Publications by authors named "Neeti Makhija"

70 Publications

Effect of change in tidal volume on left to right shunt across ventricular septal defect in children - A pilot study.

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):350-355. Epub 2021 Aug 20.

Department of Cardiac Anaesthesia, CNC, All India Institute of Medical Sciences, New Delhi, India.

Background: Pulmonary vascular resistance, an important determinant of shunting across ventricular septal defects (VSD), rises at both extremes of lung volume.

Aims: We sought to determine the effect of changes in tidal volumes (VT) on pulmonary blood flow (Qp), systemic blood flow (Qs), and shunt (Qp/Qs) in children with VSD.

Setting: Single-center teaching hospital.

Design: Prospective observational study.

Methods: Thirty children with a mean age of 11.8 ± 5 months undergoing surgical closure of VSD were studied. Hemodynamics and shunt-related parameters were assessed using transthoracic echocardiography measured at three different VT i.e. 10, 8, and 6-ml/kg keeping the minute ventilation constant.

Results: Reduction in VT from 10 to 8 to 6 ml/kg led to a reduction in gradient across VSD measuring 23.5, 20 and 13 mmHg respectively ( < 0.001). Similarly, right ventricluar outflow tract (RVOT) diameter, RVOT velocity time integral, Qp (57.3 ± 18.1, 50.6 ± 16.9, 39.9 ± 14.7 mL; < 0.001), Qs (24.1 ± 10.4, 20.0 ± 8.7, 15.3 ± 6.9 mL; < 0.001) and peak airway pressure (17.2 ± 1.5, 15.8 ± 1.3, 14.5 ± 1.2 cmHg; < 0.001) showed progressive decline with decreasing VT from 10 to 8 to 6 ml/kg, respectively. However, Qp/Qs (2.4 ± 0.4, 2.6 ± 0.4, 2.6 ± 0.4) demonstrated a minor increasing trend.

Conclusion: Lower V reduces the gradient across VSD, the pulmonary blood flow, and the peak airway pressure. Hence, ventilation with lower V and higher respiratory rate maintaining adequate minute ventilation might be preferable in children with VSD. Further studies are required to confirm the findings of this pilot study.
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http://dx.doi.org/10.4103/apc.apc_1_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457296PMC
August 2021

Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of fallot.

J Card Surg 2021 Oct 29;36(10):3679-3687. Epub 2021 Jul 29.

Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Background: Expected benefits of modified ultrafiltration (MUF) include increased hematocrit, reduction of total body water and inflammatory mediators, improved left ventricular systolic function, and improved systolic blood pressure and cardiac index (CI) following cardiopulmonary bypass (CPB). This prospective randomized trial tested this hypothesis.

Methods: Seventy-nine patients undergoing intracardiac repair of tetralogy of fallot were randomized to conventional ultrafiltration (CUF) + MUF (n = 39) or only CUF group (n = 40). The primary outcome was a change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score (IS), and CI. Serum inflammatory markers were measured.

Results: Baseline hematocrit was 50.6 ± 10.02 in the only CUF group whereas it was 43.9 ± 5.55 in the CUF + MUF group (p = .36). Following MUF, the CUF + MUF group had higher hematocrit (44.7 ± 0.50 g/dl) compared to the only CUF group (37.2 ± 0.49 g/dl), p ≤ .001 after adjusting for baseline hematocrit. Central venous pressure (mmHg) immediately following sternal closure was 9.27 ± 3.12 mmHg in the CUF + MUF group and 10.52 ± 2.2 mmHg in the only CUF group (p = .04). In the intensive care unit (ICU), they were 11.52 ± 2.20 mmHg in the only CUF group and 10.84 ± 2.78 mmHg in the CUF + MUF group (p = .02). Time to peripheral rewarming was 6.30 ± 3.91 h in the CUF + MUF group and 13.67 ± 3.91 h in the only CUF group (p = .06). Peak airway pressures in ICU were 17 ± 2 mmHg versus 20.55 ± 2.97 mmHg in CUF + MUF group & only CUF group, respectively, p < .001). Duration of mechanical ventilation was 6.3 ± 2.7 h in CUF + MUF group compared to 14.7 ± 3.5 h in the only CUF group (p = .002). IS was 11.52 ± 2.20 in the only CUF group compared to 10.84 ± 2.78 in CUF + MUFs group. Eight of 39 (20.5%) patients in the CUF + MUF group had IS > 10 compared to 22 of 40 (55%) patients in the only CUF group (p = .02). Serum Troponin-T and interleukin-6 levels were lower in the CUF + MUF group; TNF-α and CPK-MB were similar. ICU and hospital stay were similar.

Conclusion: Patients undergoing a combination of CUF and MUF had higher postoperative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes and lower interleukin-6 and Troponin-T levels. This group had better postoperative outcomes. This study was registered with the Clinical trials registry of India (CTRI/2017/11/010512) before commencement.
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http://dx.doi.org/10.1111/jocs.15841DOI Listing
October 2021

Surgical-conundrum of a hiding 'Bullet': Echocardiographic artefact clues the concealed fact!

Indian J Anaesth 2021 May 20;65(5):412-413. Epub 2021 May 20.

Division of Trauma Surgery and Critical Care, Department of Surgical Discipline, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/ija.IJA_1236_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202800PMC
May 2021

Probing Analgesic Potential With Prudence!

J Cardiothorac Vasc Anesth 2022 Jan 21;36(1):344-345. Epub 2021 May 21.

Department of Anaesthesia, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India.

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http://dx.doi.org/10.1053/j.jvca.2021.05.031DOI Listing
January 2022

Massive gastro-intestinal bleed in a case of aorto-enteric fistula: An intraoperative nightmare.

Ann Card Anaesth 2021 Apr-Jun;24(2):278-279

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/aca.ACA_144_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8253012PMC
November 2021

"" hypoxemia in COVID-19: !

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):570-571. Epub 2021 Jan 18.

Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_491_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022045PMC
January 2021

Oxygen therapy in the critically ill: ?

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):433-434. Epub 2021 Jan 18.

Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_142_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022064PMC
January 2021

Balancing a single-ventricle circulation: 'physiology to therapy'.

Indian J Thorac Cardiovasc Surg 2020 Mar 2;36(2):159-162. Epub 2020 Jan 2.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 9, 7th Floor, Ansari Nagar, New Delhi, 110029 India.

The parallel supply of the pulmonary and systemic circuits complicates the management of single-ventricle lesions. Achieving a balance between the two limbs of the circulation forms the basis of optimizing the systemic oxygen delivery, with the oxygen availability being highly sensitive to alterations in pulmonary/systemic blood flow ratio ( / ). The identification of a 'balanced' circulation is challenging wherein various parameters should be evaluated in close conjunction with each other. The prompt identification of circulatory maldistribution should be backed up with a sound management strategy aimed at attaining an equitable systemic and pulmonary perfusion. Any degree of ventricular dysfunction compromises the total output ( + ) supplying the two circuits explaining the role of inodilators in improving the myocardial performance in addition to lowering the systemic vascular resistance and optimizing / in setting of a single-ventricle physiology. Moreover, the pulmonary circulation is modulated by a multitude of factors intricately linked to the single-ventricle lesion, including anatomical characteristics unique to the underlying lesion (branch pulmonary arterial and venous stenosis), preoperative interventions, associated aortopulmonary and venovenous collaterals, plastic bronchitis, pulmonary arteriovenous fistulae, underlying ventricular dysfunction,, and many others. The article highlights the physiology, diagnosis, therapeutic optimization of a single-ventricle circulation, and the peculiarities pertaining to the pulmonary circulation of the uni-ventricular lesions.
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http://dx.doi.org/10.1007/s12055-019-00889-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525606PMC
March 2020

Effect of leukoreduction on transfusion-related immunomodulation in patients undergoing cardiac surgery.

Transfus Med 2020 Dec 15;30(6):497-504. Epub 2020 Sep 15.

Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India.

Objectives: In this study, we aimed to determine the consequences of different amounts of leukocyte transfusion on the outcome of patients undergoing cardiac surgery.

Design: This was a prospective, single-blinded cohort study conducted for 1 year from July 2018 to June 2019.

Setting: The study setting was the Department of Transfusion Medicine, along with Cardiac Anaesthesia, Cardiac Surgery and Cardiac biochemistry departments in a tertiary care cardiac centre.

Participants: A total of 150 patients undergoing cardiac surgery during the study period were divided into three groups (50 in each): Leukofiltered (LR), Buffy coat depleted (BCD) and Non-leukoreduced (NLR).

Intervention: The intervention was intra- and postoperative transfusion of packed red blood cells (PRBCs) having different amounts of leukocytes.

Measurements And Main Results: Patient details about length of intensive care unit (ICU) and hospital stay, blood usage, inotropic drug duration, mechanical ventilation, urine output and infection were recorded from the patient data sheet, whereas patients were followed up for 30 days post-operation, and any mortality was noted. Haematological parameters and biochemical parameters for renal function test were analysed on pre- and post-surgical days 1, 3, 5 and 7, whereas on postoperative days 1 and 7, cytokine-like FAS ligands, Interleukin-10 (IL-10) and Interferon-γ (INF-γ) were tested. Patients in all three groups received an average of four, two and two units of packed red blood cells, platelets and fresh frozen plasma, respectively. There was a statistically significant (P < .05) rise in total leukocyte, neutrophil and lymphocyte count in all three groups from day 0 to day 3, but it reduced to preoperative level on day 5. There was shorter ICU and hospital stay in the LR group of patients (46 ± 19.9 hours and 7.5 ± 2.4 days) compared to NLR (52.1 ± 24.2 hours and 7.9 ± 4.1 days) and BCD (53.3 ± 26.7 hours and 8.8 ± 3.1 days) group of patients, but it was statistically non-significant. The duration of mechanical ventilation was significantly lesser in LR group patients (10.2 ± 6.2 hours) as compared to NLR group (14.7 ± 12.7 hours). On risk ratio calculation of developing postoperative kidney injury, the NLR group had 1.3 and 2.6 times more risk compared to the BCD and LR groups, respectively. On postoperative days 1 and 7, FAS-L levels significantly increased in all three group of patients, whereas IL-10 increased in the NLR and BCD groups and decreased in the LR group non-significantly. The INF-γ levels decreased on day 1 in the NLR and BCD groups but increased in the LR group, but it was inversed on day 7.

Conclusion: Depletion of leukocytes decreased Transfusion Related Immunomodulation (TRIM) effects in patients undergoing cardiac surgery, but this also depends on the degree of leukoreduction. As found in our study, leukofiltration is more effective compared to buffy-coat depletion only.
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http://dx.doi.org/10.1111/tme.12714DOI Listing
December 2020

Dexmedetomidine and postoperative delirium: Decoding the evidence!

J Anaesthesiol Clin Pharmacol 2020 Jan-Mar;36(1):140-141. Epub 2020 Feb 18.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

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http://dx.doi.org/10.4103/joacp.JOACP_237_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047692PMC
February 2020

Perioperative myocardial injury and infarction following non-cardiac surgery: A review of the eclipsed epidemic.

Saudi J Anaesth 2020 Jan-Mar;14(1):91-99. Epub 2020 Jan 6.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

The perioperative period induces unpredictable and significant alterations in coronary plaque characteristics which may culminate as adverse cardiovascular events in background of a compromised myocardial oxygen supply and demand balance. This "ischemic-imbalance" provides a substrate for perioperative cardiac adversities which incur a considerable morbidity and mortality. The propensity of myocardial injury is dictated by the conglomeration of various factors like pre-existing medical condition, high-risk surgical interventions, intraoperative hemodynamic management, and the postoperative care. Perioperative myocardial infarction (PMI) differs from myocardial infarction (MI) in a non-operative setting. PMI can often be notoriously "silent" demonstrating a conspicuous absence of the classic clinical symptoms. Moreover, myocardial injury following non-cardiac surgery (MINS) characterized by an elevation of the cardiac insult biomarkers has demonstrated an independent prognostic significance in the perioperative scenario despite the lack of a formal categorization as PMI. This has evoked interest in the meticulous characterization of MINS as a discrete clinical entity. Multifactorial etiology, varying symptomatology, close differential diagnosis, and a debatable management regime makes perioperative myocardial injury-infarction, a subject of detailed discussion.
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http://dx.doi.org/10.4103/sja.SJA_499_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970380PMC
January 2020

Vasoplegic syndrome after cardiac surgery: Better the devil you know!

J Card Surg 2019 12 26;34(12):1679-1680. Epub 2019 Oct 26.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1111/jocs.14297DOI Listing
December 2019

In reply: Additional insights regarding aortic intramural hematoma.

Can J Anaesth 2020 03 1;67(3):384. Epub 2019 Oct 1.

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1007/s12630-019-01491-9DOI Listing
March 2020

Micro RNAs in Cardiac Surgery: Novel Molecular Signatures!

J Cardiothorac Vasc Anesth 2020 02 9;34(2):570. Epub 2019 Aug 9.

Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, Ansari Nagar, New Delhi, India.

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http://dx.doi.org/10.1053/j.jvca.2019.08.001DOI Listing
February 2020

Erector spinae plane block and cardiac surgery: 'A closer look'.

J Clin Anesth 2020 Mar 17;60. Epub 2019 Aug 17.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.

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http://dx.doi.org/10.1016/j.jclinane.2019.08.005DOI Listing
March 2020

Endothelial Glycocalyx and Cardiac Surgery: Newer Insights.

J Cardiothorac Vasc Anesth 2020 01 7;34(1):310-311. Epub 2019 Jul 7.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

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http://dx.doi.org/10.1053/j.jvca.2019.07.003DOI Listing
January 2020

Transesophageal echocardiographic imaging of an aortic intramural hematoma: characterizing the crescent.

Can J Anaesth 2019 Nov 31;66(11):1415-1416. Epub 2019 Jul 31.

All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1007/s12630-019-01456-yDOI Listing
November 2019

Comparison of del Nido and histidine-tryptophan-ketoglutarate cardioplegia solutions in pediatric patients undergoing open heart surgery: A prospective randomized clinical trial.

J Thorac Cardiovasc Surg 2019 Mar 27;157(3):1182-1192.e1. Epub 2018 Nov 27.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Objectives: We conducted a prospective randomized controlled trial to compare del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution in pediatric patients undergoing intracardiac tetralogy of Fallot repair.

Methods: One hundred consecutive patients 12 years of age or younger, undergoing intracardiac repair of tetralogy of Fallot were randomized into DN (n = 50) and HTK (n = 50) groups. Cardioplegia strategy consisted of a single dose of DN (20 mL/kg) or HTK (6 mL/kg/min for 6 minutes). Primary outcome was cardiac index (CI). Secondary outcomes were ventricular arrhythmias post cross-clamp release, time to peripheral rewarming, duration of mechanical ventilation, inotropic score, intensive care unit and hospital stay, and serum levels of troponin-I, interleukin-6, and tumor necrosis factor-α. Ultrastructural changes in the myocardium were assessed.

Results: CI was significantly higher in the DN group compared with the HTK group at 6 (P = .005) and 24 hours (P < .001) after surgery. It was on an average 0.44 L/min/m higher in the DN group at any time point (P = .004). Time for complete cessation of electrical activity was longer in the HTK group (P = .01) and more patients in the HTK group had ventricular arrhythmias post cross-clamp release (P = .03). Duration of mechanical ventilation (P = .006), intensive care unit stay (P = .05), and hospital stay (P < .001) were lower in the DN group. Patients in the DN group had lower troponin I levels 24 hours after cardiopulmonary bypass (P < .001). Electron microscopic studies showed more myocardial edema (P = .02) and myofibrillar disarray (P = .04) in the HTK group along with lower glycogen stores (P = .04). DN cardioplegia was more cost-effective than HTK cardioplegia (P < .001).

Conclusions: DN cardioplegia was associated with better preservation of CI, less duration of mechanical ventilation, shorter intensive care unit and hospital stays, lower inotropic scores, and less release of troponin-I. Electron microscopy showed less myocardial edema and better preservation of the myofibrillar architecture and glycogen stores in the DN group.
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http://dx.doi.org/10.1016/j.jtcvs.2018.09.140DOI Listing
March 2019

Modified Tricuspid Annular Plane Systolic Excursion for Assessment of Right Ventricular Systolic Function.

J Cardiovasc Imaging 2019 Jan;27(1):24-33

Department of Cardiac Anesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India.

Background: Tricuspid annular plane systolic excursion (TAPSE) has become a popular tool for assessing right ventricular (RV) systolic function because of its ease of application. TAPSE using transesophageal echocardiography (TEE) is limited by alignment with the lateral wall of the RV. Modified TAPSE (m-TAPSE) is a novel method for measuring TAPSE. m-TAPSE is the difference in the 'apical to lateral tricuspid annulus distance' during diastole and systole. The aim of the present study was to compare prospectively m-TAPSE with the most commonly used parameter TAPSE and near-gold standard 2D echocardiographic parameter RV fractional area change (RV FAC).

Methods: We conducted a prospective observational study of 125 consecutive patients undergoing coronary artery bypass graft surgery in a single tertiary care center. Post-anesthetic induction TAPSE was recorded using transthoracic echocardiography (TTE). m-TAPSE was recorded using TEE in the mid-esophageal four-chamber view. RV FAC was also assessed using TEE. m-TAPSE < 16 mm, TAPSE < 16 mm and RV FAC < 35% were taken as cut-offs for RV systolic dysfunction. Correlations were assessed using the Pearson correlation coefficient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using 2 × 2 cross table.

Results: m-TAPSE was significantly correlated with TAPSE (r = 0.797, p < 0.001). Similarly, a significant correlation was observed between m-TAPSE and RV FAC (r = 0.602, p < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of m-TAPSE were 100%, 98.3%, 80%, 100% and 98.4%, respectively.

Conclusions: m-TAPSE correlated well with both RV FAC and TAPSE. Therefore, m-TAPSE can be considered an easily measurable alternative parameter for evaluating RV systolic function in a busy intraoperative setting.
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http://dx.doi.org/10.4250/jcvi.2019.27.e8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358432PMC
January 2019

Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management.

Ann Card Anaesth 2019 Jan-Mar;22(1):1-5

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India.

The presence of dynamic left ventricular outflow tract obstruction (LVOTO) can complicate the postoperative course of patients undergoing surgical aortic valve replacement (AVR). The phenomenon of LVOTO is a consequence of an interplay of various pathoanatomic mechanisms. The prevailing cardiovascular milieu dictates the hemodynamic significance of the resultant LVOTO in addition to the anatomical risk factors. A thorough understanding of the predisposing factors, mechanism, and hemodynamic sequel of the obstruction is pivotal in managing these cases. A comprehensive echocardiographic examination aids in risk prediction, diagnosis, severity characterization, and follow-up of management efficacy in the setting of postoperative LVOTO. The armamentarium of management modalities includes conservative (medical) and surgical options. A stepwise approach should be formulated based on the physiological and anatomical substrates predisposing to LVOTO. The index phenomenon occurs more frequently than appreciated and should be considered when the post-AVR patients exhibit hemodynamic instability unresponsive to conventional supportive measures. The present article provides an overview of various peculiarities of this under-recognized phenomenon in the context of the perioperative management of patients undergoing AVR.
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http://dx.doi.org/10.4103/aca.ACA_226_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350428PMC
April 2020

Ischemia Begets Right Ventricular Dysfunction After Cone Repair for Ebstein's Anomaly.

J Cardiothorac Vasc Anesth 2019 01 25;33(1):261-262. Epub 2018 Sep 25.

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1053/j.jvca.2018.09.026DOI Listing
January 2019

Randomized Controlled Trial of Heparin Versus Bivalirudin Anticoagulation in Acyanotic Children Undergoing Open Heart Surgery.

J Cardiothorac Vasc Anesth 2018 12 12;32(6):2633-2640. Epub 2018 Apr 12.

Department of Perfusion Technology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To determine the safety and efficacy of bivalirudin as an anticoagulant for pediatric open heart surgery (OHS) and to determine its appropriate dosage for this purpose.

Design: Prospective, randomized controlled trial.

Setting: Tertiary care hospital.

Participants: Fifty acyanotic children aged 1-12 years undergoing OHS.

Interventions: The children were randomized to receive either 4 mg/kg of heparin (n = 25, group H) or 1 mg/kg of bivalirudin bolus followed by 2.5 mg/kg/h infusion (n = 25, group B) as the anticoagulant. The doses were adjusted to maintain activated clotting time (ACT) above 480 seconds. At the conclusion of surgery, protamine (1.3 mg/100 U of heparin) was administered to children in group H.

Measurements And Main Results: The children were comparable in both groups with regard to demographic characteristics. The mean age and weight were 51.5 months and 13.4 kg in group H, and 59.3 months and 13.4 kg in group B. The dose of anticoagulant required was 4.0 ± 0.2 mg/kg in group H and 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion in group B (p < 0.001). One child in group H required an additional dose compared to 13 (54.2%) children in group B. Intraoperatively, the ACT achieved was higher in group H compared to group B (p < 0.05). The ACT returned to baseline value after protamine administration in group H, but it remained elevated for 2 hours after termination of cardiopulmonary bypass (CPB) in group B (p < 0.01). The ACT was higher in group B compared to group H for 6 hours after termination of CPB (p < 0.05). Heparin prolonged the onset of clotting, decreased the rate and strength of thrombus formation, and inhibited platelet function to a greater extent than bivalirudin on viscoelastic coagulation testing. The total duration of surgery was prolonged in group B. The postoperative chest tube drainage was similar in group B (4.9 mL/kg) as in group H (5.9 mL/kg) in spite of higher ACT. The transfusion requirements were similar. No adverse event occurred in any patient.

Conclusion: Bivalirudin is a safe and effective anticoagulant for pediatric OHS. Though it is not suitable as a routine anticoagulant for this purpose, it may be used as a heparin alternative in instances when heparin cannot be used. The dose required to maintain ACT for more than 480 seconds was 1.7 ± 0.2 mg/kg followed by 3.0 ± 0.7 mg/kg/h infusion. The ACT remained elevated for 2 hours after stopping the infusion. Bivalirudin did not increase postoperative bleeding and transfusion requirement.
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http://dx.doi.org/10.1053/j.jvca.2018.04.028DOI Listing
December 2018

On-table extubation following off-pump bidirectional cavopulmonary anastomosis: Two sides of the coin.

Ann Card Anaesth 2018 Oct-Dec;21(4):461-462

Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/aca.ACA_31_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206804PMC
April 2019

Extracardiac Fontan With Direct Inferior Vena Cava to Main Pulmonary Artery Connection Without Cardiopulmonary Bypass.

World J Pediatr Congenit Heart Surg 2020 Jul 10;11(4):NP195-NP198. Epub 2018 Oct 10.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

We report the case of a six-year-old patient who underwent an extracardiac Fontan operation including bilateral bidirectional superior cavopulmonary anastomosis and direct inferior vena cava to main pulmonary artery connection that was performed without cardiopulmonary bypass.
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http://dx.doi.org/10.1177/2150135118765870DOI Listing
July 2020

Immediate and early post-operative sequelae of off-pump total cavopulmonary connection.

Indian J Thorac Cardiovasc Surg 2018 Oct 17;34(4):468-475. Epub 2018 Jan 17.

Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India.

Background: Extracardiac Fontan (ECF) is currently the final operation of choice for patients with a univentricular heart. Performing this procedure without cardiopulmonary bypass (CPB) carries potential benefits. In this study, we report the early results of ECF without CPB.

Patients And Methods: Between 2012 and 2015, 72 consecutive patients underwent Fontan without CPB. Their medical records were examined in detail.

Results: Mean age was 11.8 ± 5.2 (range 5 to 23, median 10) years. Intraoperative mean superior vena cava clamp time was 15.19 ± 3.8 min, and the inferior vena cava clamp time was 16.93 ± 3.31 min. There were three early deaths. No patient required conversion from off-CPB to CPB. Mean inotropic score was 4.73 ± 5.9 (range 0 to 25, median 2.5). Mean time to extubation was 9.5 ± 5.82 (range 3 to 29, median 8) hours. Pleural drainage in intensive care unit (ICU) was 551.57 ± 452.77 (median 470) ml, and mean ICU stay was 2.27 ± 3.09 (median 1.5) days. Mean daily pleural drainage after discharge from the ICU was 163.7 ± 88.01 (median 140) ml, and mean time to removal of pleural tubes was 15.76 ± 8.4 (median 14) days. Total hospital stay was 17.03 ± 8.62 (median 15) days. At an early follow-up of 2-40 (median 25) months, all survivors ( = 69) had a patent Fontan circuit with normal ventricular function on echocardiography. There were no late deaths or thromboembolic complications.

Conclusions: Off-pump ECF is a low-risk procedure that avoids the harmful effects of CPB. Post-operative course of these patients is predictable with substantial savings in costs.
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http://dx.doi.org/10.1007/s12055-017-0638-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525632PMC
October 2018

Oral thyroxin supplementation in infants undergoing cardiac surgery: A double-blind placebo-controlled randomized clinical trial.

J Thorac Cardiovasc Surg 2018 09 4;156(3):1209-1217.e3. Epub 2018 Jun 4.

Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India.

Background: Decreases in serum total thyroxin and total triiodothyronine occurs after cardiopulmonary bypass, and is reflected as poor immediate outcome. We studied effects of oral thyroxin supplementation in infants who underwent open-heart surgery.

Methods: In this prospective study, 100 patients were randomized into 2 groups: 50 in the thyroxin group (TH) and 50 in the placebo group (PL). Patients in the TH group received oral thyroxin (5 μg/kg) 12 hours before surgery and once daily for the remainder of their intensive care unit (ICU) stay. Data on intraoperative and postoperative variables were recorded. Cardiac index (CI) was measured. Perioperative serum thyroid hormone levels and serum interleukin-6 and tumor necrosis factor-α were measured. Secondary analysis was performed by dividing patients into simple and complex subcategories.

Results: Results of the primary analysis indicated a higher CI in the TH compared with the PL. In the complex category, the mean duration of mechanical ventilation was 3.85 ± 0.93 and 4.66 ± 1.55 days in the TH and PL, respectively (P = .001). Mean ICU stay was 6.79 ± 2.26 and 8.33 ± 3.09 days (P = .03), and mean hospital stay was 15.70 ± 4.77 and 18.90 ± 4.48 days (P = .01) in the TH and PL, respectively. There were no significant differences between the TH and the PL in the simple category. CI was higher in the TH at all time points (P = .004). The average therapeutic intervention scoring system scores for the first 2 days were higher in the PL in the complex category.

Conclusions: Oral thyroxin supplementation improves the CI and reduces the inotropic requirement. In addition, it reduces the duration of mechanical ventilation, ICU and hospital stay, and therapeutic intervention scoring system in infants after surgery for complex congenital heart defects.
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http://dx.doi.org/10.1016/j.jtcvs.2018.05.044DOI Listing
September 2018

Transcutaneous nerve stimulation for pain relief during chest tube removal following cardiac surgery.

J Anaesthesiol Clin Pharmacol 2018 Apr-Jun;34(2):216-220

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.

Background And Aims: In patients undergoing open heart surgery, chest tubes are removed postoperatively when patients are well awake and stable. Pain during chest tube removal can be moderate to severe and can be the worst experience of hospitalization. Various modalities of pain relief during chest tube removal have been tried with variable results. We sought to examine the effect of transcutaneous electrical nerve stimulation (TENS) as an intervention for pain relief during chest tube removal after cardiac surgery.

Material And Methods: In a tertiary care center, fifty patients undergoing open heart surgery were randomized into two groups. Group TENS ( = 25) received TENS from 30 min before and continued up to 30 min after chest tube removal. Control Group ( = 25) did not receive TENS. In both the groups, additional analgesic medication was provided on demand, besides the standard analgesic regime which was injection ketorolac 30 mg intramuscularly every 8 h. Patients were studied for pain during chest drain removal and pain related nausea, vomiting, and sense of well-being.

Results: Mean visual analog pain score assessed for chest tube removal was significantly less 4.1 ± 1.2 ( < 0.05) in TENS Group as compared to 6.1 ± 0.8 in Control Group. Significantly greater number of patients ( = 14) ( < 0.05) in Control Group demanded additional analgesia as compared to TENS Group ( = 5). Feeling of well-being, improvement in appetite, and sleep was better in TENS Group as compared to Control Group.

Conclusion: We conclude that TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well-being during chest tube removal after cardiac surgery.
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http://dx.doi.org/10.4103/joacp.JOACP_336_15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066881PMC
August 2018

An unusual combination of discreet subaortic membrane, aortopulmonary window, severe aortic insufficiency and rheumatic mitral regurgitation.

Indian J Thorac Cardiovasc Surg 2018 Jul 5;34(3):394-397. Epub 2017 Sep 5.

Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India.

We report a 15-year-old female patient with an unusual combination of discreet subaortic membrane, aortopulmonary window, severe aortic insufficiency and rheumatic mitral regurgitation.
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http://dx.doi.org/10.1007/s12055-017-0589-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523598PMC
July 2018

Ultrasound Guided Cannulation of the Carotid Artery in Extensive Aortic Dissection Involving the Aortic Arch Branch Vessels.

J Cardiothorac Vasc Anesth 2018 04 9;32(2):e47-e48. Epub 2017 Aug 9.

Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

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http://dx.doi.org/10.1053/j.jvca.2017.08.015DOI Listing
April 2018

Bleeding in the lung complicates a routine intracardiac repair: What went wrong!!!

Ann Card Anaesth 2018 Jan-Mar;21(1):78-81

Department of Cardiology, Cardiothoracic Centre, CNC, All Institute of Medical Sciences, New Delhi, India.

Cyanotic congenital heart disease presents an increased tendency to bleed in view of subtle coagulation defects. Airway bleeding can be particularly difficult to manage while maintaining an adequate ventilation. An isolated lung bleed with the exclusion of possible traumatic, medical and surgical causes of bleeding, should alert the attending anesthesiologist to the possibility of the collateral-related bleeding. Preoperative coil embolization remains an important initial management step in a case of tetralogy of Fallot (TOF) with major aortopulmonary collaterals. Nevertheless, the coiling of the collaterals in certain specific case scenarios is not feasible, rendering the management of a lung bleed, all the more challenging. We, hereby discuss a case of a 7-year-old girl with a massive endotracheal bleed at the time of weaning from cardiopulmonary bypass after corrective surgery for TOF. The subsequent approach and management are discussed. The optimal management of tetralogy with collaterals mandates an effective communication among the cardiologist, radiologist, anesthesiologist, and the surgeon.
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http://dx.doi.org/10.4103/aca.ACA_137_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791498PMC
October 2018
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