[Downloaded free from http://www.annals.in on Saturday, July 05, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
Prakash K. Dubey Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India Address for correspondence: Dr. Prakash K. Dubey, E 3/4, IGIMS Campus, Sheikhpura, Patna - 800 014, Bihar, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
5. 6.
Kapoor MC: In response to "Post extubation negative pressure pulmonary edema due to posterior mediastinal cyst in an infant": Is there reasonable evidence?. Ann Card Anaes 2014;17:249-50 Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. Can J Anaesth 1990;37:210-8. Warner LO, Martino JD, Davidson PJ, Beach TP. Negative pressure pulmonary oedema: A potential hazard of muscle relaxants in awake infants. Can J Anaesth 1990;37:580-3. Warner LO, Beach TP, Martino JD. Negative pressure pulmonary oedema secondary to airway obstruction in an intubated infant. Can J Anaesth 1988;35:507-10. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth 2011;5:308-13. Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology 1984;60:144-7. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135891
In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome The Editor, The contribution by Bhojraj et al. published in the April-June, 2014 issue of the Journal, [1] about a Annals of Cardiac Anaesthesia z Vol. 17:3 z Jul-Sep-2014
56-year-old woman, who suffered a bout of Takotsubo syndrome (TTS) in the postoperative period following vaginal hysterectomy is of interest, particularly in terms of her management. The authors summarized comprehensively what is currently known or believed to be the proper management of TTS in their discussion and “resuscitated (the patient) with atropine sulfate 0.6 mg, intravenous fluids and sodium bicarbonate 25 ml”; also “dopamine hydrochloride and noradrenaline were started at 5 μg/kg/min and 4 μg/min, respectively”. One wonders whether use of intravenous fluids, and institution of the intra-aortic balloon counter pulsation, would have been preferable, although a consensus on the above is currently lacking. Perhaps, dopamine and noradrenaline may be further aggravating an illness believed to be due to a catecholamine “storm”,[2] and atropine may be contraindicated, since it abolishes the counterbalancing to the sympathetic, parasympathetic autonomic nervous system influences. [3] However there is ambivalence about the latter, since TTS may also be mediated by the parasympathetic component of the autonomic nervous system (and thus atropine may be beneficial),[3] particularly early in the TTS, when some patients experience relative bradycardia, as the reported patient who had a heart rate of 60 beats/min. The patients' preoperative status was felt to be in an American Society of Anesthesiologists Grade I, and one wonders whether coronary arteriography could have been avoided in the presence of the profound hemodynamic deterioration associated with the described left ventricular (LV) features as per echocardiography (ECHO) with minor changes in the electrocardiogram (ECG) and with “cardiac enzymes mildly elevated”. Perhaps the ECHO-derived LV ejection fraction (LVEF) in conjunction with troponin I or T (Tp I or Tp T) and brain natriuretic peptide or N-terminal pro B-type natriuretic peptide (NT-pro-BNP) could have been used to differentiate TTS from an acute coronary syndrome in this patient, either employing the product of peak Tp I value and the LVEF,[4] or the ratio of NT-pro-BNP and Tp T (or Tp I).[5] The report includes only ECG leads aVR, aVL, aVF, and V1-V6, which reveals attenuation in the voltage of the QRS complexes (QRSATT) between the preoperative and first postoperative ECG in keeping with a recently published diagnostic insight for TTS.[6] I will be thankful if the authors could provide information on whether leads I, II, and III also revealed such QRSATT, and whether further QRSATT was noted in subsequently recorded ECGs. 251
[Downloaded free from http://www.annals.in on Saturday, July 05, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
Shilpa Bhojraj, Shirish Sheth1, Dev Pahlajani2
John E. Madias1,2 Icahn School of Medicine at Mount Sinai, Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, NY, USA 1
2
Departments of Anaesthesiology, 1Gynaecology and 2Cardiology, Breach Candy Hospital, Mumbai, Maharashtra, India
Address for correspondence: Prof. John E. Madias, Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, New York, NY 11373, USA. E-mail: madiasj@ nychhc.org
Address for correspondence: Dr. Shilpa Bhojraj, Breach Candy Hospital, Bhullabhai Desai Road, Mumbai - 400 026, Maharashtra, India. E-mail: [email protected]
REFERENCES
REFERENCES
1.
1.
2.
3. 4.
5.
6.
Bhojraj S, Sheth S, Pahlajani D. Postoperative Takotsubo cardiomyopathy. Ann Card Anaesth 2014;17:157-60. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48. Samuels MA. The brain-heart connection. Circulation 2007;116:77-84. Nascimento FO, Yang S, Larrauri-Reyes M, Pineda AM, Cornielle V, Santana O, et al. Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction. Am J Cardiol 2014;113:429-33. Fröhlich GM, Schoch B, Schmid F, Keller P, Sudano I, Lüscher TF, et al. Takotsubo cardiomyopathy has a unique cardiac biomarker profile: NT-proBNP/myoglobin and NT-proBNP/troponin T ratios for the differential diagnosis of acute coronary syndromes and stress induced cardiomyopathy. Int J Cardiol 2012 9;154:328-32. Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28-36. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135892
Authors' reply
2.
Madias J. In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome. Ann Card Anaesth 2014;17:251-2. Bhojraj S, Sheth S, Pahlajani D. Postoperative Takotsubo cardiomyopathy. Ann Card Anaes 2014;17:157-60. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135893
In response to "Magnets and implantable cardioverter defibrillators: What’s the problem?"
Dear Editor,
The Editor,
We read with interest the comments of John Madias[1] regarding our case report "Postoperative Takotsubo cardiomyopathy"[2] and appreciate his suggestions. Coronary angiography was performed since we were unsure of the diagnosis. Our institutional protocol is to perform a primary coronary intervention in case a blocked coronary artery is discovered on angiography. We did stabilize the patient prior to coronary angiography. Since the patient showed improved hemodynamics with inotropes and vasopressors intra-aortic balloon pump was not inserted. The electrocardiography leads 1, 2, and 3 also showed attenuation in QRS voltage.
The article “magnets and implantable cardioverter defibrillators (ICD): What’s the problem?” is interesting.[1] The case report highlight the drawbacks of using a magnet to suspend ICD therapy and illustrate the factors associated with electromagnetic interference (EMI). The authors note that failure to follow published expert advisory concerning ICDs may lead to adverse events.[1] The Heart Rhythm Society (HRS)/American Society of Anesthesiologists state that important informations should be given to the cardiovascular implantable electronic device (CIED) team, such that they can provide specific recommendations to the procedural team, regarding the perioperative management of
252
Annals of Cardiac Anaesthesia z Vol. 17:3 z Jul-Sep-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Prakash K. Dubey Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India Address for correspondence: Dr. Prakash K. Dubey, E 3/4, IGIMS Campus, Sheikhpura, Patna - 800 014, Bihar, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
5. 6.
Kapoor MC: In response to "Post extubation negative pressure pulmonary edema due to posterior mediastinal cyst in an infant": Is there reasonable evidence?. Ann Card Anaes 2014;17:249-50 Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. Can J Anaesth 1990;37:210-8. Warner LO, Martino JD, Davidson PJ, Beach TP. Negative pressure pulmonary oedema: A potential hazard of muscle relaxants in awake infants. Can J Anaesth 1990;37:580-3. Warner LO, Beach TP, Martino JD. Negative pressure pulmonary oedema secondary to airway obstruction in an intubated infant. Can J Anaesth 1988;35:507-10. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth 2011;5:308-13. Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology 1984;60:144-7. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135891
In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome The Editor, The contribution by Bhojraj et al. published in the April-June, 2014 issue of the Journal, [1] about a Annals of Cardiac Anaesthesia z Vol. 17:3 z Jul-Sep-2014
56-year-old woman, who suffered a bout of Takotsubo syndrome (TTS) in the postoperative period following vaginal hysterectomy is of interest, particularly in terms of her management. The authors summarized comprehensively what is currently known or believed to be the proper management of TTS in their discussion and “resuscitated (the patient) with atropine sulfate 0.6 mg, intravenous fluids and sodium bicarbonate 25 ml”; also “dopamine hydrochloride and noradrenaline were started at 5 μg/kg/min and 4 μg/min, respectively”. One wonders whether use of intravenous fluids, and institution of the intra-aortic balloon counter pulsation, would have been preferable, although a consensus on the above is currently lacking. Perhaps, dopamine and noradrenaline may be further aggravating an illness believed to be due to a catecholamine “storm”,[2] and atropine may be contraindicated, since it abolishes the counterbalancing to the sympathetic, parasympathetic autonomic nervous system influences. [3] However there is ambivalence about the latter, since TTS may also be mediated by the parasympathetic component of the autonomic nervous system (and thus atropine may be beneficial),[3] particularly early in the TTS, when some patients experience relative bradycardia, as the reported patient who had a heart rate of 60 beats/min. The patients' preoperative status was felt to be in an American Society of Anesthesiologists Grade I, and one wonders whether coronary arteriography could have been avoided in the presence of the profound hemodynamic deterioration associated with the described left ventricular (LV) features as per echocardiography (ECHO) with minor changes in the electrocardiogram (ECG) and with “cardiac enzymes mildly elevated”. Perhaps the ECHO-derived LV ejection fraction (LVEF) in conjunction with troponin I or T (Tp I or Tp T) and brain natriuretic peptide or N-terminal pro B-type natriuretic peptide (NT-pro-BNP) could have been used to differentiate TTS from an acute coronary syndrome in this patient, either employing the product of peak Tp I value and the LVEF,[4] or the ratio of NT-pro-BNP and Tp T (or Tp I).[5] The report includes only ECG leads aVR, aVL, aVF, and V1-V6, which reveals attenuation in the voltage of the QRS complexes (QRSATT) between the preoperative and first postoperative ECG in keeping with a recently published diagnostic insight for TTS.[6] I will be thankful if the authors could provide information on whether leads I, II, and III also revealed such QRSATT, and whether further QRSATT was noted in subsequently recorded ECGs. 251
[Downloaded free from http://www.annals.in on Saturday, July 05, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
Shilpa Bhojraj, Shirish Sheth1, Dev Pahlajani2
John E. Madias1,2 Icahn School of Medicine at Mount Sinai, Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, NY, USA 1
2
Departments of Anaesthesiology, 1Gynaecology and 2Cardiology, Breach Candy Hospital, Mumbai, Maharashtra, India
Address for correspondence: Prof. John E. Madias, Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, New York, NY 11373, USA. E-mail: madiasj@ nychhc.org
Address for correspondence: Dr. Shilpa Bhojraj, Breach Candy Hospital, Bhullabhai Desai Road, Mumbai - 400 026, Maharashtra, India. E-mail: [email protected]
REFERENCES
REFERENCES
1.
1.
2.
3. 4.
5.
6.
Bhojraj S, Sheth S, Pahlajani D. Postoperative Takotsubo cardiomyopathy. Ann Card Anaesth 2014;17:157-60. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48. Samuels MA. The brain-heart connection. Circulation 2007;116:77-84. Nascimento FO, Yang S, Larrauri-Reyes M, Pineda AM, Cornielle V, Santana O, et al. Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction. Am J Cardiol 2014;113:429-33. Fröhlich GM, Schoch B, Schmid F, Keller P, Sudano I, Lüscher TF, et al. Takotsubo cardiomyopathy has a unique cardiac biomarker profile: NT-proBNP/myoglobin and NT-proBNP/troponin T ratios for the differential diagnosis of acute coronary syndromes and stress induced cardiomyopathy. Int J Cardiol 2012 9;154:328-32. Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28-36. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135892
Authors' reply
2.
Madias J. In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome. Ann Card Anaesth 2014;17:251-2. Bhojraj S, Sheth S, Pahlajani D. Postoperative Takotsubo cardiomyopathy. Ann Card Anaes 2014;17:157-60. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.135893
In response to "Magnets and implantable cardioverter defibrillators: What’s the problem?"
Dear Editor,
The Editor,
We read with interest the comments of John Madias[1] regarding our case report "Postoperative Takotsubo cardiomyopathy"[2] and appreciate his suggestions. Coronary angiography was performed since we were unsure of the diagnosis. Our institutional protocol is to perform a primary coronary intervention in case a blocked coronary artery is discovered on angiography. We did stabilize the patient prior to coronary angiography. Since the patient showed improved hemodynamics with inotropes and vasopressors intra-aortic balloon pump was not inserted. The electrocardiography leads 1, 2, and 3 also showed attenuation in QRS voltage.
The article “magnets and implantable cardioverter defibrillators (ICD): What’s the problem?” is interesting.[1] The case report highlight the drawbacks of using a magnet to suspend ICD therapy and illustrate the factors associated with electromagnetic interference (EMI). The authors note that failure to follow published expert advisory concerning ICDs may lead to adverse events.[1] The Heart Rhythm Society (HRS)/American Society of Anesthesiologists state that important informations should be given to the cardiovascular implantable electronic device (CIED) team, such that they can provide specific recommendations to the procedural team, regarding the perioperative management of
252
Annals of Cardiac Anaesthesia z Vol. 17:3 z Jul-Sep-2014
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
