, randomized clinical trial . Ann. Card. Anaesth 2020, 23 (2), 177 - 82.

Opioids are traditionally used as the drug of choice for the management of postoperative pain. However, their use is limited in patients undergoing Video-assisted thoracic surgery (VATS), due to their side effects, such as respiratory depression, nausea, and vomiting. In this double-blind active-controlled randomized study, we have compared the analgesic effects of ketorolac and paracetamol to morphine. Patients were randomly chosen from a pool of candidates who were undergoing VATS and were divided into three groups. During the first 24 h postsurgery, patients in the control group received a cumulative dose of morphine 20 mg, while patients in two treatment groups received ketorolac 120 mg and paracetamol 4 g in total. Doses were administered as bolus immediately after surgery and infusion during the first 24 h. Patients? pain severity was evaluated by visual analogue scale rating (VAS) at rest and during coughing episodes. The average pain score at recovery time was 2.29 ? 2.13 and 2.26 ? 2.16 for ketorolac and paracetamol, respectively, and it was significantly lower than the morphine group with an average pain score of 3.87 (P = 0.003). Additionally, the VAS score during cough episodes was significantly higher in the control group throughout the study period compared to study groups. Comparison of mean morphine dose utilized as liberation analgesic (in case of patients had VAS >3) between three groups was not significantly different (P = 0.17). Our study demonstrates the non-inferiority of ketorolac and paracetamol to morphine in controlling post-VATS pain without causing any significant side effects. We also show that ketorolac and paracetamol are superior to morphine in controlling pain during 2 h postsurgery.

1 illus, 3 tables, 30 ref

047393   CHANDRAN R, SREEDHAR R, GADHINGLAJKAR S, DASH P, KARUNAKARAN J, PILLAI V (Anesthesia Dep, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, Email: rupa@sctimst.ac.in) : Combined effect of left stellate ganglion blockade and topical administration of papaverine on left internal thoracic artery blood flow in patients undergoing coronary revascularization . Ann. Card. Anaesth 2020, 23 (2), 170 - 6.

Left stellate ganglion blockade (LSGB) may have additive effect to topical administration of papaverine on prevention of vasospasm of left internal thoracic artery (LITA). This study aims to compare LITA blood flow with topical application of papaverine alone or in combination with LSGB. Tertiary care hospital. Prospective randomized controlled study. A total of 100 patients operated for coronary revascularization were randomly and equally allocated into two groups. In control Group-C, papaverine was applied topically during the dissection of LITA. In Group-S, the additional LSGB was performed. Blood flow was measured from cut end of the LITA for 15 s. Primary objectives of the evaluation were to observe differences in the LITA blood flow. Observing incidence of radial-femoral arterial pressure difference after cardiopulmonary bypass (CPB) was secondary objective. Student?s unpaired t-test and Fisher?s exact test to find out a significant difference between the groups. LITA flow in Group-S was insignificantly more (49.28 ? 7.88 ml/min) than Group-C (47.12 ? 7.24 ml/min), (P = 0.15). Radio-femoral arterial pressure difference remained low for 40 min after termination of CPB in the Group-S compared to the Group-C (?0.99 ? 1.85 vs. ?1.92 ? 2.26). Combining LSGB with papaverine does not increase the LITA blood flow compared to when the papaverine is used alone. However, ganglion blockade reduces radial-femoral arterial pressure difference after CPB. Blockade can be achieved successfully under the ultrasound guidance without any complications.

2 illus, 2 tables, 27 ref

047392   ARASU T, RAGAVENDRAN S, NAGARAJA PS, SINGH N G, MANJUNATHA N, BASAPPANAVAR V S (Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru - 560 069, Email: docnag10@gmail.com) : Comparison of pectoral nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion ? a pilot study . Ann. Card. Anaesth 2020, 23 (2), 165 - 9.

Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone. Thirty adult patients between the age group of 18?85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block (n = 15) or Group PT: PECS1 and TTM blocks (n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure. VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure (P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT (P = 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT (P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT (P = 0.0003). Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

2 illus, 3 tables, 16 ref

047391   HAMABA H, MIYATA Y, WADA T, TOMOHIKO HAYASAKA, HAYASHI Y (Sakurabashi-Watanabe Hospital, Osaka, Japan, 530 - 0001, Email: yhayashi@anes.med. osaka-u.ac.jp) : An analysis of prior experience influencing quality of pulmonary artery catheter placement in residents . Ann. Card. Anaesth 2020, 23 (2), 161 - 4.

Prior experience may be important for successful placement of a pulmonary artery catheter (PAC). However, there is no report about the minimum number of the placement to reach acceptable technique for the catheter placement during residency.This study was designed to examine quality of the catheter placement and to assess the effect of prior experience. Prospective, observational, cohort study. This study included eight residents and one experienced staff in our hospital. We prospectively examined the performance of placement of a PAC in eight residents for the first 2 months of their training period and one staff for previous 2 years. We examined the time required for the catheter placement and probability of ventricular arrhythmias during the placement. Each resident and the staff reported approximate number of past experience of the catheter placement according to the self-statement. In addition, we continued to examine the placement of a PAC in one resident with zero experience to show his improvement. Statistical analysis was performed by Kruskal?Wallis test, Mann?Whitney test, or Fisher?s exact test as appropriate and Benjamini and Hochberg method was used for multiple comparisons. The catheter placement time and probability of the ventricular arrhythmias of two residents with zero experience of the placement were significantly larger than those of the staff. On the other hand, the placement quality of the other residents who experienced at least 20 PAC placements was not significantly different from that of the staff. The placement quality of one resident with zero experience became comparable with that of the staff after 20 placements. Our data suggested that about 20 catheter placements may be required to reach acceptable technical level for the PAC placement.

3 tables, 8 ref

047390   ELGEBALY A S, FATHY S M, ELBARBARY Y, SALLAM A A (Anesthesia Dep, Tanta Univ, Tanta, Egypt, Email: elgebaly_13@hotmail. Com) : High thoracic epidural decreases perioperative myocardial ischemia and improves left ventricle function in aortic valve replacement alone or in addition to cabg surgery even with increased left ventricle mass index . Ann. Card. Anaesth 2020, 23 (2), 154 - 60.

High thoracic epidural (HTE) may reduce perioperative tachyarrhythmias, respiratory complications and myocardial ischemia (MI) and it may increase coronary perfusion and myocardial oxygen balance through sympatholysis and pain control. The aim of this study is to investigate the benefit of HTE in patients undergoing aortic valve replacement (AVR) alone or in addition to coronary artery bypass graft (CABG). Methods: This prospective randomized controlled study was conducted on 80 patients (40 with increased left ventricular mass index (LVMI) and 40 with normal LVMI) who were equally randomised (n = 40) to receive either GA with HTE (HTE group) or GA alone (GA group). Heart rate (HR), mean arterial blood pressure (MAP) and the incidence of ischemic ECG changes were recorded. LV functions (preoperative and postoperative by transthoracic echocardiography and intraoperative by transoesophageal echocardiography) were measured preoperative, intraoperative and till 48 H postoperative. Results: There was no significant difference in the baseline values of all measurements. HR and MAP were lower, and LV functions were improved in HTE group intraoperatively and postoperatively. Ischemic ECG changes were significantly lower in HTE group; with 42.9 % intraoperative risk reduction (95 % CI: 0.195-0.943) and 46. 6 % postoperative risk reduction (95 % CI 0.227-0.952) as compared to GA group. The risk of ischemia was significantly higher in patients with increased LVMI in GA group (2.25 times compared to normal LVMI patients with 95 % CI: 1.195-4.236), but it wasn?t increased in HTE group. LV functions were significantly improved from the induction to 48 H postoperative in HTE group as compared to GA group. Conclusion: HTE reduced the incidence of MI and improved the LV function, even with increased LVM, in patients undergoing AVR alone or in addition to CABG.

1 illus, 4 tables, 23 ref

047389   ELGEBALY A S, FATHY S M, ELMORAD M B, SALLAM A A (and PSIC, , Tanta, Egypt, Email: elgebaly_13@hotmail. Com) : Blood transfusion and lung surgeries in pediatric age group: A single center retrospective study . Ann. Card. Anaesth 2020, 23 (2), 149- 53.

Blood transfusion is not without harm, and recent studies suggest association between transfusion and poor outcome in critically ill patients. Although it is prescribed for many reasons based on the firm belief that blood transfusion improves oxygen carrying capacity, it carries notable adverse hazards. Importantly, lung surgeries are counted as moderate to high-risk operations and take a significant risk of blood loss. This study aims to reveal the association between blood transfusion and poor clinical outcomes and characterize the epidemiology of blood transfusion after pediatric chest surgery. Retrospective cohort study, done throughout 3 years. A total of 248 patients who underwent open thoracotomy and lung surgery and aged ?18 years were classified according to the need of intraoperative or postoperative blood transfusion into two groups: Group I (non-transfused = 130) and Group II (transfused = 118). SPSS v25 was used for analysis. Transfusion probability ranged between 42.8 % and 50 % according to type of surgery. As regard to postoperative variables, there was no significant difference between both groups regarding the duration of analgesia, allergic reactions, need of re-operation and in-hospital mortality. However, transfused group showed significant increase in duration of antibiotic, persistent postoperative fever, time to remove chest drains, ICU stays, hospital stay and pneumonia. Incidence of pneumonia had a relative risk 1.82 with transfused compared to non-transfused group. Transfusion group in pediatrics undergoing lung surgeries in our study was more prone to adverse outcomes such as pneumonia, delayed time to remove chest drains, prolonged ICU stay, and hospital stay.

4 tables, 23 ref

047388   BHAVSAR R, RYHAMMER P K, GREISEN J, JAKOBSEN C (Anesthesiology and Intensive Care Dep, Aarhus Univ Hospital, Denmark, Email: cjj@dadlnet.dk) : Fast-track cardiac anaesthesia protocols: Is quality pushed to the edge? . Ann. Card. Anaesth 2020, 23 (2), 142 - 8.

The quest for methods expediting rapid postoperative patient turnover has triggered implementation of various fast-track cardiac anaesthesia protocols. Using three different fast-track protocols in randomized controlled studies (RCT) conducted 2010-2016 we found minimal achievements in ventilation time together with actual and eligible length of stay in cardiac recovery unit. The comparable control group patients were evaluated in this retrospective post hoc analysis, for an association between above mentioned parameters and quality parameters, to assess whether the marginal gains have been at the expense of quality of recovery and patient comfort. 90 control patients from three RCT with comparable demographic parameters and receiving standard department treatment were evaluated using time parameters and an objective/semi-objective Intensive Care Unit (ICU) score system (IDS score). Ventilation time was statistical significant lower in latest study (C) than the early (A) and intermedium (B) studies (A=293, B=261, C=205 minutes; P=0.04). The IDS was lower at extubation and all time points in the early study compared to other studies (P< 0.001;). The average IDS in latest study were the double of previous studies at the end of observations, and marginally above the acceptable score for discharge. The postoperative morphine requirement A=15.0, B=10.0 and C=26.5 mg; P=0.002) was statistical significant higher in the latest study compared to previous studies. The implementation of strict fast-track protocols resulting in shorter ventilation time did not convert to earlier eligibility to discharge from the ICU. However, the quality of recovery appears challenged.

3 illus, 3 tables, 29 ref

047387   SAID A ELGEBALY, FATHY S M, SALLAM A A, ELBARBARY Y (Anaesthesia and PSICU Dep, , Tanta, Egypt, Email: elgebaly_13@hotmail. Com) : Cardioprotective effects of propofol-dexmedetomidine in open-heart surgery: A prospective double-blind study . Ann. Card. Anaesth 2020, 23 (2), 134 - 41.

Myocardial protection in cardiac surgeries is a must and requires multimodal approaches in perioperative period to decrease and prevent the increase of myocardial oxygen demand and consumption that lead to postoperative cardiac complications including myocardial ischemia, dysfunction, and heart failure. Prospective, controlled, randomized, double-blinded study. This study aims to study the effect of propofol-dexmedetomidine continuous infusion cardioprotection during open-heart surgery in adult patients. Sixty adult patients of both sexes aged from 30 to 60 years old belonging to the American Society of Anesthesiologists III or IV undergoing open-heart surgery were randomly divided into two equal groups: Group P (control group) received continuous infusion of propofol at a rate of 2 mg/kg/h and 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 ?g/kg/h (used as a placebo) and Group PD received continuous infusion of propofol at a rate of 2 mg/kg/h and dexmedetomidine 200 ?g diluted in 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 ?g/kg/h. Infusion for all patients started immediately preoperative till skin closure. Hemodynamic measurements of heart rate (HR), invasive mean arterial pressure, and oxygen saturation were recorded at baseline before induction of anesthesia, immediately after intubation, at skin incision, at sternotomy and every 15 min in the 1st h then every 30 min during the prebypass period then every 15 min in the 1st h then every 30 min after weaning from CPB till the end of the surgery. Serum biomarkers; cardiac troponin (cTnI) and creatine kinase-myocardial bound (CK-MB) samples were measured basally (T1), 15 min after unclamping of the aorta (T2), immediate postoperative (T3), and 24 h postoperative (T4). Intraoperative data were also recorded including the number of coronary grafts, aortic cross-clamping duration, duration of cardiopulmonary bypass (CPB), duration of surgery, and rhythm of reperfusion. Fentanyl requirement, extubation time, and length of intensive care unit (ICU) stay were also recorded for every case. There was no statistically significant differences as regard to demographic data between the studied two groups. HR and blood pressure recorded was lower in the PD group than the control group, and this difference was noted to be statistically significant. Furthermore, the PD group showed lower levels of myocardial enzymes (cTnI and CK-MB), decreased total fentanyl requirement, earlier postoperative extubation, and shorter ICU stay than the P (control) group. The use of propofol-dexmedetomidine in CPB surgeries offers more cardioprotective effects than the use of propofol alone.

2 illus, 3 tables, 28 ref

047386   SANTHOSH VILVANATHAN, BALAJI KUPPUSWAMY, SAHAJANANDAN R (Anaesthesiology Dep, Christian Medical Coll Hospital, Vellore, Tamil Nadu, Email: balooswamy @ gmail. Com) : A randomized control trial to compare thoracic epidural with intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy . Ann. Card. Anaesth 2020, 23 (2), 127 - 33.

The objective of the study is to compare the efficacy of Thoracic epidural with Intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy. This study is designed as a prospective randomized clinical trial. Christian Medical College Hospital, Vellore, India. Patients undergoing elective thoracic surgery through posterolateral thoracotomy. In Group A (TEA) patients epidural catheter was inserted at T5-6 level before induction of GA and analgesia was activated using 0.25 % of bupivacaine towards the end of the surgery, before chest closure and infusion of 0.1 % bupivacaine with 2 mcg/ml of fentanyl was started. In Group B (ICN) patients, an intercostal blockade of the 5 intercostal spaces was performed by the surgeon just before chest closure using 0.25 % bupivacaine and a continuous intravenous morphine infusion of 0.015-0.02 mg/kg/hr was started. Assessment of resting and dynamic pain intensity using Numerical rating scale and sedation using Ramsay sedation scale was done and recorded at 1, 6,12,18,24 hours during the first postoperative day. The other parameters that were measured include side effects and the requirement of rescue analgesia. Resting and Dynamic (NRS) pain scores were less in Group A (TEA) than Group B (ICN). In the first 12 hours, the differences in both the resting (P = 0.0505) and dynamic (P = 0.0307) pain scores were statistically significant. By the end of the first postoperative day, sedation scores were more or less similar in both groups. The incidence of side effects and requirement of rescue analgesia were found to be similar in both the groups. To summarize, though the results show a slightly better quality of analgesia with the thoracic epidural, the difference being clinically insignificant intercostal blockade could be considered as a valid alternative.

5 illus, 5 tables, 25 ref

047385   VOGIREDDY R. KRISHNA, PATIL N, NILESHWAR A (Anaesthesiology Dep, Kasturba Medical Coll, Manipal, Karnataka - 576 104, , Email: anitharshenoy@gmail. Com) : Prospective evaluation of the utility of CHA2DS2-VASc score in the prediction of postoperative atrial fibrillation after off-pump coronary artery bypass surgery ? an observational study . Ann. Card. Anaesth 2020, 23 (2), 122 - 6.

Off-pump coronary artery bypass (OPCAB) surgery is associated with evasion of complications of cardiac bypass. The incidence of postoperative atrial fibrillation (POAF) may also be reduced because of less ischemia and inflammation. Prospective evaluation of utility of CHA2DS2-VASc score in the prediction of POAF after OPCAB surgery. In this prospective, observational study, 99 patients who underwent elective isolated OPCAB surgery were included. Patients with pacemaker in situ, receiving antiarrhythmic drugs preoperatively, and preexisting atrial fibrillation were excluded. A detailed history taking and physical examination were done preoperatively and the CHA2DS2-VASc scores were calculated for each patient. They received a standard anesthetic including midazolam, fentanyl, propofol, vecuronium, and isoflurane. The number of grafts, inotrope usage, and blood product transfusion in the perioperative period were noted. Patients were followed up for 5 days after surgery for development of new onset POAF requiring treatment. About 20 of the 99 patients developed POAF. POAF occurred most commonly on postoperative day 2. They were older, more likely diabetic, had preoperative diastolic dysfunction, and received blood products perioperatively. POAF group had higher mean CHA2DS2-VASc score (3.6 ? 0.821 vs. 2.11 ? 1.35) and had longer hospital stay (16.85 ? 8.61 vs. 12.6 ? 4.05 days) than no POAF group. The cutoff for CHA2DS2-VASc score was 3, which showed 90% sensitivity, 77.22 % specificity, 50 % positive predictive value, and 96.63 % negative predictive value. CHA2DS2-VASc score is useful in predicting POAF after OPCAB surgery. Higher the CHA2DS2-VASc score, greater is the possibility of development of POAF.

2 illus, 7 tables, 8 ref

047384   SUHRID A TRE A, JANBURE N, GADDAM N, SHINDE D, TRE S A (Anaesthesia Dep, MCRI and Mahatma Gandhi Medical College and Hospitals, Aurangabad, Maharashtra - 431 003, , Email: sannachhatre@gmail. Com) : Anesthesiologists and job satisfaction in cardiac cath lab: do we need guidelines? . Ann. Card. Anaesth 2020, 23 (2), 116 - 21.

Cardiac cath lab procedures are developing in numbers, complexities and in demands with good outcomes. The complexicity of procedures and high risk patient factors require efficient cardiac anaesthesiologist?s care. They need good infrastructure and anaesthesia facilities. These facilities may be available at Metrocity superspeciality centres, but small units at district levels may not have all these facilities. There are many issues existing which make cardiac anaesthesiologists to prefer to work only in cardiac operation theaters than cath lab. They don?t get the job satisfaction in cath lab because of higher stress levels to overcome with the lacunaes in cath lab working. We hypothesize that cath lab in various centres are run by cardiac anaesthesiologists in majority. To analyze the infrastructure and working conditions of cath lab in perspective of anaesthesiologist, we conducted this survey. Online survey among IACTA members, through email available through IACTA site. The link was https://www.surveymonkey.com/r/9FKZ3TV. We contacted 500 IACTA members through email addresses available with us. 116 members replied to the online questionnaire done using SurveyMonkey software. Total 12 questions asked and answers analysed. The identity of responders is not disclosed by Survey monkey. Results were analysed in for options in percentage wise by Surveymonkey software.we compiled all responses and categorized the suggestions by responders. Role of anaesthesiologist and anaesthesia facilities should be given important priority in cath lab units. Healthy attitude of governing members of cathlab as well as standard guidelines for recommendation of infrastructure of cath lab, monitoring and patient care is need of the hour!

1 illus, 1 table, 12 ref

047383   SUJATA N, TOBIN R, GUPTA A, GIROTRA G (Anesthesiology and Pain Management Dep, Max Super Specialty Hospital, Saket, New Delhi -?110 017, Email: drnambiath@yahoo.com) : Wandering paravertebral catheter detected during thoracoscopy. Ann. Card. Anaesth 2020, 23 (1), 80 - 1.

We report a case of intrapleural migration of paravertebral catheter inserted under ultrasound guidance, detected during video assisted thoracoscopic surgery.

1 illus, 5 ref

047382   KHALIFA C, FOSSOUL S, MOMENI M, LACROIX V, WATREMEZ C (Anesthesiology Dep, Cliniques Univ, Brussels, Belgium, Email: celkhalifa@gmail.com) : An original backup technique to assess the correct positioning of right-sided double-lumen tubes without fiberoptic bronchoscopy: A pilot feasibility study . Ann. Card. Anaesth 2020, 23 (1), 75 - 9.

Accurate positioning of a right-sided double-lumen tube is essential but challenging due to the location and the potential obstruction of the right upper lobe bronchus. Fiberoptic bronchoscopy is, therefore, necessary but requires a specific training period for the anesthesiologist and might not always be available. We describe an original backup technique to assess the correct placement of these tubes in cases a fiberopetic bronchoscopy is lacking. Prospective pilot feasibility study with 10 adult patients scheduled for a left thoracic surgery. Operating theater in a universitary hospital. The new technique uses a fluoroscopy and an adult central venous catheter wire. The time needed to perform the new technique, its success rate and its efficacy in properly exclude the left lung were evaluated. Any oxygen desaturation episode (SpO2 <90 %) was considered. The technique was performed by two anesthesiologists with different experience in thoracic anesthesia. The success rate of our technique was 90 %, which did not depend on the anesthesiologist?s experience. The range of time to successfully place the tube in the dorsal decubitus position and subsequently in the right lateral decubitus position was respectively 1 min?6 min and 1 min?15 min. None of the patients presented any desaturation episodes. We describe an original, safe, and acceptable backup technique to properly insert right-sided double-lumen endobronchial tubes, whenever a fiberoptic bronchoscopy is not available. Moreover, this technique is easy enough to be performed by anesthesiologists with limited experience in thoracic anesthesia.

3 illus, 3 tables, 9 ref

047381   IGUIDBASHIAN J P, CHANG P H, IGUIDBASHIAN J, LINES J, MAXWELL B G (, Portland, USA, Email: bryanmaxwell@gmail. Com) : Enhanced recovery and early extubation after pediatric cardiac surgery using single-dose intravenous methadone . Ann. Card. Anaesth 2020, 23 (1), 70 - 4.

Methadone may offer advantages in facilitating early extubation after cardiac surgery, but very few data are available in the pediatric population. Community tertiary children?s hospital, retrospective case series. We performed a retrospective analysis of all pediatric cardiac surgical patients for whom early extubation was intended. A multimodal analgesic regimen was used for all patients, consisting of methadone (0.2?0.3 mg/kg), ketamine (0.5 mg/kg plus 0.25 mg/kg/h), lidocaine (1 mg/kg plus 1.5 mg/kg/h), acetaminophen (15 mg/kg), and parasternal ropivacaine (0.5 mL/kg of 0.2 %). Outcome variables were collected with descriptive statistics. A total of 24 children [median = 7 (interquartile range = 3.75?13.75) years old, 23.7 (14.8?53.4) kg] were included in the study; 22 (92 %) had procedures performed on bypass and 11 (46 %) involved a reentry sternotomy. Methadone dosing was 0.26 (0.23?0.29) mg/kg. None of the children required intraoperative supplemental opioids; 23 (96 %) were extubated in the operating room. The first paCO2 on pediatric intensive care unit admission was 51 (45?58) mmHg. Time to first supplemental opioid administration was 5.1 (3.5?9.5) h. Cumulative total supplemental opioids (in intravenous morphine equivalents) at 24 and 72 h were 0.2 (0.09?0.32) and 0.42 (0.27?0.68) mg/kg. One child required postoperative bilevel positive airway pressure support, but none required reintubation. None had pruritus; three (13 %) experienced nausea. A methadone-based multimodal regimen facilitated early extubation without appreciable adverse events. Further investigations are needed to confirm efficacy of this regimen and to assess whether the excellent safety profile seen here holds in the hands of multiple providers caring for a larger, more heterogeneous population.

2 illus, 2 tables, 9 ref

047380   VERMA S, SRINIVAS U, SATHPATHY A K, MITTAL P (Anesthesia Dep, CTOT, Hyderabad, Telangana, Email: swapnil6187@gmail. Com) : Comparison of effectiveness of tranexamic acid and epsilon-amino-caproic-acid in decreasing postoperative bleeding in off-pump cabg surgeries: a prospective, randomized, double-blind study . Ann. Card. Anaesth 2020, 23 (1), 65 - 9.

Off-pump coronary artery bypass graft (CABG) surgeries have been shown to have increased fibrinolysis due to tissue plasminogen activator release. There are no trials comparing the two available antifibrinolytics (tranexemic acid and epsilon-amino-caproic acid) in off-pump CABG surgeries. The aim of the present study was to compare the effectiveness of tranexamic acid and epsilon-amino-caproic acid with respect to postoperative bleeding at 4 and 24 hours as the primary outcome, and rate of postoperative transfusion, re-operations, complication rate, serum fibrinogen, and D-dimer levels as secondary outcomes. The study was carried out at a tertiary-level hospital between June 2017 and June 2018. It was a prospective, randomized, double-blind study. Eighty patients undergoing off-pump CABG, were randomly allocated to receive tranexamic acid or epsilon-amino-caproic acid. The patients were followed up in the postoperative period and were assessed for primary and secondary outcomes. Statistical analysis was performed using SPSS software, version 19.0 (SPSS Inc., Chicago, IL). Nonparametric data were expressed as median with interquartile range and compared using Mann?Whitney U-test, parametric data was represented as mean with standard deviation and analyzed using Student?s t-test. Nominal data were analyzed using Chi-square test. Bleeding at 4 hours did not show significant difference between groups, 180 ml (80?250) vs 200 ml (100?310). Bleeding at 24 hours was significantly lesser in tranexamic acid group as compared to epsilon-amino-caproic acid group, 350 ml (130?520) vs 430 ml (160?730) (P = 0.0022) The rate of transfusion, re-operations, seizures, renal dysfunction, fibrinogen levels, and D-dimer levels did not show significant difference between the groups. Tranexamic acid significantly reduced postoperative bleeding in off-pump CABG at 24 hours as compared to epsilon-amino-caproic-acid.

3 illus, 3 tables, 25 ref

047379   HAMID M, AKHTAR M I, AHMED S (Anaesthesia Dep, Aga Khan Univ, Karachi, Pakistan, Email: mohammad.hamid@ aku.edu) : Immediate changes in hemodynamics and gas exchange after initiation of noninvasive ventilation in cardiac surgical patients . Ann. Card. Anaesth 2020, 23 (1), 59 - 64.

Cardiac surgery is associated with pulmonary dysfunction and complications such as prolonged intubation and reintubation. Bilevel positive airway pressure (BiPAP) machine has been used in the clinical settings to improve oxygenation, reduce work of breathing, and avoid reintubation. The effect of BiPAP on cardiovascular parameters is not well established, and very few studies have targeted hemodynamic changes. The aim of the study was to assess the immediate effect of BiPAP on respiratory and hemodynamic parameters in post-cardiac surgery patients. This quasi-experimental study was done on 33 adult cardiac surgery patients. Ethical review committee approval was sought and consent was taken. All patients who were in respiratory distress with respiratory rate of >30/min and/or PaO2:FiO2 ratio of <200 were included. Hemodynamic and respiratory parameters were recorded just before and 15 min after BiPAP application. Sample size was determined on the basis of BiPAP effect on one of the variables, PaO2:FiO2 ratio. A total of 33 patients were included in the study. The average age of the patients was 60.97 ? 10.8, of which 23 (69.7 %) were males and 10 (30.7 %) females. BiPAP application leads to statistically significant improvement in ventilator parameters including SaO2 29 (87.7 %), PaO2 29 (87.8 %), PaCO2 21 (63.6 %), and PaO2:FiO2 ratio in 27 (81.8 %). Ventilatory parameters were significantly improved after BiPAP application in this study, but hemodynamic parameters showed no statistically significant change. BiPAP application was also able to decrease the need for reintubation in post-cardiac surgery patients

4 tables, 32 ref

047378   KARIM H M R, YUNUS M, DEY S (All India Institute of Medical Sciences, Raipur -?492 099, Chhattisgarh, Email: drhabibkarim@gmail. Com) : A retrospective comparison of preoperative estimated glomerular filtration rate as a predictor of postoperative cardiac surgery associated acute kidney injury . Ann. Card. Anaesth 2020, 23 (1), 53 - 8.

Cardiac surgery-associated acute kidney injury (CSA-AKI) remains common with distressingly high mortality. Over time, risk scorings systems have been developed to predict it and preoperative low estimated glomerular filtration rate (eGFR) has been regarded as one of the predicting risk factors. The present study is aimed at assessing the relation of different ranges of preoperative eGFR with an incidence of CSA-AKI defined by the AKI network (AKIN) criteria. Files of 134 patients with eGFR of >40 cc/min/1.73 m2 body surface area (BSA) who underwent cardiac surgeries on cardiopulmonary bypass were screened for data collection. Occurrences of CSA-AKI were evaluated as per the AKIN criteria over the course of 3 postoperative days. The relationships of different ranges of preoperative eGFR with CSA-AKI were analyzed by appropriate statistical tests using Instat software and P < 0.05 was considered statistically significant. A total of 60 males and 74 females with a mean + standard deviation (SD) age of 37.98 ? 12.50 years and mean + SD preoperative eGFR of 70.20 ? 20.89 cc/min/1.73 m2 were analyzed in this study. About 49.25 % of patients suffered from CSA-AKI by the 3rd postoperative day. The crude risk of CSA-AKI in patients with eGFR 40?60 cc/min/1.73 m2 was not higher (odds ratio 0.29) as compared to patients in patients with eGFR >100 cc/min/1.73 m2. The CSA-AKI trend with different eGFR was also statistically insignificant (P > 0.05). In patients with preoperative eGFR >40 cc/min/1.73 m2 BSA, a lower preoperative eGFR (40?60 cc/min/1.73 m2) does not predict higher incidence of CSA-AKI as defined by AKIN criteria as compared to higher preoperative eGFR (>100 cc/min/1.73 m2). Lower height is independently associated with higher incidence of CSA-AKI in such patients.

6 tables, 22 ref

047377   CHAUDHARY T, OBEROI D, MEHROTRA V (Anaesthesiology Dep, SRH Univ, Jolly Grant, Dehradun, Uttarakhand, Email: drdeepakoberoi@gmail. Com) : A comparison of immediate postoperative complications in using left internal mammary artery + vein versus only vein as conduit in patients undergoing off-pump coronary artery bypass grafting . Ann. Card. Anaesth 2020, 23 (1), 48 - 52.

The objective of the study is to compare the immediate postoperative cardiac complications in patients undergoing off-pump coronary artery bypass grafting (OPCABG) using mixed (arterial and venous grafts) versus only venous grafts and to compare the requirement of packed red cell units and intra-aortic balloon pump (IABP) in both the groups. This was an observational, analytical, prospective study. Fifty new patients were included in the study. Patients diagnosed with triple-vessel coronary artery disease (CAD) undergoing OPCABG with an ejection fraction (EF) of more than 30 %. Patients who have undergone prior CABG, EF <30 %, preexisting valvular heart disease, any evidence pulmonary hypertension, preoperative IABP, any history of neurological dysfunction, left atrium size more than 5.5 cm, and history of coagulation disorder was excluded from the study. The most common immediate postoperative cardiac complication observed was atrial fibrillation followed by ventricular arrhythmias in both the groups. There was no statistically significant difference in complication rate between the two groups. Postoperative requirement of IABP and requirements of blood products were also similar in both the groups. Patients undergoing off-pump CABG have similar immediate postoperative complications irrespective of the type of conduit used.

1 table, 27 ref

047376   BURRA V, PK S, NB P, PS N, SINGH N G, N M, BASAPPANAVAR V S (Cardiovascular and Thoracic Surgery Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, engaluru -?560 069, Karnataka, Email: docnag10@gmail.com) : Role of urinary PO2 analysis during conventional versus conventional and modified ultrafiltration techniques in adult cardiac surgery . Ann. Card. Anaesth 2020, 23 (1), 43 - 7.

Medullary hypoxia is the initial critical event for kidney injury during cardiopulmonary bypass, and therefore urinary PO2 with its potential of detecting medullary oxygenation for its management. Therefore, we tested the role of urinary PO2 in predicting kidney injury in those undergoing conventional versus combined (conventional and modified) ultrafiltration during cardiac surgery in adults. We prospectively evaluated 32 adults between 18 and 65 years of age undergoing elective on-pump cardiac surgery with ejection fraction >35% by conventional (group C) versus combined ultrafiltration (group CM). Urine samples were analyzed for PO2 after induction, 30 min, 3 h, and 6 h post filtration along with blood urea and serum creatinine after induction, at 6 h, 24 h, and 48 h post filtration. Demographic variables, cardiopulmonary bypass duration, flow rates, inotropic score, ventilation duration, diuretic use, and intensive care unit (ICU) stay were assessed between two groups. Both the groups (16 in each group) had comparable urinary PO2 after induction (P = 0.387) with significant decrease in group C at 30 min, 3 h, and 6 h post filtration (P < 0.05). There was a statistically significant increase in serum creatinine (mg/dL) at 48 h in group C compared with group CM (1.57 vs. 1.25, respectively; P ? 0.05). There was an increased diuretic usage and length of ICU stay in group C. Combined ultrafiltration technique had renoprotective effect in cardiac surgery analyzed by urinary PO2 levels.

2 illus, 6 tables, 22 ref

047375   SINGH N G, KUMAR K N, NAGARAJA P S, MANJUNATHA N (Cardiac Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru - 560 069, Karnataka, Email: karthiknarendrakumar@ gmail.com) : Portal venous pulsatility fraction, a novel transesophageal echocardiographic marker for right ventricular dysfunction in cardiac surgical patients . Ann. Card. Anaesth 2020, 23 (1), 39 - 42.

Right ventricular (RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function. To investigate if portal venous pulsatility fraction (PF) could serve as effective and complementary tool in identifying RV dysfunction. Thirty adult patients aged 18-65 years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility. Portal vein was demonstrated in 27 patients (90 %). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = ?0.55, P = 0.003), RV FAC (r = ?0.44, P = 0.02), and RV EF (r = ?0.53, P = 0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of ?45 % indicated RV dysfunction with sensitivity of 92.3 %, specificity of 71.4 %, positive predictive value of 75 %, and negative predictive value of 90.9 %. Area under ROC curve was 0.819 (95 % confidence interval = 0.624 ? 0.939, P = 0.0006). Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.

4 illus, 2 tables, 9 ref

047374   REDDY B G, SINGH N G, NAGARAJA PS, SUBHASH S, CG P S, N M T, CHINTHA V (Anaesthesia Dep, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru -?560 069, Karnataka, Email: docnag10@gamil.com) : Transesophageal echocardiographic evaluation of pulmonary vein diastolic wave deceleration time ? as a predictor of left atrial pressure . Ann. Card. Anaesth 2020, 23 (1), 34 - 8.

The deceleration time of the pulmonary venous diastolic flow has been well-correlated with invasive pulmonary capillary wedge pressure in several studies regardless of left ventricular systolic function. This study was conducted to correlate deceleration time of pulmonary venous diastolic wave, DT(D), and left atrial pressure (LAP), obtained noninvasively from mitral early diastolic inflow velocity-to-early diastolic mitral annulus velocity ratio (E/e?), and to assess the ease of each method in patients with coronary artery disease undergoing off-pump coronary artery bypass grafting (OPCAB) by transesophageal echocardiography. Forty-five adult patients with coronary artery disease, with left ventricular ejection fraction of ?50% posted for elective OPCAB were enrolled in the study. Forty values of LAP and DT(D) were analyzed. A significant linear correlation (r = ?0.64) was found between DT(D) and LAP. Area under the curve of DT(D) of ?183 ms for predicting elevated LAP (>15) was 0.903 (95 % confidence interval: 0.767 to 0.974, P < 0.0001). Deceleration time of pulmonary venous flow diastolic waveform, DT(D), feasible promising echocardiographic measure in determining elevated LAP and DT(D) ?183 ms predicts elevated LAP.

4 illus, 2 tables, 19 ref