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[Downloaded free from http://www.annals.in on Wednesday, July 18, 2012, IP: 125.16.60.178] || Click here to download free Android application for this journal Letters to Editor 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. Access this article online Quick Response Code: Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.95088 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 [Downloaded free from http://www.annals.in on Wednesday, July 18, 2012, IP: 125.16.60.178] || Click here to download free Android application for this journal 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 [Downloaded free from http://www.annals.in on Wednesday, July 18, 2012, IP: 125.16.60.178] || Click here to download free Android application for this journal 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. Access this article online Quick Response Code: Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.95089 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