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Md Abir Tazim Chowdhury,1 Dharmendra Joshi,2 Munama Magdum,3 Dipannita Adhikary,4 SMG Saklayen,5 Md Alauddin,6 Redoy Ranjan,4,6 Asit Baran Adhikary7 1Department of Cardiothoracic and Vascular Surgery, Evercare Hospital Dhaka, Dhaka, Bangladesh; 2Department of Cardiac Surgery, Shahid Gangalal National Heart Centre, Kathmandu, Nepal; 3Department of Preventive and Social Medicine, National Institute of Preventive and Social Medicine, Dhaka, Bangladesh; 4Department of Biological Sciences, Royal Holloway University of London, London, UK; 5Department of Vascular Surgery, Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh; 6Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; 7Department of Cardiac Surgery, Impulse Hospital, Dhaka, BangladeshCorrespondence: Md Abir Tazim Chowdhury, Department of Cardiothoracic and Vascular Surgery, Evercare Hospital Dhaka, Dhaka, Bangladesh, Tel +8801718123463, Email chowdhuryabir0@gmail.comBackground: Atherosclerosis is a systemic vascular disease commonly affecting coronary and carotid arteries, particularly in diabetes mellitus (DM). This study assessed the association of DM with significant carotid artery stenosis (CAS) among the coronary artery disease (CAD) population undergoing isolated elective coronary artery bypass graft (CABG) surgery.Methods: A prospective cross-sectional study evaluated 100 Bangladeshi CAD patients who underwent isolated elective CABG from January 2017 to September 2019. Initially, a univariate analysis curtails the risk patterns, followed by a Pearson correlation analysis of significant CAS and glycated haemoglobin (HbA1c).Results: Although the majority of patients were male, females were higher in the diabetic than non-diabetic group (38.1% vs 15.5%; p=0.01). Overall, ~38% of diabetic patients had significantly higher ≥ 50% CAS. Further, 28.6% and 9.5% of the diabetic sample had 50– 70% and > 70% CAS, respectively, which is significantly (p =0.02) higher than the non-diabetic sample (8.6% and 1.7%, respectively). Additionally, diabetes was significantly more associated with both unilateral (31.0% vs 22.4%) and bilateral (45.2% vs 22.4%) CAS than the non-diabetic population (p=0.006). The Pearson correlation coefficient shows a significant positive association between higher glycated haemoglobin levels and > 50% CAS (correlation coefficient 0.270; p = 0.007).Conclusion: We found higher HbA1c had a significant positive correlation with > 50% CAS in diabetic patients undergoing elective CABG, recommending preoperative carotid screening, especially elderly individuals.Keywords: carotid artery stenosis, coronary artery disease, diabetes mellitus, duplex scan

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Purpose of Review: To evaluate the current trends, safety, and feasibility of same-day discharge (SDD) in ambulatory cardiac procedures, with a focus on percutaneous coronary interventions (PCI). This review also discusses the impact of technological advancements and explores future directions for expanding the scope of SDD in more complex cardiac procedures., Recent Findings: Recent studies have demonstrated that SDD after PCI is both well tolerated and effective for appropriately selected patients, with outcomes comparable with those of patients who remain hospitalized overnight. Advancements in PCI technology, including improved stent designs, smaller sheath sizes, and the adoption of the transradial approach, have significantly enhanced the feasibility of SDD. Enhanced recovery after surgery (ERAS) pathways, adapted for ambulatory settings, further improve patient safety, particularly as more complex procedures are attempted. However, challenges remain in determining SDD eligibility, particularly in settings with limited emergency care capabilities., Summary: SDD is a viable and cost-effective option for low-risk patients undergoing PCI and other ambulatory cardiac procedures. The successful implementation of SDD requires careful patient selection, adherence to standardized protocols, and vigilant postprocedural monitoring. Future research should focus on refining patient selection tools, expanding the scope of SDD to include more complex procedures, and enhancing postdischarge monitoring through advanced technologies. Multidisciplinary collaboration and ongoing education are essential to support the well tolerated and effective adoption of SDD in ambulatory cardiac care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The use of endovascular, percutaneous interventions to treat cardiac, arterial, and venous pathologies is becoming increasingly common in medical practice. While endovascular device placement typically carries a low risk, device migration remains a persistent problem with these procedures for which anesthesia providers must have a high index of suspicion. Anesthesia providers should be aware of the wide range of indications for such devices, potential migration locations, and hemodynamic consequences of both the inciting pathology and device migration so they can safely care for patients in these settings. This article aims to discuss a case series of five different device migration events, review the literature surrounding the migration of each device, and propose unique anesthetic considerations as well as a systematic approach by which to approach these complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest Michael Essandoh, MD reports a relationship with Boston Scientific that includes: consulting or advisory. Michael Essandoh, MD reports a relationship with S4 Medical Corporations that includes: consulting or advisory. John Hummel, MD reports a relationship with Biosense Webster Inc that includes: consulting or advisory. John Hummel, MD reports a relationship with Abbott that includes: consulting or advisory. John Hummel, MD reports a relationship with Medtronic that includes: consulting or advisory. Co-author Michael Essandoh, MD also on the editorial board for Journal of Cardiothoracic and Vascular Anesthesia. The remaining authors have no potential conflicts to declare.

The Syncardia total artificial heart system is the only commercially approved durable device for treating biventricular heart failure patients awaiting heart transplantation. Conventionally, the Syncardia total artificial heart system is implanted based on the distance from the anterior aspect of the 10th thoracic vertebra to the sternum and the patient's body surface area. However, this criterion does not account for chest wall musculoskeletal deformities. This case report describes a patient with a pectus excavatum who developed compression of the inferior vena cava after Syncardia total artificial heart implantation and how transesophageal echocardiography guided chest wall surgery to accommodate the total artificial heart system., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Nahush A. Mokadam, MD, is a consultant for Syncardia.

Cefazolin is an antibiotic that is commonly administered perioperatively to reduce the risk of surgical site infections. Cephalosporins have a well-established safety profile, but have been associated with thrombocytopenia and neutropenia due to their myelosuppressive effects. While this effect may be benign in healthy patients undergoing minor surgery, it can be detrimental in patients with underlying hematologic disorders presenting for open-heart surgery. Herein, we discuss the first case in the literature of cefazolin-induced thrombocytopenia and severe coagulopathy in a patient with polycythemia vera (PCV) during a coronary artery bypass-grafting surgery.

Standard mitral valve replacement in patients with chronic mitral valve regurgitation and mitral valve stenosis consistently results in a decrease in early postoperative left ventricular ejection performance. Some studies showed that preservation of mitral valve leaflet and subvalvular apparatus can reduce postoperative left ventricular dysfunction. On the basis of the concept, this randomized clinical trial comparing mitral valve replacement with preservation of mitral subvalvular apparatus and conventional mitral valve replacement performed in National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh, in the period of July 2010 to December 2011. We included 60 patients of mitral regurgitation and mitral stenosis, among them 30 patients underwent mitral valve replacement with preservation of mitral subvalvular apparatus (Group A) and 30 patients underwent conventional mitral valve replacement (Group B). There was no significant difference between two groups in terms of peri-operative variables. But there was significant higher incidence of Low cardiac output (LOS) syndrome [36.7% vs. 6.9% (p<0.05)] and congestive heart failure in Group B than Group A. The duration of ICU stay was also significantly higher in conventional mitral valve replacement group [113.23±11.30 hours vs. 96.23±20.02 (p=0.001)]. Additionally, there was significantly less fall of left ventricular ejection fraction in preservation of mitral subvalvular apparatus group [preop 65.27±5.45, at discharge 54.31±3.78, after 3 months 58.28±5.20 (p<0.0001)] than conventional group [preop 66.43±4.58, at discharge 46.43±3.87, after 3 months 46.55±3.63 (p<0.0001)]. In this study left ventricular ejection fraction was used as measure of left ventricular function. We postulate that, this relative preservation of left ventricular ejection fraction was likely the result of preservation of mitral subvalvular apparatus.

Purpose: To assess the feasibility and safety of same-day discharge after S-ICD implantation by implementing a specific analgesia protocol and phone follow-up., Methods: Consecutive patients presenting for outpatient S-ICD implantation were enrolled between 1/1/2018 and 4/30/2019. An analgesia protocol included pre-operative acetaminophen and oxycodone, intraoperative local bupivacaine, and limited use of oxycodone-acetaminophen at discharge. The primary outcome was successful same-day discharge. Numerical Pain Rating Scale (NPRS) on postoperative day (POD) 1, 3, 14, and 30 and any unplanned health care visits during the 1-month follow-up period were assessed., Results: Out of 53 potentially eligible S-ICD patients, 49 patients (92.5%) were enrolled and successfully discharged on the same day. Mean age of these 49 patients was 47 ± 14 years. There were no acute procedural complications. Severe pain (NPRS ≥ 8) on POD 0, 1, and 3 was present in 14.3%, 14.3%, and 8.2% of patients, respectively. The total in-hospital stay was 534 ± 80 min. Four unplanned visits (8%) due to cardiac or device-related issues occurred during 1-month follow-up, including 2 patients with heart failure exacerbation, one patient with an incisional infection, and one patient with inappropriate shocks., Conclusions: With the appropriate institutional protocol including specific analgesics and phone follow-up, same-day discharge after outpatient S-ICD implantation is feasible and appears safe for most patients.. Device-related pain can be severe in the first 3 days post-implantation and can be successfully treated with limited supply of narcotic medications.

Background: The perioperative anesthesia care during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving., Objective: To assess the feasibility and safety of S-ICD implantation with monitored anesthesia care (MAC) versus general anesthesia (GA) in a tertiary care center., Methods: This is a single-center retrospective study of patients undergoing S-ICD implantation between October 2012 and May 2019. Patients were categorized into MAC and GA group based on the mode of anesthesia. Procedural success without escalation to GA was the primary endpoint of the study, whereas intraprocedural hemodynamics, need of pharmacological support for hypotension and bradycardia, length of the procedure, stay in the post-anesthesia care unit, and postoperative pain were assessed as secondary endpoints., Results: The study comprises 287 patients with MAC in 111 and GA in 176 patients. Compared to MAC, patients in GA group were younger and had a higher body mass index. All patients had successful S-ICD implantation. Only one patient (0.9%) in the MAC group was converted to GA. Despite a similar baseline heart rate (HR) and mean arterial blood pressure (MAP) in both groups, patients with GA had significantly lower HR and MAP during the procedure and more frequently required pharmacological hemodynamic support. Length of the procedure, stay in the postanesthesia care unit, and postoperative pain was similar in both groups., Conclusion: This retrospective experience suggests that implantation of S-ICD is feasible and safe with MAC. Use of GA is associated with more frequent administration of hemodynamic drugs during S-ICD implantation., (© 2019 Wiley Periodicals, Inc.)

Background: Pulmonary cuff dysfunction, either due to pulmonary vein obstruction, pulmonary vein stenosis, or pulmonary vein thrombosis, is an uncommon, yet serious complication after lung transplantation. Although there have been numerous reports of its occurrence, there is little consensus regarding the hemodynamic parameters associated with its presentation and diagnostic considerations. This systematic review summarizes the evidence surrounding pulmonary cuff dysfunction after lung transplantation surgery and empirically analyzes its implications., Methods: Databases were examined for all articles and abstracts reporting on pulmonary cuff dysfunction. Data collected included: number of patients studied; patients' characteristics; incidences of pulmonary vein stenosis and pulmonary vein thrombosis; and timing and imaging modality utilized for diagnosis., Results: Thirty-four full-text citations were included in this review. The point prevalence of pulmonary vein stenosis and thrombosis were 1.4% and 2.5%, respectively. The peak pulmonary cuff velocity associated with dysfunction was found to be 1.59 ± 0.66 m/sec. The diameter of the dysfunctional pulmonary vein was noted to be 0.48 ± 0.20 cm. The majority of diagnoses were made in the early post-operative period using transesophageal echocardiography. Overall, 41.3% of patients (26 of 63) required emergent procedural reintervention, and 32% of patients (20 of 63) diagnosed with pulmonary cuff dysfunction died during their hospital stay., Conclusions: This systematic review underscores the importance of identifying pulmonary cuff dysfunction after lung transplant surgery, and the usefulness of transesophageal echocardiography for detection of this complication. The clinical implications of these results warrant the further development of identification and management strategies for lung transplant patients., (Copyright © 2019 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective and Background: Autism is characterized by repetitive behaviors and impaired socialization and communication. Preliminary evidence showed possible language benefits in autism from the β-adrenergic antagonist propranolol. Earlier studies in other populations suggested propranolol might benefit performance on tasks involving a search of semantic and associative networks under certain conditions. Therefore, we wished to determine whether this benefit of propranolol includes an effect on semantic fluency in autism., Methods: A sample of 14 high-functioning adolescent and adult participants with autism and 14 matched controls were given letter and category word fluency tasks on 2 separate testing sessions; 1 test was given 60 minutes after the administration of 40 mg propranolol orally, and 1 test was given after placebo, administered in a double-blinded, counterbalanced manner., Results: Participants with autism were significantly impaired compared with controls on both fluency tasks. Propranolol significantly improved performance on category fluency, but not letter fluency among autism participants. No drug effect was observed among controls. Expected drug effects on heart rate and blood pressure were observed in both the groups., Conclusions: Results are consistent with a selective beneficial effect of propranolol on flexibility of access to semantic and associative networks in autism, with no observed effect on phonological networks. Further study will be necessary to understand potential clinical implications of this finding.

A decrease in interaction between brain regions is observed in individuals with autism spectrum disorder (ASD), which is believed to be related to restricted neural network access in ASD. Propranolol, a beta-adrenergic antagonist, has revealed benefit during performance of tasks involving flexibility of access to networks, a benefit also seen in ASD. Our goal was to determine the effect of propranolol on functional connectivity in ASD during a verbal decision making task as compared to nadolol, thereby accounting for the potential spurious fMRI effects due to peripheral hemodynamic effects of propranolol. Ten ASD subjects underwent fMRI scans after administration of placebo, propranolol or nadolol, while performing a phonological decision making task. Comparison of functional connectivity between pre-defined ROI-pairs revealed a significant increase with propranolol compared to nadolol, suggesting a potential imaging marker for the cognitive effects of propranolol in ASD.

Here we analyzed the light-responsiveness of the mammalian target of rapamycin (mTOR) cascade, a key regulator of inducible translation, in the suprachiasmatic nuclei (SCN), the locus of the master circadian clock. Brief light exposure during the subjective night, but not during the subjective day, triggered rapid phosphorylation (a marker of catalytic activity) of the mTOR translation effectors p70 S6K, ribosomal S6 protein (S6) and 4E-BP1. In the absence of photic stimulation, marked S6 and 4E-BP1 phosphorylation was detected, indicating tonic mTOR activity in the SCN. Light stimulated the colocalized activation of p70 S6K and extracellular signal-regulated protein kinase (ERK), and pharmacological disruption of ERK signaling abolished light-induced mTOR activity, revealing that the MAPK cascade is an essential intermediate that couples light to mTOR. Together these data identify a light-responsive mTOR cascade in the SCN, and thus, raise the possibility that inducible translation contributes to the clock entrainment process.