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suspected HIT and anti‑PF4/H antibodies (CHOOSE‑ON
trial). Studies on desirudin in patients undergoing
Coronary Artery Bypass Graft (CABG) showed no major
bleeding events or postoperative HIT.
Dabigatran etexilate is comparable to enoxaparin in
the prevention of venous thromboembolism (after
major orthopedic surgery) and to warfarin in stroke
prevention in those with atrial fibrillation (with lower
rates of hemorrhage).
HIT, especially in settings like cardiopulmonary
bypass, warrants prompt diagnosis and management
as cessation of heparin and emergent therapy with
alternative anticoagulation can be life‑saving.
Dilip Gude
Department of Internal Medicine/Critical Care, Medwin Hospital,
Nampally, Hyderabad, Andhra Pradesh, India
Address for correspondence:
Dr. Dilip Gude,
AMC, 3 Floor, Medwin Hospital, Chirag Ali Lane, Nampally, Hyderabad,
Andhra Pradesh ‑ 500 001, India.
E‑mail: [email protected]
rd
REFERENCES
1.
Arepally GM, Ortel TL. Clinical practice. Heparin‑induced thrombocytopenia.
N Engl J Med 2006;355:809‑17.
2. Demma LJ, Winkler AM, Levy JH. A diagnosis of heparin-induced
thrombocytopenia with combined clinical and laboratory methods
in cardiothoracic surgical intensive care unit patients. Anesth Analg
2011;113:697-702.
3. Berry C, Tcherniantchouk O, Ley EJ, Salim A, Mirocha J, Martin‑Stone S,
et al. Overdiagnosis of heparin‑induced thrombocytopenia in surgical
ICU patients. J Am Coll Surg 2011;213:10‑7; discussion 17‑8.
4. Warkentin TE, Greinacher A, Koster A, Lincoff AM; American College
of Chest Physicians. Treatment and prevention of heparin‑induced
thrombocytopenia: American College of Chest Physicians
Evidence‑Based Clinical Practice Guidelines (8 th Edition). Chest
2008;133(6 Suppl):340S‑80S.
5. Lubenow N, Eichler P, Lietz T, Greinacher A; Hit Investigators Group.
Lepirudin in patients with heparin‑induced thrombocytopenia ‑ results
of the third prospective study (HAT‑3) and a combined analysis of HAT‑1,
HAT‑2, and HAT‑3. J Thromb Haemost 2005;3:2428‑36.
6. Koster A, Hentschel T, Groman T, Kuppe H, Hetzer R, Harder S, et al.
Argatroban anticoagulation for renal replacement therapy in patients
with heparin‑induced thrombocytopenia after cardiovascular surgery.
J Thorac Cardiovasc Surg 2007;133:1376‑7.
7. Sharma VK, Chaturvedi R, Manoj Luthra V. Antiphospholipid syndrome,
cardiac surgery and cardiopulmonary bypass. Ann Card Anaesth
2011;14:146‑9.
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DOI:
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Annals of Cardiac Anaesthesia  Vol. 15:2  Apr-Jun-2012
Perioperative
management of
pulmonary atresia
with intact ventricular
septum in a 5‑year old
The Editor,
Pulmonary atresia with intact ventricular septum
(PA/IVS) is a rare congenital cardiac defect accounting
for 1–3% of patients with congenital heart disease.
[1,2]
Medical management may be required to keep the
ductus open to maintain pulmonary blood flow. We
present a 5‑year‑old boy who was born with PA/IVS
and admitted to our institution for corrective cardiac
surgery. This child had a stormy intraoperative and
postoperative course following dental extraction, which
was required prior to definitive repair. This prompted
for an urgent cardiac repair, and the intraoperative
challenges with both the cardiac and the noncardiac
procedures are highlighted.
The patient (15 kg; height 93 cm) was scheduled for
pulmonary and tricuspid valve repair along with a
Cox‑Maze procedure and right atrial size reduction.
The patient had an open pulmonary valvotomy at
4 months of age for cyanosis secondary to PA/IVS.
Subsequently, the patient presented with heart failure
secondary to severe pulmonary regurgitation, right
ventricular dilatation and progressive tricuspid valve
regurgitation. The initial chest X‑ray showed severe
cardiomegaly [Figure 1a]. Patient was uncooperative
for an echocardiogram. Extensive dental cavities and
microabscesses necessitated dental extractions prior to
cardiac surgery. Shortly after induction with sevoflurane
and administration of cefazolin 50 mg/kg for endocarditis
prophylaxis, a bigeminal rhythm developed that quickly
progressed to wide complex ventricular tachycardia
(242 bpm). Synchronized cardioversion with 5J was
performed, but this resulted in atrial fibrillation at a rate
of 180–210 bpm. A repeat shock of 5J resulted in atrial
flutter. Sevoflurane was discontinued while the patient
airway was maintaied with a mask. Dental procedure
was cancelled and the patient was transferred to the
intensive care unit (ICU) with a loading dose (50 mcg/kg
over 60 min) followed by infusion of amiodarone (5 mcg/
kg/min). The patient did not rquire intubation as he
169
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Letters to Editor
was spontaneonsly breathing upon transfer to the ICU.
Transthoracic echocardiography showed a giant right
atrium [Figure 1b] and severely dilated right ventricle
with biventricular dysfunction and pulmonary valve
regurgitation. Upon transfer to the ICU, he was in atrial
flutter with a 2:1 conduction block with a ventricular rate
of 115 bpm. Because of the high likelihood of prosthetic
valve implantations, the boy still needed his dental
restorations done before the proposed cardiac surgery.
Despite amiodarone, the patient remained in atrial
flutter and hence the plan was to cardiovert him after
induction of anesthesia in the operating room. Induction
was done with incremental midazolam and fentanyl (up
to 50 mcg/kg and 4 mcg/kg, respectively) and intubated
with rocuronim 0.6 mg/kg. An extracorporeal membrane
oxygenator setup was available in case of hemodynamic
collapse. Anesthesia was maintained with remifentanil
infusion (0.1 mcg/kg/min) and isoflurane (0.5 MAC). The
patient tolerated the procedure well and woke up with
good response to commands. An extubation trial failed
and he was tranferred to the ICU intubated. While in
Figure 1a: Chest radiograph showing massive cardiomegaly
Figure 1b: Trans-thoracic echocardiogram showing severe right atrial dilatation
(RA - right atrium; RV - right ventricle; LA - left atrium; LV - left ventricle)
170
the ICU, the patient had two cardiac arrests requiring
resuscitation. Two days later, it was decided that it was in
the best interest of the patient to undergo cardiac surgery.
The patient had endotracheal tube ETT in situ and was
sedated with morphine and midazolam infusions prior
to coming to the operating theater. He was on milrinone
and amiodarone infusions. The patient was induced
with midazolam (80 mcg/kg), fentanyl (30 mcg/kg) and
rocuronium 1 mg/kg; anesthesia was maintained with
low‑dose isoflurane, fentanyl and rocuronim boluses.
The cardiopulmonary bypass lasted 216 min, with an
aortic cross‑clamp time of 140 min. Surgery included
implantation of a bioprosthetic pulmonary mosaic and a
tricuspid mosaic valve along with a right atrial Cox‑Maze
procedure and atrial dimension reduction for atrial
fibrillation. The initial transesophageal echocardiogram
after bypass showed reduced biventricular function,
which was treated with dopamine and epinephrine
infusions. Significant bleeding required multiple blood
products and one dose of factor VIIa. The patient was
transferred to the ICU where he continued to have
frequent bigeminy and bradyarrythmias. He was
extubated on the fourth postoperative day and was
discharged home on the twentieth postoperative day.
The main therapeutic goal of PA/IVS focuses on
establishing pulmonary blood flow, initially with
alprostadil to keep ductus patent. Infants who have
pulmonary valvotomy may develop significant
pulmonary regurgitation,[3] leading to right ventricular
dilatation, dysfunction and tricuspid annular dilatation
with tricuspid regurgitation, carrying a high risk
of developing significant hemodynamic instability.
Maintaining sinus rhythm and atrioventricular
synchrony is especially important in the presence of
right ventricular failure.[4] Ventricular interdependence
is an important concept in the management of right
ventricular dysfunction as excessive volume loading
may increase pericardial constraint and result in
decreased left ventricular preload and cardiac output.[4]
Inotropic or vasopressor support may also be required.
Dobutamine or milrinone may be used to improve
ventricular function. Because of lower pressure and
flow velocity on the right side of the heart, the incidence
of clot formations on mechanical valves is higher than
on the left side.[5] However, bioprosthetic valves have
a slower rate of degeneration if used on the right side
of the heart and give the patient the freedom of not to
be on chronic anticoagulation.[5] Cox‑Maze procedure,
as performed in our patient, involves mechanical
destruction of cardiac tissue to produce scars that
eliminate abnormal electrical conduction, and that can
also help restore heart rate and rhythm control.
Annals of Cardiac Anaesthesia  Vol. 15:2  Apr-Jun-2012
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Letters to Editor
Mazen Faden
Department of Anesthesia, The Hospital for Sick Children,
Toronto‑Canada
Address for correspondence:
Dr. Mazen Faden,
Department of Anesthesia, The Hospital for Sick Children,
555 University Avenue, Room 2303, Toronto, ON M5G 1X8, Canada.
E‑mail: [email protected]
REFERENCES
1.
Trusler GA, Yamamoto N, Williams WG, Izukawa T, Rowe R, Mustard WT.
Surgical treatment of pulmonary atresia with intact ventricular septum.
Br Heart J 1976;38:957‑60.
2. Humpl T, Soderberg B, McCrindle BW, Nykanen DG, Freedom RM,
Williams WG, et al. Percutaneous balloon valvotomy in pulmonary
atresia with intact ventricular septum: Impact on patient care.
Circulation 2003;108:826‑32.
3. Buechel ER, Dave HH, Kellenberger CJ, Dodge‑Khatami A, Pretre R,
Berger F, et al. Remodelling of the right ventricle after early
pulmonary valve replacement in children with repaired tetralogy of
Fallot: Assessment by cardiovascular magnetic resonance. Eur heart J
2005;26:2721‑7.
4. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in
cardiovascular disease, part II: Pathophysiology, clinical importance,
and management of right ventricular failure. Circulation 2008;
117:1717‑31.
5. Scully HE, Armstrong CS. Tricuspid valve replacement: Fifteen years of
experience with mechanical prostheses and bioprostheses. J Thorac
Cardiovasc Surg 1995;109:1035‑41.
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Tracheal injury
causing massive air
leak during mitral
valve replacement
surgery
The Editor,
Median sternotomy is a routinely performed procedure
during cardiac surgery for gaining access to the
mediastinal structures.[1] Engaging the sternal saw in
the suprasternal notch requires dissection and division
of interclavicular ligaments. We describe a case where
Annals of Cardiac Anaesthesia  Vol. 15:2  Apr-Jun-2012
the trachea was injured during sternotomy leading to
massive air leak.
A 40‑year‑old, male patient with severe calcific mitral
stenosis was scheduled for mitral valve replacement.
Airway examination was unremarkable. Anesthesia
workstation (Datex‑Ohmeda Aestiva S5, Helsinki,
Finland), breathing circuit and endotracheal tube (ETT)
cuff leak test were satisfactory. Electrocardiogram, pulse
oximetry (SpO2), end tidal carbondioxide (EtCO2) and
invasive radial artery pressure monitoring were initiated
prior to induction.
General anesthesia was induced and trachea was
intubated with a 9.0‑mm cuffed polyvinyl chloride
(PVC) ETT (Smiths Portex, Kent, UK), which was fixed
at 22 cm at the right angle of the mouth. Anesthesia and
neuromuscular blockade was maintained with repeated
doses of fentanyl, midazolam, vecuronium bromide
intravenously and sevoflurane‑air‑oxygen mixture
through the inhalational route.
The sternal notch was made prominent by placing a sand
bag underneath the shoulder. The lungs were deflated
by disconnecting the ETT from the ventilator prior to
sternotomy as per institutional protocol and ETCO2
read zero with a flat capnograph. The sternotomy saw
could not be engaged in the suprasternal notch in the
first attempt. The ‘inter‑clavicular ligament’ was excised
with scissors; the saw was reinserted, and the sternum
was divided. A SarnsTM sternotomy saw (Ann Arbor,
MI, USA) was used to perform the midline sternotomy.
On resuming mechanical ventilation, the capnograph
reappeared, but a low airway pressure alarm prompted
us to check ETT connection and the pilot balloon
assembly. The pilot balloon could not be inflated
despite repeated attempts to do so. Clamp was applied
at the insertion point of the inflation tube to the ETT to
demonstrate that the pilot balloon and the tubing were
intact. Hissing sounds and air bubbles emerging from the
cranial end of the sternotomy wound were also noted.
The surgeon was informed immediately and manual
ventilation was started with increased fresh gas flow
(FGF) from 2 to 12 L/min with 100% O2. The surgical
trainee detected a rent in the trachea and tried to occlude
it with the tip of his index finger, but then air started
leaking from the oropharynx. It was apparent that the
ETT needed replacement as it’s PVC cuff was damaged.
The ETT was pushed further inside by about 2 inches
to facilitate ventilation during tracheal repair. Once the
trachea was repaired, the damaged ETT [Figure 1] was
171