Pulmonary endarterectomy for saddling pulmonary embolism by Aspergillus fungus in an immunocompetent patient

We present a case of Tricuspid valve Aspergillus endocarditis with saddle shaped massive pulmonary embolism occurring in an immunocompetent host. The patient was managed uniquely by pulmonary endarterectomy (PEA) and combination antifungal chemotherapy with Liposomal amphotericin-B + caspofungin

Effect of preoperative ivabradine on hemodynamics during elective off-pump CABG

Background: Ivabradine is a specific heart rate (HR)-lowering agent which blocks the cardiac pacemaker If channels. It reduces the HR without causing a negative inotropic or lusitropic effect, thus preserving ventricular contractility. The authors hypothesized that its usefulness in lowering HR can be utilized in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Objective: To study the effects of preoperative ivabradine on hemodynamics (during surgery) in patients undergoing elective OPCAB surgery. Methods: Fifty patients, New York Heart Association (NYHA) class I and II, were randomized into group I (control, n = 25) and group II (ivabradine group, n = 25). In group I, patients received the usual anti-anginal medications in the preoperative period, as per the institutional protocol. In group II, patients received ivabradine 5 mg twice daily for 3 days before surgery, in addition to the usual anti-anginal medications. Anesthesia was induced with fentanyl, thiopentone sodium, and pancuronium bromide as a muscle relaxant and maintained with fentanyl, midazolam, pancuronium bromide, and isoflurane. The hemodynamic parameters [HR and mean arterial pressure (MAP)] and pulmonary artery (PA) catheter-derived data were recorded at the baseline (before induction), 3 min after the induction of anesthesia at 1 min and 3 min after intubation and at 5 min and 30 min after protamine administration. Intraoperatively, hemodynamic data (HR and MAP) were recorded every 10 min, except during distal anastomosis of the coronary arteries when it was recorded every 5 min. Post-operatively, at 24 hours, the levels of troponin T and brain natriuretic peptide (BNP) were measured. This trial's CTRI registration number is CTRI/005858. Results: The HR in group II was lower when compared to group I (range 59.6–72.4 beats/min and 65.8–80.2 beats/min, respectively) throughout the study period. MAP was comparable [range (78.5–87.8 mm Hg) vs. (78.9-88.5 mm Hg) in group II vs. group I, respectively] throughout the study period. Intraoperatively, 5 patients received metoprolol in group I to control the HR, whereas none of the patients in group II required metoprolol. The incidence of preoperative bradycardia (HR <60 beats/min) was higher in group II (20%) vs. group I (8%). There was no difference in both the groups in terms of troponin T and BNP level after 24 hours, time to extubation, requirement of inotropes, incidence of arrhythmias, in-hospital morbidity, and 30-day mortality. Conclusion: Ivabradine can be safely used along with other anti-anginal agents during the preoperative period in patients undergoing OPCAB surgery. It helps to maintain a lower HR during surgery and reduces the need for beta-blockers in the intraoperative period, a desirable and beneficial effect in situations where the use of beta-blockers may be potentially harmful. Further studies are needed to evaluate the beneficial effects of perioperative Ivabradine in patients with moderate-to-severe left ventricular dysfunction

The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery

Aims and objectives: Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. Materials and Methods: The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. Results: The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. Conclusion: IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations