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before 3 months of age,[2].the fact that this infant had tolerated such a complex CHD without demonstrating any major symptoms was quite remarkable. Cardiac murmurs in a tachycardic, crying infant may be difficult to perceive. In dark-skinned persons, central cyanosis may not be detected until the SpO2 has declined to 75%.[3].Since the child was comfortable at SpO2 levels of 85–86%, significant clinical cyanosis was masked. A pulmonary-to -systemic blood flow ratio of approximately 1.3:1, SpO2 between 80 and 85% due to the mixing of systemic and pulmonary venous return, and a hematocrit of 45–50% are considered optimal in this group of patients.[4].Unaware of the exact nature of the cardiac lesion, the realization that the child was having some kind of unrestrictive intracardiac shunt led us to adopt an approach of balancing systemic hemodynamics along with acceptance of lower SpO2 levels by decreasing the inspired oxygen concentration.
Satyen Parida, RM Mohan, Ravindra R Bhat, Sandeep K Mishra, Ashok S Badhe Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India Address for correspondence: Dr. Satyen Parida, Qr. No. E-44, JIPMER Campus, Dhanvantari Nagar, Pondicherry – 605 006, India. E-mail:
[email protected]
REFERENCES 1.
2. 3.
4.
Krane EJ, Philip BM, Yeh KK, Domino KB. Anesthesia for pediatric neurosurgery. In: Motoyama EK, Davis PJ, editors. Smith’s Anesthesia for Infants and Children. 7th ed. Philadelphia: Mosby, Elsevier; 2005. p. 668. Black AE. Medical assessment of the paediatric patient. Br J Anaesth 1999;83:3-15. Braunwald E. Hypoxia and cyanosis. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 16th ed. New York : McGraw Hill; 2005. p. 210. Beekman RH, Tuuri DT. Acute hemodynamic effects of increasing haemoglobin concentration in children with a right and left ventricular shunt and relative anemia. J Am Coll Cardiol 1985;5:357-62.
End to end anastomosis of an injured left anterior descending coronary artery PMID: ****
DOI: 10.4103/0971-9784.69071
The Editor, We present a case of a 2-year-old child weighing 7 kg Annals of Cardiac Anaesthesia Vol. 13:3 Sep-Dec-2010
with a diagnosis of Tetralogy of Fallot (TOF), in whom inadvertent division of the left anterior descending coronary artery (LAD) occurred at surgery. It was successfully managed by end to end anastomosis. Bypass grafting using saphenous vein or left internal mammary artery are the only reported methods to restore blood supply distal to an inadvertently transected LAD.[1-3].To the best of our knowledge, this is the first report of end to end anastomosis of an injured LAD. Pre-operatively, transthoracic echocardiogram revealed the diagnosis of TOF with a large perimembranous ventricular septal defect and infundibular pulmonary stenosis. Coronary angiography in the patient was inconclusive of anomalous LAD. However, anomalous LAD from the right coronary artery coursing across the right ventricular outflow tract (RVOT) over the epicardium was observed intra-operatively. The left circumflex artery was arising normally from the left sinus. It was decided to perform total correction via the transatrial approach, as the pulmonary annulus seemed to be adequate in size. However, the LAD was bisected during vigorous dissection of muscle bands from the RVOT. Considering that precious time might be lost in taking down a mammary or a vein of uncertain caliber, and as both the ends of the artery were visible, it was decided to perform end to end anastomosis of the injured artery. This was successfully accomplished using an 8-0 polypropylene suture. The opened-up area of the right ventricle was patched by autologous pericardium. Initially, there was difficulty in weaning the patient off cardiopulmonary bypass, probably due to myocardial ischemia in LAD territory, but with the empirical addition of diltiazem (0.5 mg/h) to milrinone (0.5 mics/kg/min) and dobutamine (5 mics/kg/min), he could be weaned off successfully from cardiopulmonary bypass. I was assumed at that time that diltiazem helped in relieving spasm in the repaired LAD. The post-operative right ventricular to left ventricular pressure ratio was acceptable at 0.5. The remaining course was uneventful and the patient was extubated after 36 h of elective ventilation. Transthoracic echocardiography on the third post-operative day revealed normal biventricular function. He was discharged on the seventh day after surgery. Anomalous coronary artery anatomy occurs in 2–9% of the patients with TOF, with LAD arising from the right coronary artery and coursing across the RVOT being the commonest.[4] LAD injury during intra-cardiac repair for TOF is a catastrophic complication that must be prevented (and repaired if injury is suspected) at 267
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all costs. However, in the unfortunate circumstance of such an event occurring, end to end anastomosis of the divided artery, as we have demonstrated, remains a viable surgical option. However, long-term follow-up with coronary angiography or exercise testing when the child is older would be indicated to conclusively demonstrate the patency of the repaired LAD.
Akhlesh S Tomar, Saket Agarwal1, Aditya Singh1, Shivsagar Mandiye1, Devesh Dutta, Vishnu Datt Departments of Anesthesiology, 1Cardio-vascular and Thoracic Surgery, G.B. Pant Hospital, New Delhi, India Address for correspondence: Dr. Saket Agarwal, Department of Cardiovascular & Thoracic Surgery, G.B. Pant Hospital, New Delhi, India. E-mail:
[email protected]
REFERENCES 1.
2. 3.
4.
Bhutani AK, Koppala MM, Abraham KA, Balakrishnan KR, Desai RN. Inadvertent transection of anomalously arising left anterior descending artery during tetralogy of Fallot repair: Bypass grafting with left internal mammary artery. J Thorac Cardiovasc Surg 1994;108: 589-90. Berry BE, McGoon DC. Total correction for tetralogy of Fallot with anomalous coronary artery. Surgery 1973;74:894-8. Ruzmetov M, Jimenez MA, Pruitt A, Turrentine MW, Brown JW. Repair of tetralogy of fallot with anomalous coronary arteries coursing across the obstructed right ventricular outflow tract. Pediatr Cardiol 2005;26:537-42. Cooley DA, Duncan JM, Gillette PC, McNamara DG. Reconstruction of coronary artery anomaly in an infant using the internal mammary artery. Pediatr Cardiol 1987;8:257-9.
To evaluate the heart or not in emergency neurosurgical headinjured patients with ST elevation PMID: ****
DOI: 10.4103/0971-9784.69073
The Editor, We read with interest the letter to the editor, “ST elevation in a head-injury patient for emergency neurosurgery: Do we routinely need a cardiac evaluation?”[1] The inference of the authors seems simple, yet debatable. The presence of ST elevation signifying the possibility of myocardial ischemia cannot be denied. Further, in head injury patients, echocardiographic findings of myocardial dysfunction have been well documented. [2] Left ventricular wall motion may be significantly 268
decreased in patients with subarachanoid hemorrhage (SAH) and ST elevation compared to those without. [3]. Naidech et al., observed elevated levels of cardiac troponin (cTn)-a 100% sensitive and specific marker for cardiac injury-in up to 20% of patients with aneurysmal SAH. [4] They recommended routine measurement of troponin I (cTI) in SAH patients who present with electrocardiographic changes or clinical signs.of potential cardiovascular dysfunction. Acute cTI elevation >2.0 µg/L after SAH should trigger a screening echocardiogram and may be useful in identifying patients who might benefit from invasive hemodynamic monitoring in the perioperative period. [4] A recent metaanalysis revealed that the markers for cardiac damage and dysfunction are associated.with an increased risk of hypotension requiring vasopressor therapy, delayed cerebral ischemia, poor neurological outcome and death after SAH.[5] Therefore, myocardial injury may occur in patients with SAH, and may be responsible for unstable hemodynamics during the perioperative period in such patients. Although the authors were fortunate that their patient had good neurological outcome, the need for inotropic support following induction of anesthesia in the described case was suggestive of significant cardiac risk. The need for, and value of, preoperative cardiac evaluation will also depend on the urgency of surgery. In case of emergency surgical procedures, such as those for ruptured abdominal aortic aneurysm, major trauma or perforated viscus, cardiac evaluation will not change the course and result of the intervention, but may influence the management in the immediate postoperative period. A head-injured patient with acute subdural hematoma is possibly such a condition.[6] Nevertheless, the presence of ST-segment elevation raises two anesthetic issues: firstly, the optimum timing for induction of general anesthesia and surgery and, secondly, the management of the possible risk of perioperative cardiovascular deterioration. Myocardial injury in the recent past has been consistently identified as risk factors for perioperative cardiac events.[6] Hence, the argument on whether preoperative cardiology consultation needs to be obtained or not is rather unsubstantiated. The presence of ST elevation certainly raises an alarm for the risk of perioperative cardiovascular complications. Measures to minimize intraoperative cardiac risk should be considered, such as using invasive hemodynamic monitoring, avoiding myocardial depressant agents and maintaining optimal myocardial oxygen supply and demand. One should be prepared to manage any event of hemodynamic instability with vasopressors and cardiotonic drugs. Annals of Cardiac Anaesthesia Vol. 13:3 Sep-Dec-2010
