Journal of the American Society of Echocardiography, 2000
Antiphospholipid antibody syndrome (APS) commonly presents with thrombotic events, pregnancy morb... more Antiphospholipid antibody syndrome (APS) commonly presents with thrombotic events, pregnancy morbidity, and recurrent pregnancy loss [1]. APS presenting as fever of unknown origin (FUO) is rare. To date, there are only a few case reports that have described FUO as presenting manifestation of APS [2]. Intra-cardiac thrombus and pulmonary thromboembolism (PTE) are lifethreatening thrombotic events of APS, but asymptomatic presentation of intra-cardiac thrombus with PTE is rare [3]. Case report A 41-year-old man presented with 4-months history of highgrade fever, 38.8-40 8C, associated with chills and rigor, 1-2
Thyroid swellings with retrosternal extension are usually diagnosed by the history, clinical exam... more Thyroid swellings with retrosternal extension are usually diagnosed by the history, clinical examination, and imaging. An intrathoracic mass extending into the neck can easily be mistaken for a thyroid swelling with retrosternal extension. A high degree of suspicion is necessary to identify such swellings that are confusing in their presentation. Here we report a case of mediastinal mass masquerading as a goitre with retrosternal extension along with spontaneous chylothorax, and was diagnosed to have non-Hodgkin's lymphoma (NHL). She was administered chemotherapy after the diagnosis.
Background: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) ... more Background: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) lacks the carcinoma label, avoiding aggressive therapy, physiological, social and financial impact of cancer diagnosis. Unfortunately, the preoperative diagnosis is still a challenge. Varied incidence of NIFTP has been document with limited data on preoperative cytological, radiological characteristics and the impact on risk of malignancy in each category of the Bethesda system of reporting thyroid cytopathology. Method: Retrospective analysis of 20 NIFTPs with an attempt to provide a preoperative diagnostic algorithm based on the cytological and ultrasound features along with incidence and implication on risk of malignancy in various Bethesda categories with its impact on patient management. Result: Incidence of NIFTP in our study was higher in comparison to that documented from other Asian countries. TIRADS 3 was the most common sonographic diagnosis. NIFTP was commonly preceded by indeterminate or benign Bethesda category. Major impact of excluding NIFTP form malignant category was seen on Bethesda categories II and IV with 20% and 27% reduction in risk of malignancy, respectively. Conclusion: Retrospective analysis should not be confined only to follicular variant of papillary thyroid carcinoma but cases of follicular adenoma and adenomatous colloid nodule should always be included in review to ascertain the true incidence of NIFTP. NIFTPs are less likely to have malignant preoperative cytology. NIFTP shares major cytological and ultrasound features with follicular adenoma, adenomatous colloid nodule and minimally invasive follicular papillary carcinoma. When analyzed together, taking minor findings in consideration, can favor a diagnosis.
Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal de... more Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal defect an easy and effective management option. Although there are reports of aortic and tricuspid valvular regurgitation after deployment of ASOD, only few cases of tricuspid stenosis (TS) has been reported so far in the literature. We report a case of malaligned ASOD that occurred after successful device closure resulting in TS along with mild tricuspid and aortic regurgitation requiring surgical retrieval. Transesophageal echocardiography played crucial role in detecting the cause of tricuspid valve dysfunction besides providing continuous monitoring during the procedure. We intend to emphasize the need of echocardiographic evaluation of the tricuspid valvular apparatus and aortic valve during and after the device deployment even after the successful device closure to prevent this rare complication.
Silicone tracheobronchial stents are being increasingly used in a large number of patients for th... more Silicone tracheobronchial stents are being increasingly used in a large number of patients for the treatment of tracheal stenosis. One very rare complication due to tracheobronchial stenting is bronchoesophageal fistula (BEF), which has been associated with the use of metallic stents. We report intraoperative management of a patient undergoing repair of a BEF, following previous insertion of a silicone Y-stent that is soft in texture and has not been implicated for this complication till date. In addition, misalignment of this silicone tracheobronchial Y-stent resulted in a tracheal mucosal bulge proximal to the stent that vanished after its removal.
Background Renal dysfunction is a well-recognized major complication after coronary artery bypass... more Background Renal dysfunction is a well-recognized major complication after coronary artery bypass grafting. Off-pump coronary artery bypass theoretically appears to have less impact on renal function. We estimated preoperative and postoperative creatinine clearance as a marker of renal dysfunction in patients undergoing off-pump and on-pump coronary artery bypass. Methods Thirty patients undergoing coronary artery bypass were randomly allocated to undergo either on-pump ( n = 15) or off-pump surgery ( n = 15). The two groups had similar preoperative demographic characteristics. Serum creatinine and creatinine clearance were measured for 4 days postoperatively and the results were compared with preoperative levels. Results The rise in serum creatinine on postoperative day 1 was 0.28 mgċdL(-1) in the on-pump group and 0.22 mgċdL(-1) in the off-pump group ( p = 0.27); on postoperative day 4 it was 0.15 mgċdL(-1) and 0.10 mgċdL(-1), respectively, ( p = 0.28). Similarly, the fall in crea...
Journal of cardiothoracic and vascular anesthesia, Jan 4, 2017
To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients u... more To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass for congenital cyanotic heart disease. Prospective, observational study. Single university hospital. Eighty-seven pediatric patients undergoing cardiac surgery for congenital cyanotic heart disease. Laboratory coagulation parameters (prothrombin time, international normalization ratio, activated partial thromboplastin time, fibrinogen, D-dimer) as well as point-of-care Sonoclot glass bead activation time, clot rate, and platelet function (gbPF) were done before induction of anesthesia and following heparin reversal after termination of cardiopulmonary bypass (CPB) in all patients. Postoperative blood loss was monitored by the amount of chest tube drainage. The primary outcome was to define Sonoclot parameters for prediction of postoperative bleeding. Secondary outcomes studied were amount of postoperative blood loss, transfusion requi...
Journal of Cardiothoracic and Vascular Anesthesia, 2016
continuously during the procedure because it will interfere with the surgical field. Hence in its... more continuously during the procedure because it will interfere with the surgical field. Hence in its present form, TDE can be used to make an easy, fast, and accurate diagnosis when there is a crisis (eg, emboli, myocardial ischemia) during which mobilization of TEE or floating a Pulmonary artery catheter (PAC) may be time-consuming and cumbersome. Most modern methods to determine cardiac output and volume status have been found to not influence patient outcomes, 4 despite the added expenses of invasive catheters and additional monitors and inculcating expertise to use and interpret data. TDE offers a cheap, easily available, and effective alternative in most smallscale transplant centers, and if enough scientific research is invested, may supplant other modalities in the not-too-distant future in both adult and pediatric liver transplantations and other major abdominal surgeries.
Journal of Cardiothoracic and Vascular Anesthesia, 2016
To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary... more To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary hypertension and left ventricular dysfunction. A prospective, randomized study. Tertiary care teaching hospital. The study included patients with valvular heart disease and pulmonary artery hypertension undergoing valve surgery. Forty patients were allocated randomly to receive either milrinone, 50 µg/kg bolus followed by infusion at a rate of 0.5 µg/kg/min (group 1), or levosimendan, 10 µg/kg bolus followed by infusion at a rate of 0.1 µg/kg/min (group 2) for 24 hours after surgery. Hemodynamic parameters were measured using a pulmonary artery catheter, and biventricular functions were assessed using echocardiography. Mean pulmonary artery pressures and the pulmonary vascular resistance index were comparable between the 2 groups at several time points in the intensive care unit. Biventricular function was comparable between both groups. Postcardiopulmonary bypass right ventricular systolic and diastolic functions decreased in both groups compared with baseline, whereas 6 hours postbypass left ventricular ejection fraction improved in patients with stenotic valvular lesions. Levosimendan use was associated with higher heart rate, increased cardiac index, decreased systemic vascular resistance index, and increased requirement of norepinephrine infusion compared with milrinone. The results of this study demonstrated that levosimendan was not clinically better than milrinone. Levosimendan therapy resulted in a greater increase in heart rate, decrease in systemic vascular resistance, and a greater need for norepinephrine than in patients who received milrinone.
The Journal of Thoracic and Cardiovascular Surgery, 2008
The purposes of this study were to identify the occurrence of fibrillin-1 gene polymorphisms or m... more The purposes of this study were to identify the occurrence of fibrillin-1 gene polymorphisms or mutations in exons 24 to 28 and to identify the relationship between "DNA sequence variants" and aortic dilatation in the presence of abnormal aortic histopathology and other variables in patients undergoing intracardiac repair of tetralogy of Fallot. Operatively excised full-thickness aortic wall tissue and 5 to 10-mL venous blood samples from 74 consecutive patients undergoing intracardiac repair of tetralogy of Fallot were studied. Histopathologic evaluation was done by light microscopy. Polymerase chain reaction amplification of fibrillin-1 gene was carried out for 5 exons (24-28), and amplified products were subjected to single-strand conformation polymorphism analysis to identify sequence alterations, if any. Logistic regression analysis was done to identify the relationship between patients with and without "exonic DNA variants" with other risk factors causing aortic dilatation. Sixteen aortic tissue specimens (21.6%) were indicated as histologically normal and used as controls. Of 51 patients with dilated aorta, 48 (94.1%) exhibited histologic abnormalities. The incidences of significant lamellar loss, abnormal histopathology, and fibrillin-1 "DNA sequence variants" in tetralogy of Fallot with…
The Journal of Thoracic and Cardiovascular Surgery, 2008
Objective: The purposes of this study were to evaluate the histologic characteristics of the aort... more Objective: The purposes of this study were to evaluate the histologic characteristics of the aortic wall and the risk factors related to histopathology and aortic dilatation in patients undergoing intracardiac repair of tetralogy of Fallot. Methods: Operatively excised full-thickness aortic wall tissue from 98 consecutive patients undergoing intracardiac repair of tetralogy of Fallot aged 6 months to 47 years (mean 104.5 Ϯ 102.8 months; median 72 months) were studied by light microscopy. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of loss of lamellar counts and multiple logistic regression models. Results: Twenty-five (25.5%) aortic tissue specimens were indicated as histologically normal and were used as normal controls. The incidence of elastic fragmentation, increased ground substance, medionecrosis, smooth muscle disarray, and fibrosis was 74.5%, 54%, 39.8%, 26.5%, and 57.1%, respectively. A lamellar count of less than 60 was associated with a sensitivity of 80% and a specificity of 87.67%. Area under the receiver operating characteristic curve indicated that 93.37% (standard error Ϯ 0.039) of the time the value of lamellar count was lower for the abnormal histopathology group than for the normal group (P Ͻ .001). The risk of aortic dilatation was 15.97 times higher in patients with histopathologically abnormal aorta. Conclusions: The majority of aortic media of the ascending aorta in cyanotic tetralogy of Fallot indicates significant loss of lamellar units and pre-existing intrinsic aortopathy. The changes are present since infancy and are more pronounced in older patients subjected to long-standing cyanosis and volume overload and may account for or may coexist with the higher incidence of aortic dilatation encountered in these patients.
Journal of the American Society of Echocardiography, 2000
Antiphospholipid antibody syndrome (APS) commonly presents with thrombotic events, pregnancy morb... more Antiphospholipid antibody syndrome (APS) commonly presents with thrombotic events, pregnancy morbidity, and recurrent pregnancy loss [1]. APS presenting as fever of unknown origin (FUO) is rare. To date, there are only a few case reports that have described FUO as presenting manifestation of APS [2]. Intra-cardiac thrombus and pulmonary thromboembolism (PTE) are lifethreatening thrombotic events of APS, but asymptomatic presentation of intra-cardiac thrombus with PTE is rare [3]. Case report A 41-year-old man presented with 4-months history of highgrade fever, 38.8-40 8C, associated with chills and rigor, 1-2
Thyroid swellings with retrosternal extension are usually diagnosed by the history, clinical exam... more Thyroid swellings with retrosternal extension are usually diagnosed by the history, clinical examination, and imaging. An intrathoracic mass extending into the neck can easily be mistaken for a thyroid swelling with retrosternal extension. A high degree of suspicion is necessary to identify such swellings that are confusing in their presentation. Here we report a case of mediastinal mass masquerading as a goitre with retrosternal extension along with spontaneous chylothorax, and was diagnosed to have non-Hodgkin's lymphoma (NHL). She was administered chemotherapy after the diagnosis.
Background: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) ... more Background: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) lacks the carcinoma label, avoiding aggressive therapy, physiological, social and financial impact of cancer diagnosis. Unfortunately, the preoperative diagnosis is still a challenge. Varied incidence of NIFTP has been document with limited data on preoperative cytological, radiological characteristics and the impact on risk of malignancy in each category of the Bethesda system of reporting thyroid cytopathology. Method: Retrospective analysis of 20 NIFTPs with an attempt to provide a preoperative diagnostic algorithm based on the cytological and ultrasound features along with incidence and implication on risk of malignancy in various Bethesda categories with its impact on patient management. Result: Incidence of NIFTP in our study was higher in comparison to that documented from other Asian countries. TIRADS 3 was the most common sonographic diagnosis. NIFTP was commonly preceded by indeterminate or benign Bethesda category. Major impact of excluding NIFTP form malignant category was seen on Bethesda categories II and IV with 20% and 27% reduction in risk of malignancy, respectively. Conclusion: Retrospective analysis should not be confined only to follicular variant of papillary thyroid carcinoma but cases of follicular adenoma and adenomatous colloid nodule should always be included in review to ascertain the true incidence of NIFTP. NIFTPs are less likely to have malignant preoperative cytology. NIFTP shares major cytological and ultrasound features with follicular adenoma, adenomatous colloid nodule and minimally invasive follicular papillary carcinoma. When analyzed together, taking minor findings in consideration, can favor a diagnosis.
Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal de... more Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal defect an easy and effective management option. Although there are reports of aortic and tricuspid valvular regurgitation after deployment of ASOD, only few cases of tricuspid stenosis (TS) has been reported so far in the literature. We report a case of malaligned ASOD that occurred after successful device closure resulting in TS along with mild tricuspid and aortic regurgitation requiring surgical retrieval. Transesophageal echocardiography played crucial role in detecting the cause of tricuspid valve dysfunction besides providing continuous monitoring during the procedure. We intend to emphasize the need of echocardiographic evaluation of the tricuspid valvular apparatus and aortic valve during and after the device deployment even after the successful device closure to prevent this rare complication.
Silicone tracheobronchial stents are being increasingly used in a large number of patients for th... more Silicone tracheobronchial stents are being increasingly used in a large number of patients for the treatment of tracheal stenosis. One very rare complication due to tracheobronchial stenting is bronchoesophageal fistula (BEF), which has been associated with the use of metallic stents. We report intraoperative management of a patient undergoing repair of a BEF, following previous insertion of a silicone Y-stent that is soft in texture and has not been implicated for this complication till date. In addition, misalignment of this silicone tracheobronchial Y-stent resulted in a tracheal mucosal bulge proximal to the stent that vanished after its removal.
Background Renal dysfunction is a well-recognized major complication after coronary artery bypass... more Background Renal dysfunction is a well-recognized major complication after coronary artery bypass grafting. Off-pump coronary artery bypass theoretically appears to have less impact on renal function. We estimated preoperative and postoperative creatinine clearance as a marker of renal dysfunction in patients undergoing off-pump and on-pump coronary artery bypass. Methods Thirty patients undergoing coronary artery bypass were randomly allocated to undergo either on-pump ( n = 15) or off-pump surgery ( n = 15). The two groups had similar preoperative demographic characteristics. Serum creatinine and creatinine clearance were measured for 4 days postoperatively and the results were compared with preoperative levels. Results The rise in serum creatinine on postoperative day 1 was 0.28 mgċdL(-1) in the on-pump group and 0.22 mgċdL(-1) in the off-pump group ( p = 0.27); on postoperative day 4 it was 0.15 mgċdL(-1) and 0.10 mgċdL(-1), respectively, ( p = 0.28). Similarly, the fall in crea...
Journal of cardiothoracic and vascular anesthesia, Jan 4, 2017
To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients u... more To assess the utility of Sonoclot in prediction of postoperative bleeding in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass for congenital cyanotic heart disease. Prospective, observational study. Single university hospital. Eighty-seven pediatric patients undergoing cardiac surgery for congenital cyanotic heart disease. Laboratory coagulation parameters (prothrombin time, international normalization ratio, activated partial thromboplastin time, fibrinogen, D-dimer) as well as point-of-care Sonoclot glass bead activation time, clot rate, and platelet function (gbPF) were done before induction of anesthesia and following heparin reversal after termination of cardiopulmonary bypass (CPB) in all patients. Postoperative blood loss was monitored by the amount of chest tube drainage. The primary outcome was to define Sonoclot parameters for prediction of postoperative bleeding. Secondary outcomes studied were amount of postoperative blood loss, transfusion requi...
Journal of Cardiothoracic and Vascular Anesthesia, 2016
continuously during the procedure because it will interfere with the surgical field. Hence in its... more continuously during the procedure because it will interfere with the surgical field. Hence in its present form, TDE can be used to make an easy, fast, and accurate diagnosis when there is a crisis (eg, emboli, myocardial ischemia) during which mobilization of TEE or floating a Pulmonary artery catheter (PAC) may be time-consuming and cumbersome. Most modern methods to determine cardiac output and volume status have been found to not influence patient outcomes, 4 despite the added expenses of invasive catheters and additional monitors and inculcating expertise to use and interpret data. TDE offers a cheap, easily available, and effective alternative in most smallscale transplant centers, and if enough scientific research is invested, may supplant other modalities in the not-too-distant future in both adult and pediatric liver transplantations and other major abdominal surgeries.
Journal of Cardiothoracic and Vascular Anesthesia, 2016
To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary... more To compare the effects of levosimendan with milrinone in cardiac surgical patients with pulmonary hypertension and left ventricular dysfunction. A prospective, randomized study. Tertiary care teaching hospital. The study included patients with valvular heart disease and pulmonary artery hypertension undergoing valve surgery. Forty patients were allocated randomly to receive either milrinone, 50 µg/kg bolus followed by infusion at a rate of 0.5 µg/kg/min (group 1), or levosimendan, 10 µg/kg bolus followed by infusion at a rate of 0.1 µg/kg/min (group 2) for 24 hours after surgery. Hemodynamic parameters were measured using a pulmonary artery catheter, and biventricular functions were assessed using echocardiography. Mean pulmonary artery pressures and the pulmonary vascular resistance index were comparable between the 2 groups at several time points in the intensive care unit. Biventricular function was comparable between both groups. Postcardiopulmonary bypass right ventricular systolic and diastolic functions decreased in both groups compared with baseline, whereas 6 hours postbypass left ventricular ejection fraction improved in patients with stenotic valvular lesions. Levosimendan use was associated with higher heart rate, increased cardiac index, decreased systemic vascular resistance index, and increased requirement of norepinephrine infusion compared with milrinone. The results of this study demonstrated that levosimendan was not clinically better than milrinone. Levosimendan therapy resulted in a greater increase in heart rate, decrease in systemic vascular resistance, and a greater need for norepinephrine than in patients who received milrinone.
The Journal of Thoracic and Cardiovascular Surgery, 2008
The purposes of this study were to identify the occurrence of fibrillin-1 gene polymorphisms or m... more The purposes of this study were to identify the occurrence of fibrillin-1 gene polymorphisms or mutations in exons 24 to 28 and to identify the relationship between "DNA sequence variants" and aortic dilatation in the presence of abnormal aortic histopathology and other variables in patients undergoing intracardiac repair of tetralogy of Fallot. Operatively excised full-thickness aortic wall tissue and 5 to 10-mL venous blood samples from 74 consecutive patients undergoing intracardiac repair of tetralogy of Fallot were studied. Histopathologic evaluation was done by light microscopy. Polymerase chain reaction amplification of fibrillin-1 gene was carried out for 5 exons (24-28), and amplified products were subjected to single-strand conformation polymorphism analysis to identify sequence alterations, if any. Logistic regression analysis was done to identify the relationship between patients with and without "exonic DNA variants" with other risk factors causing aortic dilatation. Sixteen aortic tissue specimens (21.6%) were indicated as histologically normal and used as controls. Of 51 patients with dilated aorta, 48 (94.1%) exhibited histologic abnormalities. The incidences of significant lamellar loss, abnormal histopathology, and fibrillin-1 "DNA sequence variants" in tetralogy of Fallot with…
The Journal of Thoracic and Cardiovascular Surgery, 2008
Objective: The purposes of this study were to evaluate the histologic characteristics of the aort... more Objective: The purposes of this study were to evaluate the histologic characteristics of the aortic wall and the risk factors related to histopathology and aortic dilatation in patients undergoing intracardiac repair of tetralogy of Fallot. Methods: Operatively excised full-thickness aortic wall tissue from 98 consecutive patients undergoing intracardiac repair of tetralogy of Fallot aged 6 months to 47 years (mean 104.5 Ϯ 102.8 months; median 72 months) were studied by light microscopy. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of loss of lamellar counts and multiple logistic regression models. Results: Twenty-five (25.5%) aortic tissue specimens were indicated as histologically normal and were used as normal controls. The incidence of elastic fragmentation, increased ground substance, medionecrosis, smooth muscle disarray, and fibrosis was 74.5%, 54%, 39.8%, 26.5%, and 57.1%, respectively. A lamellar count of less than 60 was associated with a sensitivity of 80% and a specificity of 87.67%. Area under the receiver operating characteristic curve indicated that 93.37% (standard error Ϯ 0.039) of the time the value of lamellar count was lower for the abnormal histopathology group than for the normal group (P Ͻ .001). The risk of aortic dilatation was 15.97 times higher in patients with histopathologically abnormal aorta. Conclusions: The majority of aortic media of the ascending aorta in cyanotic tetralogy of Fallot indicates significant loss of lamellar units and pre-existing intrinsic aortopathy. The changes are present since infancy and are more pronounced in older patients subjected to long-standing cyanosis and volume overload and may account for or may coexist with the higher incidence of aortic dilatation encountered in these patients.
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Papers by Anand Mishra