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Babu S, Molli K, Menon S, Gohain D, Sasidharan B, Koshy T. An Intraoperative Transesophageal Echocardiographic Artifact Mimicking a Tear in Left Ventricle Apex In a Case of Massive Pericardial Effusion. J Cardiothorac Vasc Anesth 2019; 33:2605-2607. [PMID: 31230965 DOI: 10.1053/j.jvca.2019.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 11/11/2022]
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Khera R, Pandey A, Koshy T, Ayers C, Nallamothu BK, Das SR, Drazner MH, Jessen ME, Kirtane AJ, Gardner TJ, de Lemos JA, Bhatt DL, Kumbhani DJ. Role of Hospital Volumes in Identifying Low-Performing and High-Performing Aortic and Mitral Valve Surgical Centers in the United States. JAMA Cardiol 2019; 2:1322-1331. [PMID: 29117319 DOI: 10.1001/jamacardio.2017.4003] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Identifying high-performing surgical valve centers with the best surgical outcomes is challenging. Hospital surgical volume is a frequently used surrogate for outcomes. However, its ability to distinguish low-performing and high-performing hospitals remains unknown. Objective To examine the association of hospital procedure volume with hospital performance for aortic and mitral valve (MV) surgical procedures. Design, Setting, and Participants Within an all-payer nationally representative data set of inpatient hospitalizations, this study identified 682 unique hospitals performing surgical aortic valve replacement (SAVR) and MV replacement and repair with or without coronary artery bypass grafting (CABG) between 2007 and 2011. Procedural outcomes were further assessed for a 10-year period (2005-2014) to assess representativeness of study period. Main Outcomes and Measures In-hospital risk-standardized mortality rate (RSMR) calculated using hierarchical models and an empirical bayesian approach with volume-based shrinkage that allowed for reliability adjustment. Results At 682 US hospitals, 70 295 SAVR, 19 913 MV replacement, and 17 037 MV repair procedures were performed between 2007 and 2011, with a median annual volume of 43 (interquartile range [IQR], 23-76) SAVR, 13 (IQR, 6-22) MV replacement, and 9 (IQR, 4-19) MV repair procedures. Of 225 SAVR hospitals in the highest-volume tertile, 34.7% and 36.0% were in the highest-RSMR tertile for SAVR + CABG and isolated SAVR procedures, respectively, while 21.5% and 17.5% of the 228 SAVR hospitals in the lowest-volume tertile were in the lowest respective RSMR tertile. Similarly, 36.8% and 43.5% of hospitals in the highest tertile of volume for MV replacement and repair, respectively, were in the corresponding highest-RSMR tertile, and 17.4% and 11.2% of the low-volume hospitals were in the lowest-RSMR tertile for MV replacement and repair, respectively. There was limited correlation between outcomes for SAVR and MV procedures at an institution. If solely volume-based tertiles were used to categorize hospitals for quality, 44.7% of all valve hospitals would be misclassified (as either low performing or high performing) when assessing performance based on tertiles of RSMR. Conclusions and Relevance Hospital procedure volume alone frequently misclassifies hospital performance with regard to risk-standardized outcomes after aortic and MV surgical procedures. Valve surgery quality improvement endeavors should focus on a more comprehensive assessment that includes risk-adjusted outcomes rather than hospital volume alone.
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Daniel M, Sulistio M, Koshy T, Luna M, Khera A, Ayers C. PRE-CARDIAC CATHETERIZATION SIMULATION TRAINING IN CARDIOVASCULAR FELLOWSHIP: OUTCOMES OVER TWO YEARS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)33197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Chigurupati K, Sukesan S, Lovhale PS, Dharan BS, Koshy T. Comprehensive intraoperative transesophageal echocardiography of anomalous left coronary artery from pulmonary artery: What to look for and where to look? Echocardiography 2018; 35:391-395. [DOI: 10.1111/echo.13798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Misra S, Koshy T, Shriram Lovhale P, Mathew T. Role of Transesophageal Echocardiography in Surgery for Hemitruncus Arteriosus. Anesth Analg 2017; 125:1153-1155. [PMID: 28742769 DOI: 10.1213/ane.0000000000002306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sarvana Babu MS, Aggarwal N, Asha A, Ashok DS, Koshy T. Importance of 3D real time perioperative tee in ASD device embolisation. Ann Card Anaesth 2017; 20:278. [PMID: 28393802 PMCID: PMC5408547 DOI: 10.4103/0971-9784.203960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Borde DP, George A, Joshi S, Nair S, Koshy T, Gandhe U, Chakravarthy M. Variations of transesophageal echocardiography practices in India: A survey by Indian College of Cardiac Anaesthesia. Ann Card Anaesth 2017; 19:646-652. [PMID: 27716695 PMCID: PMC5070324 DOI: 10.4103/0971-9784.191580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Use of perioperative transesophageal echocardiography (TEE) has expanded in India. Despite attempts to standardize the practice of TEE in cardiac surgical procedures, variation in practice and application exists. This is the first online survey by Indian College of Cardiac Anaesthesia, research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA). AIMS We hypothesized that variations in practice of intraoperative TEE exist among centers and this survey aimed at analyzing them. SETTINGS AND DESIGN This is an online survey conducted among members of the IACTA. SUBJECTS AND METHODS All members of IACTA were contacted using online questionnaire fielded using SurveyMonkey™ software. There were 21 questions over four pages evaluating infrastructure, documentation of TEE, experience and accreditation of anesthesiologist performing TEE, and finally impact of TEE on clinical practice. Questions were also asked about national TEE workshop conducted by the IACTA, and suggestions were invited by members on overseas training. RESULTS Response rate was 29.7% (382/1222). 53.9% were from high-volume centers (>500 cases annually). TEE machine/probe was available to 75.9% of the respondents and those in high-volume centers had easier (86.9%) access. There was poor documentation of preoperative consent (23.3%) as well as TEE findings (66%). Only 18.2% of responders were board qualified. Almost 90% of the responders felt surgeons respected their TEE diagnosis. Around half of the responders felt that new intraoperative findings by TEE were considered in decision-making in most of the cases and 70% of the responders reported that surgical plan was altered based on TEE finding more than 10 times in the last year. Despite this, only 5% of the responders in this survey were monetarily awarded for performing impactful skill of TEE. Majority (57%) felt that there is no need for overseas training for Indian cardiac anesthesiologists. CONCLUSIONS In this survey of members of the IACTA, use of TEE has increased substantially, but still a lot of variations in practice patterns exist in India. There is urgent need for improving TEE certification and upgrade documentation standards, motivate use of TTE across all centers, promote awareness and usefulness of TEE use among surgical fraternity, monitor impact of TEE, and support separate remuneration policy in India.
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Muralidhar K, Tempe D, Mehta Y, Kapoor PM, Mukherjee C, Koshy T, Tewari P, Shastri N, Misra S, Belani K. Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination. Ann Card Anaesth 2017; 19:S73-S78. [PMID: 27762250 PMCID: PMC5100245 DOI: 10.4103/0971-9784.192626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient's outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of “Fellowship” is by way of conducting IACTA – TEE fellowship (F-TEE) examination. This has been done annually for the past 7 years using well-established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F-TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F-TEE certification process.
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Shriram Lovhale P, Misra S, Koshy T. Midesophageal Short-Axis Views of the Pulmonary Valve With Conventional 2-Dimensional Transesophageal Echocardiography: A Useful View in Pediatric Patients. J Cardiothorac Vasc Anesth 2017; 31:e36-e38. [PMID: 28153455 DOI: 10.1053/j.jvca.2016.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Indexed: 11/11/2022]
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Koshy T, Misra S, Chatterjee N, Dharan BS. Accuracy of a Chest X-Ray-Based Method for Predicting the Depth of Insertion of Endotracheal Tubes in Pediatric Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:947-53. [PMID: 27238432 DOI: 10.1053/j.jvca.2016.01.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The incidence of endotracheal tube (ETT) malposition in children with various described methods is 15% to 30%. Chest x-ray (CXR) is the gold standard for confirming appropriate ETT position. The aim of this study was to measure the accuracy of a preoperative CXR-based method in determining depth of insertion of ETTs and to compare it with methods based on the intubation depth mark or formulae (age, height, and ETT internal diameter) in children undergoing cardiac surgery. DESIGN Prospective observational study. SETTING University-affiliated tertiary care hospital. PARTICIPANTS Sixty-six consecutive children scheduled for elective pediatric cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The distance from carina to mid-trachea was measured for each child preoperatively on the CXR displayed as a computed radiography image in a picture archival and communications system computer. Following intubation, ETTs deliberately were pushed endobronchially and then pulled back to the carina; they were further withdrawn by the previously measured carina to mid-tracheal distance and secured. CXRs postoperatively were repeated to confirm ETT position. The ETT position was measured with other methods using the picture archival and communications system ruler on the postoperative CXR and compared with the CXR method. The proportion of appropriate ETT position with the CXR method was 98.5% (p≤0.001 v other methods). In children younger than 3 years, the appropriate proportion was 97.4%. CONCLUSION The appropriate positioning of ETTs in the trachea by the CXR method is superior to other methods.
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Kundan S, Varma PK, Koshy T. Real-time three-dimensional transoesophageal echocardiography for diagnosing the extent of dehiscence of Starr-Edward valve prosthesis in the mitral position. Eur Heart J Cardiovasc Imaging 2014; 15:1060. [PMID: 24780873 DOI: 10.1093/ehjci/jeu068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Moore N, Koshy T. Direct stool EHEC testing. MLO: MEDICAL LABORATORY OBSERVER 2014; 46:7. [PMID: 24783675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Burgwinkle P, Pigott V, Liska G, Koshy T. Follow the protocol: teaching patients to self-test. Nursing 2014; 44:20-22. [PMID: 24531579 DOI: 10.1097/01.nurse.0000443325.96478.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Gopalakrishna K, Chatterjee N, Koshy T, Sudhir B. Novel technique in placement of transesophageal echocardiography probe in neurosurgical procedures. Saudi J Anaesth 2014; 8:S129-31. [PMID: 25538513 PMCID: PMC4268520 DOI: 10.4103/1658-354x.144111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Misra S, Koshy T. A review of the practice of sedation with inhalational anaesthetics in the intensive care unit with the AnaConDa(®) device. Indian J Anaesth 2013; 56:518-23. [PMID: 23325934 PMCID: PMC3546236 DOI: 10.4103/0019-5049.104565] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The intensive care unit (ICU) environment is often perceived to be hostile and frightening by patients due to unfamiliar surroundings coupled with presence of numerous personnel, monitors and other equipments as well as a loss of perception of time. Mechanical ventilation and multiple painful procedures that often need to be carried out in these critically ill patients add to their overall anxiety. Sedation is therefore required not only to allay the stress and anxiety, but also to allow for mechanical ventilation and other invasive therapeutic and diagnostic procedures to be performed. The conventional intravenous sedative agents used in ICUs suffer from problems of over sedation, tachyphylaxis, drug accumulation, organ specific elimination and often lead to patient agitation on withdrawal. All this tend to prolong the ventilatory as well as ICU and hospital discharge time, which increase the risk for infection and add to the overall increase in morbidity, mortality and hospital costs. In 2005, the anaesthetic conserving device (AnaConDa(®)) was marketed for ICU sedation with volatile anaesthetic agents. A number of trials have shown the effectiveness of using volatile anaesthetic agents for ICU sedation with the AnaConDa device. Compared with intravenous sedatives, use of volatile anaesthetic agents have resulted in shorter wake up and extubation time, lesser duration of mechanical ventilation and faster discharge from hospitals. This review shall focus on the benefits, technical pre-requisites and status of sedation with volatile anaesthetic agents in ICUs with the AnaConDa(®) device.
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Misra S, Dash PK, Koshy T, Varma PK, Pal S, Dineshkumar US, Banayan J, Capdeville M. CASE 5—2012: Incidentally Detected Patent Foramen Ovale in A Patient Undergoing Aortic Valve Replacement: To Close or Not to Close? J Cardiothorac Vasc Anesth 2012; 26:721-8. [DOI: 10.1053/j.jvca.2012.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Indexed: 11/11/2022]
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Suneel PR, Koshy T, Unnikrishnan KP. High cuff pressure in the silicone endotracheal tube of the LMA-Fastrach: implications for patient safety. J Clin Anesth 2011; 23:666-7. [PMID: 22137523 DOI: 10.1016/j.jclinane.2010.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 11/16/2010] [Accepted: 12/15/2010] [Indexed: 11/26/2022]
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Misra S, Koshy T, Pal S. False Tendons and Accessory Papillary Muscle in the Left Ventricle. Anesth Analg 2011; 113:1016-8. [DOI: 10.1213/ane.0b013e31822bbfb9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Misra S, Koshy T, Kumar Dash P. Supracardiac Total Anomalous Pulmonary Venous Connection in an Adult Patient: Role of Transesophageal Echocardiography. Echocardiography 2011; 28:925-8. [DOI: 10.1111/j.1540-8175.2011.01450.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Misra S, Koshy T, Mahaldar DAC. Sudden decrease in end-tidal carbon-dioxide in a neonate undergoing surgery for type B interrupted aortic arch. Ann Card Anaesth 2011; 14:206-10. [PMID: 21860194 DOI: 10.4103/0971-9784.84020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Interruption of the aortic arch is a rare anomaly affecting 1% of children with congenital heart disease. The systemic circulation is ductal dependent and is determined principally by the ratio of the resistances in the systemic and the pulmonary vascular bed. Any increase in the pulmonary vascular resistance may increase the dead space ventilation due to acute pulmonary hypoperfusion. We report a case where sudden decreases in the end-tidal carbon-dioxide due to pulmonary hypoperfusion mimicked accidental endotracheal tube extubation in an infant undergoing repair of interrupted aortic arch.
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Suneel PR, Koshy T, Unnikrishnan M. Complete recovery from paraplegia following apparently failed cerebrospinal fluid drainage in a case of thoracoabdominal aortic aneurysm repair. Ann Card Anaesth 2011; 14:236-8. [PMID: 21860201 DOI: 10.4103/0971-9784.84036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Christus T, Shukkur AM, Rashdan I, Koshy T, Alanbaei M, Zubaid M, Hayat N, Alsayegh A. Coronary Artery Disease in Patients Aged 35 or less - A Different Beast? Heart Views 2011; 12:7-11. [PMID: 21731802 PMCID: PMC3123520 DOI: 10.4103/1995-705x.81550] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: To assess the extent and severity of coronary artery disease (CAD) in 200 consecutive patients aged 35 years or less undergoing diagnostic coronary angiography. Patients and Methods: Findings in these 200 patients (≤ 35 years of age) were analyzed to find the extent and severity of CAD. The mean age was 31.69 (±3.76) years. Majority were males (94%) and from the Arab ethnicity (70.5%). Result: Smoking (71%) and history of premature CAD (27%) were the most frequent risk factors (RF). History of previous ST elevation myocardial infarction (MI) was present in 68%. Anterior wall MI was the most frequent location (63.3%). The majority (54.3%) had moderate or large size MI. Ejection fraction (EF) less than 50% was noted in 30.3%. Left main or triple vessel CAD was seen in 15%. One- and two-vessel CAD was seen in 32.5% and 19% patients, respectively. Coronary angiogram was completely normal in 23.5%. The majority (54.5%) were treated conservatively and the rest (45.5%) needed percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The mean number of stents used was 1.3 ± 0.67 and the mean length of stents used was 20.3 ± 12.6 mm. Conclusion: The extent and severity of CAD was very significant in this subgroup of very young (≤35 years) Asian patients. Smoking was the main risk factor and half of the patients needed either PCI or CABG.
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Misra S, Unnikrishnan KP, Koshy T, Dash PK, Panda S. A Phantom in the Aortic Valve: Tumor, Thrombus, or Artifact? J Cardiothorac Vasc Anesth 2011; 25:380-1. [DOI: 10.1053/j.jvca.2010.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Indexed: 11/11/2022]
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Misra S, Koshy T, Dash PK. Diagnosis of Shone's anomaly by intraoperative transesophageal echocardiography in an adult patient undergoing repair of coarctation of the aorta. J Cardiothorac Vasc Anesth 2010; 25:838-40. [PMID: 20728379 DOI: 10.1053/j.jvca.2010.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Indexed: 11/11/2022]
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Misra S, Koshy T, Sinha PK, Kapilamoorthy TR, Sivadasanpillai H. A Ring Artifact in the Left Ventricle on Transesophageal Echocardiography After Mitral Valve Replacement. Anesth Analg 2010; 110:731-3; discussion 733. [DOI: 10.1213/ane.0b013e3181cc5451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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