Patients with acute aortic dissection present with such varied symptoms that diagnosis becomes difficult. Various imaging techniques like computed tomography angiography (CTA), magnetic resonance imaging and ultrasonography are used to diagnose this entity, but they too have their limitations. We present a case, which was falsely diagnosed as acute aortic dissection by CTA, which resulted in patient undergoing sternotomy.
Transesophageal echocardiography (TEE) is widely used in cardiac surgery. TEE provides important diagnostic and functional information before and after cardiopulmonary bypass thereby having a very important impact on perioperative clinical outcomes. We describe a case in which intraoperative TEE was instrumental in the timely diagnosis of inadvertant closure of the inferior vena cava (IVC) opening during minimally invasive surgical closure of atrial septal defect.
The aims were to compare the European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II system against three established risk scoring systems for predictive accuracy in an urban Indian population and suggest improvements or amendments in the existing scoring system for adaptation in Indian population.EuroSCORE-II, Parsonnet score, System-97 score, and Cleveland score were obtained preoperatively for 1098 consecutive patients. EuroSCORE-II system was analyzed in comparison to each of the above three scoring systems in an urban Indian population. Calibrations of scoring systems were assessed using Hosmer-Lemeshow test. Areas under receiver operating characteristics (ROC) curves were compared according to the statistical approach suggested by Hanley and McNeil.All EuroSCORE-II subgroups had highly significant P values stating good predictive mortality, except high-risk group (P = 0.175). The analysis of ROC curves of different scoring systems showed that the highest predictive value for mortality was calculated for the System-97 score followed by the Cleveland score. System-97 revealed extremely high predictive accuracies across all subgroups (curve area >80%). This difference in predictive accuracy was found to be statistically significant (P < 0.001).The present study suggests that the EuroSCORE-II model in its present form is not validated for use in the Indian population. An interesting observation was significantly accurate predictive abilities of the System-97 score.
A 32-year-old female presented to the hospital with dyspnoea and chest pain (on exertion) since one year. Electrocardiography showed Q wave in lead I and aVL. Transthoracic echocardiography (TTE) showed dilated right coronary artery (RCA), continuous flow in the proximal main pulmonary artery (MPA), scarring in the antero-lateral papillary muscle and mild hypo kinetic distal interventricular septum with 60% ejection fraction. A computed tomography (CT) angiography traced the origin of the left coronary artery (LCA) from the MPA. [Figure 1] Cardiac catheterization revealed dilated RCA [Figure 2] and left to right shunt at the level of MPA. This completed the diagnosis of the anomalous origin of left coronary artery from pulmonary artery (ALCAPA).Figure 1: CTa angio showing LCA arising from pulmonary arteryFigure 2: Cardiac catheterization showing dilated Right coronary artery. A= Right coronary arteryThe patient was scheduled for closure of anomalous LCA ostium from MPA along with left internal mammary artery anastomosis to the left artery descending artery. She was induced using standard opioid based technique. Transesophageal echocardiography (TEE) probe was inserted atraumatically after induction of anesthesia. Mid esophageal short axis [Figure 3] and long axis aortic valve view showed the dilated RCA [Figure 4]. Upper esophageal short axis aortic arch view showed MPA on the right side of the imaging sector with ostium of LCA distal to the pulmonary valve [Figure 5]. Color Doppler revealed retrograde flow from the ostium of LCA to MPA (blue color) [video file Figure 6 and 6A]. Though the preoperative TTE mentioned continuous flow in MPA, we found retrograde flow to MPA during systole. (Video file attached). A transgastric mid-papillary view showed brightness in the antero-lateral papillary muscle [Figure 7]. Thus, TEE confirmed the diagnosis in this case. Surgery and the postoperative course were uneventful. Postoperative TTE showed no residual flow in the MPA.Figure 3: Midesophageal Short axis aortic valve showing dilated right coronary artery. A= Dilated right coronary arteryFigure 4: Midesophageal long axis aortic valve showing dilated right coronary artery. A= Dilated right coronary arteryFigure 5: Upper esophageal short axis aortic arch view showing left coronary artery ostium distal to the pulmonary valve. A= Ostium of the left coronary arteryFigure 6: Upper esophageal short axis aortic arch view showing color flow in the ostium of the left coronary artery and in the main pulmonary artery. A= Retrograde flow (Blue Color) from Left coronary arteryFigure 7: Transgastric mid-papillary view showing brightness in the antero-lateral papillary muscle. B= Antero-lateral papillary muscleALCAPA is a rare but serious congenital cardiac anomaly accounting for 0.25-0.50% of all congenital heart diseases.[1] ALCAPA is of two types based on the survival pattern - adult and infantile type. In the infantile type, the collateral circulation is poorly developed and therefore, if left untreated, the mortality rate in the first year of life is 90% secondary to myocardial infarction and mitral valve insufficiency leading to congestive heart failure. In the adult type, delayed presentation is due to development of good collateral circulation.[2] However, there is an estimated 80-90% incidence of sudden death at a mean age of 35 years in this group. Electrocardiogram-gated multi detector CT angiography and magnetic resonance (MR) imaging play important roles as noninvasive modalities in assessment of the ALCAPA syndrome.[3] They enable the direct visualization of the LCA arising from MPA and reversed flow from the left coronary artery into the MPA. They also replace the need of cardiac catheterization which is an invasive procedure. These modalities, though very accurate, are expensive and not easily available. On the other hand, 2-D echocardiography is also a noninvasive diagnostic modality which provides fairly accurate diagnosis. Both 2-D images and color Doppler may identify origin of LCA from MPA by showing turbulent flow at the ostium. LCA ostium which is sometimes not visible on TTE could be seen well on TEE.[4] It also demonstrates the retrograde flow from the LCA to the MPA. The presence of retrograde flow is dependent on the development of collaterals between the left and right coronary artery system. If collateralization has not occurred, as may be the case with pediatric age group, this finding may be absent. Abnormal dilation of the RCA reflects development of extensive collateral between left and right coronary artery system. Another finding which is not sensitive but highly specific is abnormal "brightness" of the left ventricular papillary muscles.[5] TEE monitoring is commonly used during cardiac surgery. However, we could not find TEE images during our literature search and hence this study aimed to present TEE images of ALCAPA. Source of Support Nil, Conflicts of interest None declared.
Background The incidence of acute renal dysfunction has not changed much over the years, despite improvements in perioperative care. Our objectives were to evaluate the impact of timing of cardiac surgery after coronary angiography on acute renal dysfunction, to identify risk factors associated with development of acute renal dysfunction, and to measure the association between acute renal dysfunction and mortality. Patients and methods The patients were divided into 3 groups: group A (cardiac surgery 0–3 days after angiography), group B (surgery 4–6 days after angiography), and group C (surgery > 6 days after angiography). Endpoints were acute renal dysfunction, defined as serum creatinine > 25% of baseline on the 3rd postoperative day, and mortality. Results In 749 patients, the incidence of acute renal dysfunction was 15%; 5% required dialysis. Hypertension, congestive heart failure, chronic obstructive pulmonary disease, ejection fraction < 40%, prolonged cardiopulmonary bypass time, intraaortic balloon pump use, and urgent surgery were risk factors for acute renal dysfunction after cardiac surgery. Patients in group C had a lower risk of acute renal dysfunction. Conclusion Acute renal dysfunction has a definite relationship with the time period between angiography and cardiac surgery. The causative factors for this condition are multiple and also show a consistent association with mortality.
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