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ISSN: 2771-5434
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Article Type : Review Article
Current Trends and Future Prospect of Treatment of Mitral Valve Disease: Role of Interventional
Cardiologists and Cardiac Surgeons
Authors : Anisuzzaman M, Hosain N, Rashid Z and Ferdous S
DOI : 10.51737/cardiovascular.2021.007
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Article Type : Case Reports
Lead Erosion of Subcutaneous Implantable Cardioverter-Defibrillator: Successful Management without

Device Removal
Authors : Chu MF, Lam UP, Mok TM, Ip MF, Tam WC, and Evora M
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Malignant Anomalous Course of Right Coronary Artery
Authors : Cakir M, Bakirci EM, Degirmenci H and Karayumak MR
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Herbal Remedies for Management of COVID-19 Induced Myocarditis
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Hemorrhagic Cardiac Tamponade Apixaban - Induced: A Case Report
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Efficacy of Continuous Local Anaesthetic Infiltration at Sternal Incision Site in Patients Undergoing
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Authors : Banerjee A, SenDasgupta C and Goswami A
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SunText Review of Cardiovascular Sciences Open Access
Review Article
Volume 1:1
Current Trends and Future Prospect of Treatment

Received date: 30 September 2021; Accepted date:
of Mitral Valve Disease: Role of Interventional 20 October 2021; Published date: 11 October 2021
Cardiologists and Cardiac Surgeons Citation: Anisuzzaman M, Hosain N, Rashid Z and

Ferdous S (2021). Current Trends and Future Prospect
Anisuzzaman M1, Hosain N1,*, Rashid Z2 and Ferdous S2 of Treatment of Mitral Valve Disease: Role of
Interventional Cardiologists and Cardiac Surgeons.
1Department SunText Rev Cardiovasc Sci 1(1): 107.
of Cardiac Surgery, Chittagong Medical College, Chittagong, Bangladesh
2Department of Cardiac Surgery, NICVD, Dhaka, Bangladesh
Copyright: © 2021 Anisuzzaman M, et al. This is an
*Corresponding open-access article distributed under the terms of the
author: Hosain N, Department of Cardiac Surgery, Chittagong Medical College,
Creative Commons Attribution License, which permits
Chittagong, Bangladesh; E-mail: heartsurgeon007@gmail.com unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Abstract
The treatment of mitral valve disease is rapidly changing. The excellent results and success rates of mitral valve repairs for primary
mitral regurgitation were just a prelude. The cases of mitral valve replacement with both bioprosthetic and mechanical prosthetic
valves, has produced good long-term results still having a lot of problems. The introduction of Minimally Invasive Cardiac Surgery,
endoscopic systems and Robotics has eliminated the need for sternotomy. At the same time these have reduced the access to the mitral
valve via small incision only, maintaining excellent long-term results comparable to traditional techniques. Similarly, recent
interventional procedures can offer treatment options to high-risk patients. With new technologies, instrumentation and devices, the
treatment of mitral valve disease will remain in focus for the year to come.
Keywords: Mitral valve; MICS; MACS
Cardiovascular surgery [5]. The first artificial mitral valve was
Introduction
implanted by Dr. Nina Starr Braunwald in 1960 at the National
The first successful valve surgery of any kind, a mitral valve Institute of Health that was a homemade device and never
repair (blind mitral commissurotomy) was performed at Peter produced commercially. The first commercially successful valve
Bent Brigham Hospital (now Brigham and Women’s Hospital) in was revolutionized by Dr. Albert Starr and his collaborator M.
Massachusetts, USA by Dr Elliot C. Cutler in a young girl Lowell Edwards at the University of Oregon in the early 1960s.
comatose from low cardiac output with rheumatic mitral stenosis The misconceptions of deleterious effect of valve surgery on left
in 1923 [1,2]. In 1925, Sir Henry S. Souttar performed the first ventricle of the 1970s was changed by the demonstration of the
finger fracture of mitral stenosis. After the Second World War, importance of the mitral apparatus in maintaining good left
Dr. Dwight E. Harken (famous for removing shell fragments ventricular function after mitral valve surgery by Dr. Miller and
lodged in soldiers’ hearts) at the Peter Bent Brigham Hospital, colleagues at Stanford University[6,7]. In 1980s, there was an
performed a large series of closed mitral valvuloplasties for mitral increased incidence of mitral valve repair and Dr. Alain F.
stenosis. He worked very closely with Dr. Laurence B. Ellis, a Carpentier of the University of Paris outlined the
cardiologist there. This exemplifies the concept that mitral valve pathophysiological classification of mitral valve lesions and
problems are best treated by a team involving cardiac surgeons, provided the tools for collaborative work of cardiologists, cardiac
cardiologists and cardiac anesthesiologists working together [3]. surgeons and cardiac anesthetists. But, the recurrence of
The first open mitral valve repair for mitral insufficiency was regurgitation was a problem and Dr. Carlos M. G. Duran
performed by Dr. C W Lillehei at the University of Minnesota in pioneered flexible ring as a solution. Patients with regurgitant
1957 [4]. Dr. Dwight C. McGoon of the Mayo Clinic reported the myxomatous mitral valves that underwent repair with ring had a
nouvelle techniques of valve repair to repair a ruptured cord in the recurrence rate of 3.6% (Figures 1 and 2).
posterior leaflet in a 1960 issue of Journal of Thoracic and
Citation: Anisuzzaman M, Hosain N, Rashid Z and Ferdous S (2021). Current Trends and Future Prospect of Treatment of Mitral Valve
Disease: Role of Interventional Cardiologists and Cardiac Surgeons. SunText Rev Cardiovasc Sci 1(1): 107.
Anisuzzaman, SunText Rev Cardiovasc Sci (2021), 1:1
But repair without ring had a recurrence rate of 15%. The Minimal access mitral surgery
development of treatment for mitral valvular disease behind the
Since the first mitral valve repair procedure for mitral stenosis,
iron curtain during 60 covers another interesting chapter. Until
mitral valve surgery has been evolving rapidly. Prosthetic mitral
recently many of these stories were not known to the Western
valves have been developed for mitral valve replacement, which
world d ue to censorship and language barrier. The first valvular
can be performed using transcatheter access. Similarly, mitral
prosthesis in USSR was implanted by a Ukrainian surgeon
valve repair has progressed form closed commissurotomies to
Nikolai Mikhailovich Amosov. In 1965 he also developed a valve
open complex mitral valve repairs using artificial cordaes and
made of antithrombotic materials. He was also famous for his
rings. Access to the mitral valve is achieved through small
writings. His famous novel Mysli i serdce (Thoughts and heart) is
incisions with the use of endoscopes and robotic systems, thus
actually based on the story of the first valve implantation. This
avoiding sternotomy.
amazing book has been translated in more than 30 different
languages. It’s a must read for any cardiac surgeon. Endoscopic minimal access mitral surgery
Anticoagulation has always been an issue with the mechanical
Endoscopic minimal access mitral surgery was introduced in
valves. Daily intake of anticoagulants and regular checking of
1996. It incorporates the use of endoscope and instruments
prothrombin time made life difficult for the valve recipients. One
specially designed to minimize surgical trauma caused by the
solution of this problem was implanting biological valves.
conventional access to the mitral valve through the median
Various bioprosthetic devices were designed and marketed for
sternotomy as much as possible. In a typical setting, the patient is
implantation in the mitral position incorporating porcine, bovine,
connected with the cardiopulmonary bypass circuit through the
equine tissue. These valves had excellent hemodynamic
peripheral vessels. For venous drainage, internal jugular and
properties and didn’t require anticoagulation, but the long term
femoral veins are used, and for arterial access the femoral artery
durability has been a major concern. These valves tend to
is typically cannulated. The aorta is then clamped with the use of
degenerate and a difficult second redo surgery for replacing the
either a cross-clamp or an endoballoon, which acts as an
degenerated valve is often warranted.
occlusion device. Cardioplegic solution is then instilled into the
coronary arteries and the heart is arrested in a similar manner to
conventional procedures. The mitral valve is access from a right
lateral minithoracotomy (4-6cm) or even a right peri-areolar
incision. Visualization and exposure of the mitral valve is
optimized with the use of endoscopes, which can provide two-
dimensional (2D) or three-dimensional (3D) images. With the use
of thoracoscopic instrumentation, the mitral valve is assessed and
repaired with contemporary techniques, which include ring
implantation, artificial chordal replacement, leaflet resection etc.
From the same minimal access, mitral valve can be replaced with
a mechanical or a biological prosthesis. Many concomitant
Figure 1: Mitral valve repair with Annuloplasty ring. procedures can also be performed using the above set-up,
including tricuspid valve surgery, atrial septal defect closure,
relief of hypertrophic obstructive cardiomyopathy, excision of
masses such as myxomas, atrial fibrillation surgery and closure of
left atrial appendage [8]. From the description above, one can
understand why the phrase “minimal access mitral surgery” is
better suited to these techniques, as opposed to the term “minimal
invasive mitral surgery”. Despite the fact that access is minimal,
the procedure to the heart itself has a similar degree of
“invasiveness” to conventional mitral surgery performed through
a median sternotomy.
Robotic mitral surgery

Robotic systems mainly consist of a console and a robotic cart.
Figure 2: Mechanical and bioprosthetic valve. Through small incisions, robotic instruments and endoscopes are
introduced to the chest cavity and the operation is performed by similar to a control population when the procedure is carried out
the operating surgeon unscrubbed, controlling the robotic early and the patient is in NYHA class I or II. These excellent
instruments from a distance. The main advantages of robotic results serve as a bench mark to which minimal access mitral
implementation include superior 3D visualization, elimination of procedures should be compared. Reports and meta-analysis that
tremor, seven angles of freedom for the instruments (compared to compare traditional and minimal access endoscopic techniques
four in endoscopic access). However, it involves a loss of tactile demonstrate less pain, improved cosmesis, reduced blood
feedback for the surgeon and higher cost when compared to transfusions, reduced wound infections, less incidence of atrial
endoscope or traditional access mitral surgery [9]. Establishment fibrillation, and reduced ventilation time, intensive care length of
of cardiopulmonary bypass and cardiac arrest is similar between stay and hospital length of stay for minimal access surgery. In a
endoscopic and robotic mitral surgery, with similar incisions and large series, the mortality rate remained low (1.1%) and in 95%
identical possibilities for concomitant procedures. Therefore, mitral valve repair was feasible with a 94% freedom from
robotic mitral surgery can also be classified as “minimal access”. reoperation at 15 years. Robotic mitral surgery has demonstrated
The robotic system that has been used most in cardiac surgery similar excellent outcomes with mortality rates of <1% despite
worldwide is the da Vinci family from Intuitive Surgical the fact that cross-clamp and cardiopulmonary bypass times were
(Sunnyvale, CA, USA). First applications for mitral operations slightly longer [9]. In hospital morbidity for endoscopic minimal
started in 1998 and since then there has been a gradual adaptation access mitral surgery procedures has been low. Conversion to
in many centres in Europe and the USA. Currently, over 100 sternotomy has been reported to be as low as 2%, incidence of
robot-assisted mitral procedures per year are taking place in stroke 0.3%, myocardial infarction 0.6%, new-onset atrial
Europe and over 1700 in the USA. The main limitation of further fibrillation 17%, need for permanent pacemaker implantation
expansion is the increased cost and steeper learning curve of 2.3%, renal insufficiency 2.6% and wound infection 0% [11]. The
robotic training compared to endoscopic [10]. above results show excellent perioperative mortality, morbidity,
and long-term outcomes of minimal access mitral surgery.
Contraindications of minimal access mitral surgery
However, there are currently no randomized control trials with
Minimal access mitral surgery, despite being technically more enough power to demonstrate significant superiority of these
demanding and having a learning curve, offers the complete range techniques when compared to conventional sternotomy mitral
of surgical options for the treatment of mitral valve disease. There surgery.
are however, a few contraindications and limitations to minimal
Other minimal invasive mitral valve procedure
access approaches. Pleural adhesions and history of extensive
radiation to the chest could complicate the entrance to the chest Technological advances in transcatheter aortic valve replacement
cavity and access to the heart. As single lung ventilation is (TAVR) have also been implemented to the mitral valve.
required until cardiopulmonary bypass is stablished, patient with Transcatheter mitral valve replacement procedures have been
poor lung function or inability to tolerate single lung ventilation introduced, which are performed in centres experienced in TAVR.
should be excluded from these techniques. Patients with These procedures aim to replace the mitral valve using a catheter
peripheral vascular disease and aortic regurgitation should also be delivery system without the need for cardiopulmonary bypass or
excluded, and chest deformities such as pectus excavatum can cardiac arrest. Four different systems have currently been
make access very difficult. Minimal access robotic mitral surgery implemented into humans; they are all still under clinical
is also associated with increased operation times compared to investigation and are not available commercially. These are the
conventional sternotomy approach, leading some surgeons to CardioAQ (Edwards Lifesciences, Irvine, CA, USA),
avoid minimal access surgery in patients with many comorbidities TendyneTM (Tendyne Inc. [now Abbott], Roseville, MN, USA),
or reduced left ventricular function who may benefit from a TiaraTM (Neovasc Inc., Richmond, BC, Canada) and the Twelve
quicker operation. valve (Medtronic, Minneapolis, MN, USA). All these valves are
delivered through the apex of the heart following a small left
Outcomes of minimal access mitral surgery
anterior thoracotomy, with the exception of the CardioAQ valve
The short and long term data for conventional mitral valve which is designed also to be delivered trans-femorally and trans-
surgery, and more specifically mitral valve repair through septally. There are anatomical and morphological limitations
sternotomy approach, demonstrate excellent results. The STS which make transcatheter mitral valve replacement more complex
database revealed a 1.2% mortality for isolated mitral valve compared to TAVR. There is however, increased interest from the
repairs, which is further reduced to 0.6% when the patients are industry as more devices are currently under development [12].
asymptomatic. Reports of long-term outcomes show freedom Minimal invasive chordal replacement techniques have recently
from reoperation which reaches 95% in 15 years and survival become commercially available. The Neocord (Neocord, Inc., St.
Louis Park, MN, USA) is a device which introduces artificial References

chordae’s from the cardiac apex and secures them at the edge of
1. Cohn LH, Soltesz EG. The evolution of mitral surgery: 1902-2002.
the posterior mitral leaflet. The other end is then tied at the
Am Heart Hosp J. 2003; 1: 40-46.
epicardial surface of the left ventricle, with chordal length
2. Cutler EC, Levine SA. Cardiotomy and valvulotomy for mitral
adjustment happening in real time with a beating heart under stenosis; experimental observations and clinical notes concerning
echocardiographic guidance. Long-term results are awaited from an operated case with recovery. Boston Med Surg J. 1923; 188:
this exciting new technique. Finally, interventional cardiologists 1023-1027.
have an armamentarium of innovative therapies for the treatment 3. Ellis LB, Harken DE. Closed valvuloplasty for mitral stenosis. A
of mitral regurgitation. These techniques are the Mitraclip twelve-year follow-up study of 1571 patients. N Engl J Med. 1964;
(Abbott Vascular, Santa Clara, CA, USA), mitral annular 270: 643-650.
remodeling devices and ventricular remodeling devices. The 4. Lillehei CW, Gott VL, Dewall RA. Surgical correction of pure
mitral insufficiency by Annuloplasty under direct vision. J Lancet.
MitraClip is by far the one that has been most extensively
1957; 77: 446-449.
implanted and investigated. First implantations took place in
5. McGoon DC. Repair of mitral insufficiency due to ruptured
2003, and CE mark and FDA approval was granted in 2008 and chordae tendineae. J Thorac Cardiol Surg. 1960; 39: 357-362.
2013, respectively. This device, inspired by the surgical edge-to- 6. Hansen DE, Cahill PD, DeCampli WM. Valvular-ventricular
edge repair initially described by Alfieri, is a clip which is interaction: importance of the mitral apparatus in canine left
introduced through a femoral vein and advanced to the mitral ventricular systolic performance. Circulation. 1986; 73: 1310-1320.
valve through the atrial septum. Under echocardiographic and 7. Thoughts on the experiment. Nikolay Amosov. 27: 2018.
fluoroscopic imaging, the clip is deployed to grasp anterior and 8. Glauber M, Miceli A. State of the art for approaching the mitral
posterior mitral valve leaflets, which results in increased valve; sternotomy, minimal invasive or total endoscopic robotic.
Eur J Cardiothorac Surg. 2015; 48: 639-641.
coaptation and reduced regurgitation. The procedure is performed
9. Bush B, Nifong LW, Alwair H, Chitwood WR Jr. Robotic mitral
typically by interventional cardiologists without any use of
valve surgery-current status and future directions. Ann
cardiac arrest or cardiopulmonary bypass and is effective in high Cardiothorac Surg. 2013; 2: 814-817.
and prohibitive risk patients suffering from primary and 10. Pettinari M, Navarra E, Noirhomme P, Gutermann H. The state of
secondary mitral regurgitation. Results from the randomized robotic cardiac surgery in Europe. Ann Cardiothorac Surg. 2017; 6:
control trial EVEREST II were promising, despite the fact that a 1-8.
recurrence in mitral regurgitation was observed in 25% of the 11. Casselman FP, Van Slycke S, Wellens F, DeGeest R, Degrieck I,
patients in one year. Furthermore, the randomized COAPT trial Van Praet F, et al. Mitral valve surgery can now routinely be
recently published results that demonstrate reduced rates of performed endoscopically. Circulation. 2003; 108: 1148-1154.
12. Merwe JVD, Casselman F. Mitral valve replacement-current and
hospitalizations and death, as well as improved quality of life and
future perspectives. Open J Cardiovasc Surg. 2017; 9.
functional capacity for symptomatic patients suffering from
13. Feldman T, Kar S, Elmariah S, Smart SC, Trento A, Siegel RJ, et
secondary mitral regurgitation and heart failure. These patients al. Investigators. Randomized comparison of percutaneous repair
were receiving maximum tolerated optimum medical therapy and and surgery for mitral regurgitation: 5-year Results of EVEREST
were also treated with MitraClip. As other studies, such as the II. J Am Coll Cardiol. 2015; 66: 2844-2854.
MITRA-FR, found no benefit for patients suffering from
secondary mitral regurgitation treated with MitraClip, we can
therefore assume that there is need for further evidence with
regards to indications of MitraClip implantation [13].
Conclusions
The treatment of mitral valve disease is evolving rapidly. The
excellent long-term results of conventional mitral surgery can
now be achieved through smaller incisions by using endoscopic
and robotic techniques. For high risk and inoperable patients,
minimal invasive transcatheter therapies are currently available
and many others are under development. These offer the cardiac
surgeon and interventional cardiologist a choice of different
approaches to meet each and every patient’s needs.
Case Report
Volume 1:1
Lead Erosion of Subcutaneous Implantable

Received date: 04 July 2021; Accepted date: 08 July
Cardioverter-Defibrillator: Successful Management 2021; Published date: 11 July 2021
without Device Removal Citation: Chu MF, Lam UP, Mok TM, Ip MF, Tam
WC, Evora M (2021). Lead Erosion of Subcutaneous
Chu MF, Lam UP, Mok TM, Ip MF, Tam WC* and Evora M Implantable Cardioverter-Defibrillator: Successful
Management without Device Removal. SunText Rev
Department of Cardiology, Centro Hospitalar Conde Sao Januario, Macau SAR, China Cardiovasc Sci 1(1): 106.
*
Corresponding author: Tam WC, Department of Cardiology, Estrada do Visconde de S. Copyright: © 2021 Chu MF, et al. This is an open-
access article distributed under the terms of the
Januário, Centro Hospitalar Conde de S. Januario, Macao, China; E-mail:
chio_2001_2@hotmail.com unrestricted use, distribution, and reproduction in any
Abstract credited.
Without intra-cardiac involvement, the management of subcutaneous implantable cardioverter-defibrillator (S-ICD) related
complication differs from those of traditional transvenous ICD. Herein, we presented one rare case with S-ICD lead erosion at the
xiphoid without systemic bloodstream infection. We performed the conservative surgical debridement without complete device
removal. Moreover, lead erosion at the xiphoid is one rare but serious complication. This may be caused by extreme superficial lead
placement during implantation. To avoid this complication, suturing the lead with a sleeve to the submuscular layer during the
implantation may be necessary to ensure adequate tissue coverage, especially in slim individuals.
Keywords: lead erosion; subcutaneous implantable cardioverter-defibrillator; infection
defibrillation. He denied any family history of sudden death.
Introduction
Echocardiography and electrophysiological study with flecainide
Patients at high risk of sudden cardiac death benefit from ICD challenge test were unremarkable, cardiac MRI showed absence
therapy. Due to extra-thoracic position of the S-ICD lead, the of structural abnormalities or arrhythmic scar formation. Under
trans venous lead related complication is significantly reduced in the impression of idiopathic ventricular fibrillation, He was
S-ICD patents [1]. Most of S-ICD complications were associated indicated for implantable cardioverter-defibrillator (ICD) for
with generator pocket, including poor healing and localized secondary prevention. Finally, subcutaneous implantable
infection [2]. However, S-ICD lead erosion at the xiphoid is a cardioverter-defibrillator (S-ICD) implantation was performed
serious complication that has rarely been reported. This with 2 incision implant technique without any complication. Two
complication may arise from implantation technique and incision wounds were healed as well as appropriate S-ICD
mechanical trauma. Complete device removal is the gold standard function during follow-up. About 5 months after the procedure,
treatment in patients with trans venous ICD lead erosion [3]. the patient complained of subcostal wound swelling with
However, owing to the lower risk of blood-borne infection in exudative discharge The S-ICD lead was partially exposed at the
patients with S-ICD, the treatment option for S-ICD lead erosion subcostal region. At that time, we haven’t documented any
may be different from trans venous lead erosion. Herein, we interrogated record regarding the sensing failure and
demonstrated a reasonable and effective treatment strategy for S- inappropriate shock. Although the lead was partially exposed, the
ICD lead erosion without systemic infection. whole S-ICD system was not removed immediately. Furthermore,
we considered the empirical antibiotics and conservative
Case Presentation treatment because there was no systemic inflammatory response
This 17-year-old male patient suffered from out-of-hospital in blood examination and exudative discharge did not cultivate
cardiac arrest and ventricular fibrillation during the marathon, any organism. However, after 6 weeks of wound care, the wound
successful recovery of spontaneous circulation after CPCR, and was not healed well finally, we performed the surgical
Citation: Chu MF, Lam UP, Mok TM, Ip MF, Tam WC, Evora M (2021). Lead Erosion of Subcutaneous Implantable Cardioverter-
Defibrillator: Successful Management without Device Removal. SunText Rev Cardiovasc Sci 1(1): 106.
Chu, SunText Rev Cardiovasc Sci (2021), 1:1
debridement of necrotic tissue and surgical reposition of the S- well. The patient was discharged after full course antibiotics.
ICD lead into the intermuscular layer at the xiphoid region. After Follow-up S-ICD interrogation didn’t show any vector alternation
the debridement, chest x ray showed appropriate position of the or sensing abnormalities. No inappropriate shock was delivered
lead without displacement the wound at the xiphoid was healed from the S-ICD system (Figure 1).
Figure 1: (A) Wound swelling with exudative discharge at xiphoid region (B) Partial erosion of S-ICD lead and poor wound dehiscence (C) S-ICD
lead at fascial layer before debridement (D) After surgical debridement of necrotic tissue, reposition part of the S-ICD lead into the intermuscular
layer at xiphoid region (E) Chest x ray showed appropriate position of S-ICD lead (F) the wound was healed well eventually
ICD were entire system removal because of the concern of

Discussion bacteremia and infective endocarditis [3]. However, based on the
S-ICD implantation is one therapeutic option for patients with unnecessity of trans venous lead, the incidence of device-related
ICD indication, in whom without bradycardia or ventricular bacteremia and endocarditis is significantly decreased in the S-
tachycardia required pacing. The S-ICD system has been reported ICD population [5]. Previous cohort studies showed that neither
to have significantly lower lead-related complication rates infective endocarditis nor blood-borne infection was observed in
compared with the trans venous ICD [4]. The recommendation of the S-ICD population during follow-up [1]. Partial lead erosion of
device erosion and pocket infection management for trans venous S-ICD without systemic infection can be managed conservatively
Chu, SunText Rev Cardiovasc Sci (2021), 1:1
without entire device removal. A similar study reported that Green UMB, Carrillo R, et al. 2017 HRS expert consensus
minimal lead erosion can be managed conservatively with a statement on cardiovascular implantable electronic device
course of antibiotics or surgical approach [6]. This conservative lead management and extraction. Heart Rhythm. 2017; 14:
strategy may be less invasive and more reasonable than those with 503-551.
entire device removal. S-ICD lead erosion at the xiphoid is a rare 4. Bardy GH, Smith WM, Hood MA, Crozier IG, Melton IC,
but serious complication that may be related to the implantation Jordaens L, et al. An entirely subcutaneous implantable
process, mechanical stress and hypertrophic scar formation. In cardioverter-defibrillator. N Engl J Med. 2010; 363: 36-44.
some slim patients, the subcutaneous fat tissue at the xiphoid may 5. Friedman DJ, Parzynski CS, Varosy PD, Prutkin JM, Patton
be too thin which may not provide adequate protection of the S- KK, Mithani A, et al. Trends and In-Hospital Outcomes
ICD lead. The superficial fat tissue at the xiphoid is damaged associated with adoption of the subcutaneous implantable
after mechanical trauma or scratching hypertrophic scar tissue, cardioverter defibrillator in the United States. JAMA
thus the lead may be eroded. To avoid and manage this Cardiol. 2016; 1: 900-911.
complication, we can consider to fixate part of S-ICD lead with a 6. Fukata M, Arita T, Kadota H, Odashiro K, Maruyama T,
sleeve to the sub muscular layer (sternal is muscle), rather than Akashi K, et al. Successful management of wound
the superficial fascia layer. This case report demonstrated dehiscence after implantation of a subcutaneous implantable
successful management of S-ICD lead erosion without systemic cardioverter-defibrillator without device removal. Heart
infection. Localized surgical debridement following embedding Rhythm Case Rep. 2017; 3: 415-417.
the lead into deeper muscle layer and closure with adjacent skin 7. Gómez R, Hontanilla B. The reconstructive management of
flap was done without alternation of vectors and sensing hardware-related scalp erosion in deep brain stimulation for
threshold. A similar interventional approach was also used for Parkinson disease. Ann Plast Surg. 2014; 73: 291-294.
neurological device erosion. Reconstructive surgery with skin flap
for hardware-related erosion had been successfully managed
without entire device removal [7]. Our case showed a reasonable
treatment option of S-ICD lead erosion without entire system
removal and without alternating the function of S-ICD.
Conclusion
S-ICD lead erosion at the xiphoid can be treated conservatively
without entire device removal. To avoid this complication, we
may fixate the sleeve with part of S-ICD lead to the sub muscular
layer during implantation, especially in some slim patients.
Ethical Approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institution or
practice at which the studies were conducted.
References
1. Burke MC, Gold MR, Knight BP, Barr CS, Theuns D,
Boersma LVA, et al. Safety and efficacy of the totally
subcutaneous implantable defibrillator: 2-year results from a
pooled analysis of the IDE Study and EFFORTLESS
registry. J Am Coll Cardiol. 2015; 65: 1605-1615.
2. Brouwer TF, Driessen AHG, Nordkamp LRAO, Kooiman
KM, Groot JRD, Wilde AAM, et al. Surgical management
of implantation-related complications of the subcutaneous
implantable cardioverter-Defibrillator. JACC Clin
Electrophysiol. 2016; 2: 89-96.
3. Kusumoto FM, Schoenfeld MH, Wilkoff BL, Berul CI,
Case Report
Volume 1:1
Malignant Anomalous Course of Right Coronary

Received date: 01 July 2021; Accepted date: 06 July
Artery 2021; Published date: 10 July 2021
Cakir M*, Bakirci EM, Degirmenci H and Karayumak MR Citation: Cakir M, Bakirci EM, Degirmenci H,
Karayumak MR (2021). Malignant Anomalous Course
Department of Cardiology, Erzincan Binali Yildirim University, Turkey of Right Coronary Artery. SunText Rev Cardiovasc Sci
1(1): 105.
Copyright: © 2021 Cakir M, et al. This is an open-

*Corresponding author: Cakir M, Faculty of Medicine, Department of Cardiology, Erzincan access article distributed under the terms of the
Binali Yıldırım University, Erzincan/Turkey; E-mail: dr.murat24@gmail.com Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
Abstract credited.
Nowadays, Coronary Computed Tomography (CT) angiography with use which is one of the non-invasive imaging methods in the
exclusion of coronary artery disease an increase in the incidence of coronary arteries has been observed. Coronary artery anomalies are
the second most common cause of sudden cardiac death, especially in young athletes. Although 20% of patients have myocardial
ischemia, syncope, ventricular arrhythmia, sudden cardiac death, it is generally benign and asymptomatic. In this case report, our aim
is to reveal the contribution of coronary CT angiography in the investigation of cardiac ischemia.
Keywords: Coronary computed tomography angiography; Coronary artery anomalies; Cardiac ischemia
Malignant coronary artery anomalies are usually seen between the
Introduction
pulmonary artery and aorta and are mostly demonstrated by
Coronary artery anomalies and variants are rare congenital autopsies after cardiac death in young athletes [1-5]. In this case,
cardiac disease. Although the frequency is below 1%, patients we present a right coronary artery patient with malignant left
may become symptomatic under heavy exercise and severe sinus Valsalva between the pulmonary artery and aorta (Table 1).
emotional stress. The abnormal course of coronary arteries is
divided into malignant and benign. While 51% of sudden deaths
Case Report
at a young age were responsible for cardiac abnormality, the most The 64-year-old non-smoker, with diabetes mellitus, hypertension
common of these was coronary artery abnormality (61%). and previously Covid-19, was admitted to our clinic with
Table 1: Anomalous course of coronary arteries. complaints of chest pain for 1 year according to physical stress
and decreases with rest cardiovascular classification (CCS 2). The
Bening Course Malignant Course patient was comfortable and painless on cardiac examination.
Prepulmonic course Inter-arterial course of the Blood pressure was 135/76 mmHg, pulse 82 beats / minute, and
oxygen saturation at room air 98%. Other physical examination,
left coronary artery
routine blood tests, chest radiography were found to be normal.
Retroaortic course Inter-arterial course of the There was no abnormality in his electrocardiography.
Transthoracic echocardiographic examination revealed mild
right coronary artery
global left ventricular hypertrophic findings as pathological
Transseptal course findings in the patient without coronary artery disease and cardiac
catheterization. Ejection fraction was evaluated as normal. The
İntra-atrial course of the patient was referred to the radiology department for coronary CT
angiography. The coronary CT angiography device used in our
right coronary artery
hospital was shot with 128-slice double detector, high voltage 70-
110 kvp, 825 mass, coverage 64-0.6 mm and rotation time 0.33 s
Citation: Cakir M, Bakirci EM, Degirmenci H, Karayumak MR (2021). Malignant Anomalous Course of Right Coronary. SunText Rev
Cardiovasc Sci 1(1): 105.
Cakir, SunText Rev Cardiovasc Sci (2021), 1:1
(Brilliance-128, Siemens, and The Germany). In the coronary CT malignant course of the right coronary artery was confirmed.
angiography report, the right coronary artery (RCA) was There was also a muscular Bridger in the left anterior descending
observed, leaving the left sinus from the Valsalva anteriorly artery (LAD). A middle-aged patient without critical stenosis of
between the pulmonary artery and the aorta. In addition, there was his coronary arteries and severe exertional angina was discharged
a middle segmented muscular bridge in the left anterior after conservative medical treatment. In the control examination,
descending artery (LAD) and the circumflex was found to be it was understood that it was asymptomatic and that it was
normal. Diagnostic coronary angiography was performed and the beneficial from the medical conservative approach (Figures 1-3).
Figure 1: The patient’s electrocardiyography is in normal sinus rhythm.
Figure 2: The patient's Multislice CT Coronary Arteries, A and B: The right coronary artery is located between the aorta and the pulmonary artery ,
C and D: 3D view of the right coronary artery.
Figure 3: The image on the left shows the right coronary artery(RCA), while the right figure shows the LAD (Left anterior descending artery) and CX
( circumflex artery)
Citation: Cakir M, Bakirci EM, Degirmenci H, Karayumak MR (2021). Malignant Anomalous Course of Right Coronary. SunText Rev
Discussion 2. Satija B, Sanyal K, Katyayni JK. Malignant anomalous right
coronary artery detected by multidetector row computed
Malignant anomaly of the interatrial located right coronary artery tomography coronary angiography. Cardiovasc Dis Res.
in the population is between 0.03-0.2, and it is more common 2012; 3: 40-42.
than left coronary artery anomaly. However, it is more common 3. Angelini P, Velasco JA, Flam S. Coronary anomalies:
in left coronary artery anomalies, ventricular arrhythmia and Incidence, pathophysiology and clinical relevance.
sudden cardiac death. The pathophysiology of coronary artery Circulation. 2002; 105: 2449-2454.
anomalies and variants are not clearly known [6-12]. In several 4. Anand M, Rahalkar, Mukund D, Rahalkar. Pictorial essay:
hypotheses, it can be expressed as the compression of the right Coronary artery variants and anomalies. Indian J Radiol
coronary artery between the aorta and the pulmonary artery and Imaging. 2009; 19: 49-53.
the artery being under pressure in the intramural cleft of the aorta. 5. Kastellanos S, Aznaouridis K, Vlachopoulos C, Tsiamis E,
It is detected incidentally in coronary artery angiography or non- Oikonomou E, Tousoulis D, et al. Overview of coronary
invasive tests. The treatment modality of coronary artery artery variants, aberrations and anomalies. World J Cardiol.
anomalies is still controversial in the literature. The heart team 2018; 10: 127-140.
should determine the treatment algorithm according to the 6. Krishnan R, Marwah V, Gupta T, Kalyanpur A. Images:
patient's symptom, age, participation in competitive sports, and Malignant right coronary artery - 64-slice CT. Indian J
the anatomy of the coronary artery. If the patient is asymptomatic Radiol Imaging. 2008; 18: 126-127
and middle-aged in the abnormal course of the right coronary 7. Narayanan MA, DeZorzi C, Akinapelli A, Haddad TM,
artery, conservative medical treatment, exercise restriction and Smer A, Baskaran J, et al. Malignant course of anomalous
close follow-up can be kept. Although there is not enough left coronary artery causing sudden cardiac arrest: A case
information in the guidelines, intracardiac defibrillator (ICD) report and review of the literature. Case Rep Cardiol. 2015;
therapy may be considered in malign coronary artery anomalies to 806291.
prevent ventricular arrhythmia and sudden cardiac death. İn the 8. Daniel JB, Radswiki. Anomalous course of coronary
treatment options can be listed surgical revascularization, arteries.
percutaneous coronary intervention, and conservative medical 9. Ali N, Baggan K, Khan S, Maharaj P, Ali R. Missed
treatment. Among the surgical techniques, the most frequently myocardial infarction in a vicenarian with malignant
used roof opening method is recommended, where the intramural anomalous right coronary artery causing acute coronary
segment in the aorta is opened and coronary osteal re- syndrome: A case report. J Med Case Rep. 2021; 15: 166.
implantation is anatomically possible. In addition, coronary artery 10. Ayalp R, Mavi A, Sercelik A, Batyraliev T, Gumusburun E.
bypass surgery can be considered as an alternative. While Frequency in the anomalous origin of the right coronary
percutaneous coronary intervention is recommended as an artery with angiography in a Turkish population. Int J
alternative to surgery, there is no study demonstrating its Cardiol. 2002; 82: 253-257.
superiority to each other. Percutaneous coronary intervention 11. Lembcke A, Diibel HP, Elgeti T, Rutsch W. Multislice
mortality was found to be less than 15% at 5-year follow-up. spiral computed tomography of a malignant single coronary
Conclusion artery. Eur J Cardiothorac Surg. 2007; 32: 801.
12. Trivellato MD, Angelini P, Robert D, Leachman MD.
Although it is a rare pathology, malignant anomalies and Variations in coronary artery anatomy: Normal versus
variations of coronary arteries should be kept in mind in patient abnormal. Cardiovasc Dis. 1980; 7: 357-370.
groups with myocardial ischemia. Coronary CT angiography,
which is one of the non-invasive methods, can contribute to the
reduction of mortality and morbidity in early diagnosis and
treatment. In this case report, our aim was to emphasize the
importance of multislice coronary CT angiography in coronary
artery anomaly.
References
1. Gräni C, Kaufmann PA, Windecker S, Buechel RR.
Diagnosis and management of anomalous coronary arteries
with a malignant course. Interv Cardiol. 2019; 14: 83-88.
Citation: Cakir M, Bakirci EM, Degirmenci H, Karayumak MR (2021). Malignant Anomalous Course of Right Coronary. SunText Rev Cardiovasc
Sci 1(1): 105.
Review Article
Volume 1:1
Herbal Remedies for Management of COVID-19

Received date: 07 June 2021; Accepted date: 21 June
Induced Myocarditis 2021; Published date: 27 June 2021
Ghaffari M* Citation: Ghaffari M (2021). Herbal Remedies for

Management of COVID-19 Induced Myocarditis.
College of Science and Health, Benedictine University, USA SunText Rev Cardiovasc Sci 1(1): 104.
*Corresponding
Copyright: © 2021 Ghaffari M. This is an open-access
author: Ghaffari M, College of Science and Health, Benedictine University, article distributed under the terms of the Creative
USA; Tel: +1 (630)829-2270; E-mail: mghaffari@ben.edu Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
Abstract credited.
Novel Coronavirus (COVID-19), which first appeared in late 2019, is a pandemic that has spread over the world. This virus quickly
spread over the world due to its great transmissibility, creating serious health problems. COVID-19 is easily transmitted from person to
person. When an infected individual coughs or sneezes, it spreads through their respiratory secretions, such as fluid droplets. This virus
not only harms the lungs, but it also harms the heart. The virus causes inflammatory cells to infiltrate the body, causing significant
edema. All of these factors can have a negative impact on heart function, leading to the development of HF. Myocarditis can be caused
by a virus-induced cell-mediated autoimmune response. Edema of the cardiac interstitium, as well as necrosis of the myocardium and
interstitial connective tissue, are symptoms of this form of virus-induced myocarditis. There are currently no specific medications that
can effectively block the virus. In-silico, in-vitro, and in-vivo techniques were used to explore several natural treatments and
chemicals, including alkaloids, terpenes, flavonoids, and benzoquinones, but there was insufficient data. Natural antiviral compounds
having a broad antiviral range could provide a safe, effective, and low-cost platform for discovering new SARS-CoV-2 treatments.
This article summarizes the epidemiology and pathophysiology of COVID-19, as well as herbal therapies that can target inflammation,
inflammatory cells, and the respiratory and cardiac consequences that come with them.
Keywords: COVID-19; Myocarditis; Herbal medicine; Inflammation
infection is critical for better understanding the relationships
Introduction
between cardiovascular disease (CVD) and COVID-19 [1].
The World Health Organization (WHO) declared the COVID-19 SARS-CoV-2 infects the host cell by triggering cell membrane
outbreak a pandemic on March 11, 2020, after it was first receptors, notably the ACE2 receptor, to recognize the virus's
reported on December 8, 2019 in China's Hubei region. Dr. Zhang spike proteins. Lung, kidney, heart, and gastrointestinal cells all
Jixian of Hubei Provincia Hospital of Integrated Chinese and have ACE2 receptors. The viral envelope merges with the host's
Western Medicine identified this condition as an infection with a cell membrane after this interaction and a conformational shift in
novel beta coronavirus [1]. Coronaviruses are single-stranded the spike protein, releasing the viral RNA into the host cell. The
RNA viruses that belong to the Coronaviridae family of viruses. viral RNA replicates its genetic material and synthesizes new
Within the coronavirus family, there are four different genera, proteins once inside the host cell [2]. Integrins may also be used
Alphacoronavirus, Betacoronavirus, Gammacoronavirus, and by SARS-CoV-2 to enter the host cell. Integrins are a class of
Deltacoronavirus. Middle East respiratory sickness (MERS-CoV), cell-surface receptors made up of non-covalently linked subunits
SARS CoV, SARS-like bat CoV, and now SARS-CoV-2 are all that identify and bind to ECM proteins and regulate cell survival,
members of the Betacoronavirus lineage within the Coronaviridae proliferation, differentiation, and migration [2]. COVID-19
subfamily [2]. Despite the fact that it has a preference for the infection is linked to systemic inflammation, a pro-inflammatory
lungs, where it produces interstitial pneumonitis, in the most cytokine storm, and sepsis, which can lead to multiorgan failure
severe instances, multiorgan failure ensues. COVID-19 appears to and death. There is a time lag between the onset of symptoms and
have intricate interactions with the cardiovascular (CV) system. the occurrence of cardiac injury. COVID-19 binds to the
Understanding the underlying pathobiology of coronavirus transmembrane ACE2 to gain access to host cells such as type 2
Citation: Ghaffari M (2021). Herbal Remedies for Management of COVID-19 Induced Myocarditis. SunText Rev Cardiovasc Sci 1(1): 104.
Ghaffari, SunText Rev Cardiovasc Sci (2021), 1:1
pneumocytes, macrophages, endothelial cells, pericytes, and cardiac damage is a common extra pulmonary symptom of
cardiac myocytes, causing inflammation and multiorgan failure. COVID-19, and it can have long-term repercussions. Myocarditis
Infection of endothelial cells or pericytes, in particular, could is difficult to diagnose because of its diverse clinical presentation,
cause significant microvascular and macrovascular dysfunction. It which can range from asymptomatic left ventricular systolic
can also destabilize atherosclerotic plaques and explain the dysfunction to mimicking the symptoms of acute myocardial
development of acute coronary syndromes when combined with infarction. Myocarditis is characterized by inflammation brought
immunological over-reactivity [1]. Despite the fact that the virus's on by immune system cells' activity. Natural killer cells come
primary organ of harm is the lung, COVID-19 is now considered first, within 5 days of viral infection, according to animal studies,
a systemic disease that affects a wide range of other critical followed by CD4 and CD8 T cells 5 to 7 days later. T cell
organs, including the heart, liver, and kidney. However, it's still invasion is accompanied by neutrophil and macrophage
unclear whether organ and tissue damage in COVID-19 infiltration, which contributes significantly to the
individuals is a direct or indirect result of the viral infection [3]. pathophysiology of myocarditis. When there is a long enough
The virus could target organs and tissues that have ACE2 period of inflammation, Th17 T cells have been found to enter the
expression. ACE2, a major regulator of blood pressure and myocardium [11].
cardiac contractility, is known to be highly expressed in
COVID-19 cardiovascular epidemiology
cardiovascular cells [4]. Patients with COVID-19 have been
reported to have changes in cardiac-specific biomarkers in their COVID-19 is a disease that affects the cardiovascular system.
peripheral blood. As previously indicated, hs-cTnI is a specific Patients with acute myocardial infarction were older, with a
biomarker for myocardial damage. Other non- or less-specific higher prevalence of previous CVD, according to a new statistic.
cardiac biomarkers, such as creatine kinase (CK), creatine kinase COVID-19 patients with acute heart damage accounted for 12%
MB isoenzyme (CK-MB), and lactate dehydrogenase, may also of the total. Furthermore, a rent review article found that cardiac
rise in COVID-19 cardiovascular problems (LDH). The Troponin, a biomarker of myocardial damage, was elevated in
biomarkers, on the other hand, may not always change in the roughly 5–25 percent of hospitalized COVID-19 cases [12]. In
same way [5]. Recent autopsy findings revealed significant levels 3470 COVID-19 patients, a systematic analysis of 72 papers from
of inflammatory infiltrates in the lung and heart tissues, different countries found a pooled prevalence of cardiovascular
demonstrating the inflammatory character of tissue damage disease and hypertension of 8.3% and 13.3%, respectively [13].
caused by SARS-CoV-2 infection. SARS-CoV-2 has the potential
The pathophysiology of patients with COVID-19
to directly infect cardiomyocytes, resulting in viral myocarditis
and damage. However, the precise cellular process by which COVID-19 can damage cardiomyocytes by recognizing ACE2
SARS-CoV-2 infects and damages cardiomyocytes has yet to be receptor infections and generating numerous inflammatory
identified. COVID-19 treatment has largely been limited to responses, according to the pathophysiology of COVID-19
supportive measures because of the lack of a specific therapy for patients. ARDS can generate an inflammatory storm and/or an
this condition to date. Pre-existing health problems raise the oxygen supply imbalance by directly damaging infected cardiac
likelihood of cardiovascular comorbidity, which leads to a worse cells via ACE2 receptors on these cells. Cardiovascular symptoms
prognosis. COVID-19-induced myocardial damage is more are common in COVID-19 individuals as a result of systemic
common in patients over 60 and those with diabetes [6]. inflammatory reactions and immune system dysfunction. COVID-
19 infection has been linked to myocardial injury due to a
Coronavirus Related Cardiovascular Consequences
cytokine storm triggered by an unbalanced response including
Myocarditis and/or pericarditis can be caused by the coronavirus, Th1 and Th2 cells, which can result in respiratory failure,
which may or may not be accompanied with pneumonia. Heart hypoxemia, shock, or hypotension. Myocardial damage occurs
failure, arrhythmias, diffuse ST-segment abnormalities, and during an infection, especially in people with chronic CVD, since
substantial production of myocardial enzymes such as natriuretic the burden on the heart is increased and there is an imbalance in
peptides and troponin are all symptoms of this myocarditis. the oxygen supply and demand. Angiotensinogen, renin,
COVID-19 patients have been documented to experience a angiotensin II (Ang II), Ang II receptors, such as AT1 and AT2
variety of cardiovascular problems. Acute myocardial damage, receptors, and angiotensin converting enzyme (ACE) make up the
myocarditis, arrhythmia, pericarditis, heart failure, and shock are renin-angiotensin system (RAS). ACE2 is found in venous and
all common consequences [7-10]. The etiologic agent of COVID- arterial smooth muscle cells, as well as endothelial cells, and is
19, severe acute respiratory syndrome-coronavirus 2 (SARS- involved in the immunological response and cardiovascular
CoV-2), can infect the heart, vascular tissues, and circulating cells mechanisms that lead to myocardial injury. COVID-19 infection
via ACE2, the host cell receptor for the viral spike protein. Acute is caused by the viral spike protein binding to ACE2, according to
several studies. One major proteinase is encoded by all noticeable. The lung and heart tissues contain significant levels of
coronaviruses. This major proteinase is known as a 3C-like inflammatory infiltrates, demonstrating the inflammatory
proteinase. As a result, the coronavirus enzyme is known as one character of tissue damage caused by SARS-CoV-2 infection
major proteinase is encoded by all coronaviruses. This major [12].
proteinase is known as a 3C-like proteinase. Coronavirus 3C-like
proteinase, or 3CLpro, is the name given to the coronavirus
COVID-19 Treatment and Management
enzyme. The 3CLpro is similar to the 3Cpro, which is the major COVID-19 is primarily treated with supportive care. Support is
picornaviral protease. Coronaviruses also contain one (group 3) or frequently necessary for myocarditis-related diseases such as
two (groups 1 and 2) papain-like proteases, known as PLP1pro arrhythmia and heart failure. There is currently no specific
and PLP2p, respectively. The coronavirus replication complex is treatment for this condition. SARS-Cov-2 RNA transcription was
controlled by the primary viral proteinase (3CLpro). It may be an reduced when broad-spectrum antiviral medicines like
appealing therapeutic target. PLpro might also be regarded an Remdesivir were used. These medications are still being studied
important target for antiviral medicines because to its significant in clinical trials. ACE inhibitors and angiotensin receptor
role. For the SARS coronavirus (SARS-CoV) and SARS-CoV-2 blockers, neutralizing antiviral plasma, stem cell transplantation,
to reach the host target cells, ACE2 is a functional receptor. As a anti-ischemic therapy, and traditional herbal medicines are among
result, ACE2 inhibition could be evaluated for antiviral research the other treatment options. Blocking the angiotensin-converting
against SARS- CoV and SARS-CoV-2 [13]. As a result, these enzyme (ACE), which is required for SARS-CoV-2 cell adhesion,
three proteins are promising targets for therapeutic development. is one of the most intriguing mechanisms. As a result, two
Inflammatory reactions triggered by COVID-19 infection are proteins, 3C-like protease (3CLpro) and angiotensin-converting
classified as primary or secondary. Prior to the formation of enzyme 2 (ACE2), have been proposed as potential targets for
neutralizing antibodies, the major inflammatory response usually screening medicines for their capacity to suppress SARS-CoV-2
occurs after viral infections. Adaptive immunity and antibody replication and proliferation. The ability of herbal therapies
neutralization are the first steps in the secondary inflammatory developed from traditional medicines to cure myocarditis is now
response. Myocardial damage is observed to be worsened in being researched. These medicines might be made up of extracts
patients with increased inflammatory activity, platelet activation, from a single plant species or extracts from numerous sources.
increased thromboxane production, and reduced fibrinolytic The sections that follow provide an overview of complementary
function after an acute infection. The early inflammatory and and herbal medicine.
immunological response has caused a significant cytokine storm
[IL-6, IL-7, IL-22, IL-17] during COVID-19's rapid proliferation. Herbalism and complementary medicine
C-reactive protein (CRP) levels that are elevated in COVID-19 The term complementary medicine refers to a wide range of
patients indicate the presence of inflammation. In addition, health-care techniques that aren't part of a country's traditional or
patients with CAD had higher levels of inflammatory cytokine conventional medicine and aren't fully incorporated into the
expression in epicardial adipose tissue (EAT). COVID-19 dominant health-care system. In certain countries, they are used
infection can cause a variety of heart symptoms, including interchangeably with traditional medicine. The purpose of this
myocardial damage, arrhythmia, and even cardiac collapse. review is to summarize the effects of a few herbal treatments on
Increased high-sensitivity cardiac troponin I (cTnI) levels have the cardiovascular and immune systems. Herbal medicines
been found to indicate myocardial damage due to COVID-19 include herbs, herbal materials, herbal preparations, and
infection in some patients. Heart failure has been proposed as one completed herbal products that contain active substances, plant
of the most common COVID-19 consequences, which could be parts, other plant materials, or combinations thereof as a
caused by worsening preexisting cardiac dysfunctions as well as supplemental medical method. Herbal products, botanical goods,
newly formed cardiomyopathy and myocarditis [14,15]. Patients and phytomedicines are items manufactured from botanicals or
with COVID-19 in the early stages may have a normal or low plants that are used to treat ailments or maintain health. Taking
total white blood cell count, as well as a low lymphocyte count. herbal supplements has been around for thousands of years [7].
As a result of the higher ratio of neutrophils to lymphocytes that Herbal supplements are considered foods by the FDA, not
occurs with lymphopenia, the higher ratio of neutrophils to medicines. As a result, they are exempt from the same testing,
lymphocytes is considered a negative prognostic factor. LDH, manufacturing, and labeling requirements as pharmaceuticals.
muscle enzymes, and C-reactive protein levels may be elevated in Complementary and alternative medicine (CAM) has exploded in
patients. In critically ill patients, the thrombogenic biomarker D- popularity in the United States in recent years. The Institute of
dimer may rise, blood lymphocyte counts fall steadily, and Medicine claimed in their book, Complementary and Alternative
laboratory changes in multiorgan damage biomarkers become Medicine in the United States, that more than one-third of
American adults use some type of CAM, and that annual visits to oxide and cyclic ether. It possesses anti-inflammatory and
CAM providers outnumber visits to primary care physicians. bronchodilatory properties, and it has a high pharmacological
Herbal drugs are regulated by the FDA as dietary supplements in effect against respiratory disorders. It's used to treat a wide range
the United States. The approval and marketing of herbal remedies of respiratory and inflammatory conditions. Furthermore, it has
in the European Union is governed by national legislation. If a been demonstrated that it inhibits the expression of NF-B in
product has been used in the European Union for at least 15 years humans [19-23].
(traditional use registration), no clinical testing or efficacy trials 6-gingerol: Turmeric contains a bioactive compound called 6-
are required [11]. Herbal items have labels that explain how herbs gingerol. It contains anti-inflammatory, antiviral, antibacterial,
might affect various bodily functions. Herbal supplement anti-diabetic, anti-oxidant, and anti-cancer properties, according
labeling, on the other hand, cannot relate to the treatment of to studies. TNF-, IL-2, and IL-8 expression in infected cells were
specific medical diseases. This is due to the fact that herbal all regulated by 6-gingerol. It inhibits the cell's production of pro-
supplements are not subjected to the same clinical research or inflammatory cytokines [23].
manufacturing regulations as prescription or over-the-counter Anethole: It is a phenlypropanoid (natural aromatic chemical)
pharmaceuticals [8]. Herbal drugs, unlike conventional drugs, do generated from essential oils. It's found in fennel seed and star
not require clinical trials or formal regulatory permission before anise. Anethole decreased TNF-, IL-6, and IL-1 expression in
being marketed, and as a result, their efficacy and safety are infected mice, according to a study. Anti-inflammatory cytokine
rarely demonstrated. Although herbs have been shown to have an (IL-10) expression rose at the same time.
influence on biological mechanisms associated to the Apigenin: It is a flavonoid that can be found in large
cardiovascular system, there is a dearth of data on clinical effects. concentrations in parsley, celery, onions, oranges, and plants.
Physicians should always evaluate their patients' use of herbal Apigenin has been shown to have antioxidant, antihyperglycemic,
drugs and discuss the potential advantages and adverse effects anti-inflammatory, and antiapoptotic effects (in myocardial
with them. Herbs have been utilized for medical purposes for ischemia). Biological effects, such as cytostatic and cytotoxic
thousands of years in the past. Herbal drugs have been more activity against various cancer cells, antiatherogenic and
popular in cardiovascular medicine than in other medical protective actions in hypertension, cardiac hypertrophy, and
professions. Digoxin and digitoxin, which are derived from autoimmune myocarditis, have been detailed in a recent review,
Digitalis lanata and Digitalis purpurea, respectively; reserpine, indicating additional potential health advantages. The mechanism
which is derived from Rauwolfia serpentina and was originally of action of apigenin is based on its modulatory actions on
used to treat psychosis; and acetylsalicylic acid (aspirin), which is dendritic cells, which are responsible for immunological
obtained from willow bark. Efficacy of herbal treatments in homeostasis [18].
treating myocarditis is being studied in a number of clinical trials. Astragaloside IV (ASIV): It is a pharmacologically active
One of the problems with employing these medicines is that the component of Astragalus membranaceus, a traditional Chinese
contents of these mixtures are mostly unknown, as well as the medicine with anti-inflammatory, antifibrotic, antioxidant,
heterogeneity of herbal medicines. Based on the pathophysiology antiasthma, and immune-regulatory properties [14]. Several
of COVID-19 and its multisystem effects, herbal treatments with studies have showed that using ASIV can help in the treatment of
antiviral activity, immune system enhancement, and anti- cardiovascular disorders such hypertension, myocardial
inflammatory effects are some of the therapeutic methods that can infarction, and cardiomyopathy. ASIV increased cardiac function
be used. The following section will go over these topics. and reduced cardiac hypertrophy in studies by upregulating Nrf2,
which was largely done via boosting the Nrf2/HO-1 signaling
Herbal Remedies
pathway [21].
Medicinal herbs and extracts have been utilized for decades in Capsaicin: A phytochemical found in chili peppers. In cells,
ethnobotany, traditional Chinese medicine (TCM), and Ayurvedic capsaicin reduces the expression of NO, TNF-, and IL-1.
medicine because they appear to have favorable effects on health. Furthermore, it stimulates IB expression while preventing NF-B
A recent study in Wuhan, China, found a link between the TCM p65 from translocating from the cytoplasm to the nucleus. It also
notion of "invigorating spleen and removing moisture" and an stopped NOS and COX-2 from working in cells. It stopped NF-B
improvement in new coronavirus pneumonia (NCP), highlighting from activating. As a result, it inhibited pro-inflammatory
the relevance of intestinal function and microenvironmental signaling in infected cells [23].
balance. The treatment comprised TCM ingredients such Carvone: Peppermint oil contains carvone, a bioactive molecule
quercetin, luteolin, and kaempferol [16-18]. (essential oil). Because of its pharmacological and biological
1,8-Cineole: (Eucalyptol)-is a natural chemical found in a variety qualities, it is widely used as an antiviral, antibacterial, anti-
of plants, including cardamom and bay leaf. It's a monoterpene inflammatory, anti-cancer, and anti-oxidant. Carvone has the
potential to suppress neuraminidase (NA). Carvone linked to the due to its inhibitory effect on prostaglandin generation and
influenza virus's neuraminidase active site successfully [23]. neutrophil/macrophage chemotaxis [23].
Cinnamaldehyde: A naturally occurring phenylpropanoid Garlic: Newer research suggests that garlic essential oil may be a
component of cinnamon essential oil. It has anti-inflammatory, helpful natural antivirus option for preventing CoV attacks on the
anti-viral, anti-oxidant, anti-immunomodulatory, anti-bacterial, human body, while additional research is needed. The inhibitory
anti-cancer, and anti-cholesterol properties, among others. In effect of the organosulfur compounds found in garlic essential oil
lung-damaged tissues, it reduced viral generation and on the host receptor ACE2 protein in the human body has been
inflammation [23]. confirmed using a molecular docking technique. This is a
Coconut oil: Consumption has been linked to a variety of health significant discovery about individual garlic compounds'
advantages, including improved antibacterial, antifungal, coronavirus resistance on the SARS-CoV-2 main protease
antiviral, antiparasitic, antidermatophytic, antioxidant, and (PDB6LU7) protein; seventeen organosulfur compounds,
immunostimulant activity. The medium-chain fatty acids accounting for 99.4% of the garlic essential oil constituents, had
(MCFA), particularly lauric acid, which is the most abundant in remarkable interactions with the amino acids of the ACE2 protein
coconut oil, are responsible for the wide range of antimicrobial and the main protease PDB6LU7.
properties. In the human body, lauric acid is transformed to Glycyrrhizin: (a saponin made up of triterpenes)-Due to its
monolaurin, which has the antibacterial and antiviral properties beneficial pharmacological effects, such as downregulating pro-
stated previously [18]. inflammatory cytokines, binding ACE2, obstructing intracellular
Curcumin (Curcuma longa): Turmeric is made from the dried reactive oxygen species (ROS) accumulation, thrombin inhibition,
rhizome of Curcuma longa, a widely used spice in meals and provoking endogenous interferon, and inhibiting the extra
Ayurvedic medicine. It has a number of pharmacologic qualities, formation of airway exudates, it may be a potential therapeutic
including antioxidant, anti-inflammatory, and antifibrotic effects. option for COVID19.
Curcumin, a polyphenol produced from turmeric, has been Jinhua Qinggan: Honeysuckle, gypsum, ephedra (honey), bitter
studied for its antiviral properties against SARS-CoV-2. The almond, baicalin, forsythia, fritillaria, burdock seed, artemisia
possible mechanism of action relies on the Ang II type 1 (AT1) annua, mint, and licorice are all found in Jinhua Qinggan
receptor protein level being reduced and the Ang II type 2 (AT2) granules. In clinical practice, Jinhua Qinggan has been utilized as
receptor being upregulated. Even at high oral quantities, curcumin an adjuvant therapy for COVID-19. Fever, cough, weariness,
is not hazardous, and it is already licensed and widely utilized in sputum, and anxiety were greatly reduced when Jinhua Qinggan
the food business. Curcumin inhibited the expression of pro- was added [19].
inflammatory cytokines such as IL-6, IL-10, IFNc, and MCP-1 Kaempferol: Kaempferol is a flavonoid found in foods including
via reducing NFB p65 phosphorylation [18]. spinach, cabbage, kale, beans, tea, and broccoli that has been
Diallyl trisulfide: The organosulphur compound diallyl trisulfide shown to have antioxidant and anti-inflammatory properties.
was obtained from garlic. It has a number of medicinal qualities, Several research have looked into how effective these flavanols
including antiviral, anti-inflammation, antibacterial, anti- are at blocking the 3a ion channel created by ORF 3a-coded
cholesterol, and anti-oxidant effects. Asthma, cancer, heart proteins, reducing viral generation and release from host cells.
disease, osteoarthritis, and acute or chronic liver injury have all This capacity allows the body's immune system to change in
been treated with it [23]. Diosgenin-is a phytocompound derived order to combat the viral infection. Because the benefits of
from fenugreek seed extract that is a steroidal sapogenin. It has kaempferol can be limited by the autoxidation process, the dosage
been found to have antiviral, antioxidant, anti-inflammatory, anti- must be large and modified according to the circumstance [18].
diabetic, anti-viral, anti-oxidant, anti-inflammatory, anti-diabetic, Lianhua Qingwen granules: contain forsythia, honeysuckle,
and anti-diabetic properties, as well as in hypercholesterolemia ephedra, bitter almond, gypsum, isatis, mianma guanzhong,
and gastrointestinal ailments. Diosgenin inhibited viral mRNA houttuynia cordata patchouli, rhubarb, rhodiola rosea, menthol,
expression and, as a result, viral replication via inhibiting STAT3 and licorice, and is a TCM compound preparation based on the
expression [23]. principle of plague prevention and cure. It can prevent
Eugenol: The phenolic component obtained from essential oil is inflammation-induced lung tissue damage by inhibiting the
eugenol (allyl chain-substituted guaiacol). Eugenol is found in release of inflammatory mediators.
clove, cinnamon, nutmeg, basil, bay leaf, and black pepper, Linalool-is a monoterpene that can be extracted from coriander
among other things. In cells, it suppresses the activity of COX-2 leaves. Cinnamon, rosemary, basil, cardamom, and thyme all
and TNF-. It also prevents NF-B from becoming activated. It also contain it. Infected mice's IL-1, IL-18, TNF-, and IFN- expression
inhibits the expression of pro-inflammatory cytokines in levels were reduced [23].
macrophages. Its anti-inflammatory mechanism mode is active
Monolaurin- Piperine: An amide alkaloid obtained from black, for severe pneumonia, Shenmai can lower inflammatory factors,
white, and long pepper extracts' fruits. It has been found to have raise anti-inflammatory factors, and lower the quantity of white
anti-inflammatory, anti-viral, analgesic, anti-convulsant, and anti- blood cells, C - reactive protein, and procalcitonin [19].
cancer biological and pharmaceutical therapeutic properties. Shufeng Jiedu granules: To treat acute upper respiratory tract
Inflammatory disorders such as asthma, Alzheimer's disease infections. Polygonum cuspidatum, forsythia, radix isatidis,
(AD), Parkinson's disease, arthritis, gastritis, and endometritis are bupleurum, radix, verbena, reed root, and licorice are among the
also treated with it. Piperine's anti-inflammatory activities inhibit granules. Shufeng Jiedu's anti-inflammatory properties are linked
inflammatory signaling in chronic diseases via NF-B, MAPK, to the down-regulation of NF-kB mRNA expression and
AP-1, COX-2, NOS-2, IL-1, TNF-, PGE2, and STAT3 [23]. suppression of the MAPK/NF-kB signaling pathway [19].
Quercetin: A flavonoid present in a variety of foods, including Sulforaphane: The active anti-inflammatory ingredient in
onions, grapes, shallots, tea, tomatoes, and a variety of seeds, mustard leaf extract is sulforaphane. Isothiocyanate is a kind of
nuts, flowers, barks, and medicinal botanicals such as Ginkgo isothiocyanate (group of sulfur-containing organic compounds).
biloba, Hypericum perforatum, and Sambucus canadensis. It has Sulforaphane inhibited the human immunodeficiency virus (HIV)
antioxidant, anti-inflammatory, and antiviral properties, with infection in macrophages via regulating the transcription of the
some preliminary evidence of anticancer benefits. These effects regulator Nrf2. In HIV-infected cells, sulforaphane inhibited
are related to lipid peroxidation inhibition, platelet aggregation infection before the development of long terminal repeat (2-LTR)
inhibition, lipopolysaccharide-induced tumor necrosis factor viral DNA rings [23].
production in macrophages, and lipopolysaccharide-induced IL-8 Tanreqing: Scutellaria baicalensis, bear bile powder, goat horn,
production in lung cells [18]. honeysuckle, and forsythia make up Tanreqing. Tanreqing
Reduning: Honeysuckle, gardenia, and artemisia annua are used contains quercetin and luteolin, which have anti-influenza a virus
to make Reduning. Pharmacological effects of the injection action in vitro. Quercetin has been shown in studies to lower
include antipyretic, anti-inflammatory, and antiviral properties. TGF-1, -SMA, and TNF- expression, block rat alveolar cell death,
Anti-inflammatory, antiviral, and immunomodulatory properties and diminish inflammation and fibrosis destruction in rat lung
of reduning injection The method of action could involve IL-17, tissue. Baicalin inhibits the expression of TNF- and IL-1, which
C-type lectin receptor, HIF-1, and other pathways operating on can minimize inflammatory damage to lung tissue [19].
IL-6, CASP3, MAPK1, CCL2, and other targets via the IL-17, C- Thymoquinone: The monoterpene substance thymoquinone is
type lectin receptor, HIF-1, and other pathways. Reduning has present in the seeds of black cumin. It has anti-oxidant, anti-
been shown to be effective in the treatment of lung damage and inflammatory, anti-cancer, immunomodulatory, anti-viral, and
cardiovascular disease [19]. anti-bacterial properties, among other things.
Shenfu: Red ginseng and black monkshood are used to make Xingnaojing: Musk, turmeric, borneol, gardenia, and other
Shenfu, which is extensively used to treat cardiovascular and components make up Xingnaojing. Acute poisoning, viral
cerebrovascular illnesses. It can also be used alone or in encephalitis, craniocerebral damage, acute cerebrovascular
combination with other medications to treat severe pneumonia, disease, pulmonary encephalopathy, pneumonia, respiratory
sepsis, multiple organ failure, and malignancies. Shenfu reduces failure, and sepsis are all common clinical uses. During the
the levels of pro-inflammatory cytokines TNF-, IL-6, IL-8, adjuvant therapy of ventilator-associated pneumonia, Xingnaojing
procalcitonin, and hypersensitivity CRP in the serum of sepsis can suppress the overexpression of serum CRP, IL-6, and TNF-.
patients, improving therapeutic benefits. Shenfu can lower IL-6 It can also lower the risk of an inflammatory reaction and harm to
levels, raise the amount of CD3 +, CD4 +, and CD8 + -T cells in several organ functions [19].
the peripheral blood, and maintain the pro-inflammatory/anti- Xin-Ji-Er-Kang (XJEK): Is a traditional Chinese herbal
inflammatory balance, all of which improve sepsis therapy medicinal combination made up of fourteen different herbs,
efficacy [19]. including Panax ginseng C.A. Mey., Astragalus Mongolic Bunge,
Shengmai: Red ginseng, ophiopogon japonicas, and schisandra Ophiopogon japonicus (Thunb). Ker Gawl., and Polygonatum
chinensis make up Shengmai. Clinically, Shengmai has been odoratisms (Mill). Clinical trials and laboratory studies have
utilized to treat cardiovascular and cerebrovascular illnesses. revealed that it protects against “Xiong-Bi” disease, viral
Shenmai: Red ginseng and ophiopogon japonicus make up myocarditis, and toxic myocarditis. XJEK efficiently lowers
Shenmai. It's used to treat conditions like coronary artery disease, blood pressure and may diminish vascular oxidative stress, as
viral myocarditis, chronic pulmonary artery disease, and well as ACh-induced relaxation and endothelial dysfunction [20].
neutropenia. Saponins, sugars, amino acids, flavonoids, lignans, Xiyanping: The major ingredient of Xiyanping is an
organic acids, and other chemicals are the major components of andrographolide substance. In COVID-19 patients, Xiyanping can
Shenmai injection. When administered as an adjuvant treatment reduce inflammation and relieve symptoms like cough, fever, and
rales in the lungs. Reducing viral replication and infection, conducted to determine the genuine therapeutic benefits and side
inhibiting concurrent bacterial infections, increasing body effects of herbal therapies in the treatment of myocarditis.
immunity, and enhancing liver function and cardiovascular
damage are some of the other advantages [19].
References
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2. Amruta N, Chastain WH, Paz M, Solch RJ, Brown ICM, Befeler JB,
China, Xuebijing is commonly used to treat severe pneumonia,
et al. SARS-CoV-2 mediated neuroinflammation and the impact of
chronic obstructive pulmonary disease, acute respiratory distress
COVID-19 in neurological disorders. Cytokine Growth Factor
syndrome, and other life-threatening illnesses [19]. Reviews. 2021; 58: 1-15.
3. Li X, Wang L, Yan S, Yang F, Xiang L, Zhu J, et al. Clinical
Summary and Discussions
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ACE2 in cardiovascular physiology. Trends Cardiovascular Med.
problems. There are currently no specific treatments that
2003; 13: 93-101.
effectively block the virus, and developing new medications takes
5. Buja LM, Zehr B, Lelenwa L, Ogechukwu E, Zhao B, Dasgupta A, et
about ten years of research. In-silico, in-vitro, and in-vivo al. Clinico pathological complexity in the application of the universal
techniques were used to explore a variety of natural cures and definition of myocardial infarction. Cardiovascular Pathol. 2020; 44:
chemicals, including alkaloids, terpenes, flavonoids, and 107153.
benzoquinones. Despite the vast amount of data obtained by a 6. Geng YJ, Wei ZY, Qian HY, Huang J, Lodato R, Castriotta RJ, et al.
computational approach, experimental proof is rarely available. Pathophysiological characteristics and therapeutic approaches for
As a result, naturally occurring compounds with a broad antiviral pulmonary injury and cardiovascular complications of coronavirus
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discovering new SARS-CoV-2 treatments. However, before
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separated bioactive components are required. Many experimental 9. Madjid M, Naeini PS, Solomon SD. Potential effects of
attempts to treat COVID-19 inflammatory and cardiac alterations coronaviruses on the cardiovascular system: A review. JAMA
with natural treatments have yielded positive outcomes. However, Cardiol. 2020; 5: 831-840.
because of the low methodological quality, small sample size, and 10. Augoustides JG. Cardiovascular consequences and considerations of
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negatively regulates autoimmune myocarditis by suppress-ing local
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cure products. The following FDA website (https://www.fda.gov) and cardiac injury clinical manifestations, biomarkers, mechanisms,
has a list of companies who have received such warning letters diagnosis, treatment, and follow up. Expert Review of Anti-infective
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the Explant Lungs of a Patient With COVID-19 Treated With
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Case Report
Volume 1:1
Hemorrhagic Cardiac Tamponade Apixaban -

Induced: A Case Report 2021; Published date: 12 June 2021
Badawaki H1, Awada B2, Mokdad R3, Tekriti Z4 and Chaddad R2,* Citation: Badawaki H, Awada B, Mokdad R, Tekriti
Z, Chaddad R (2021). Hemorrhagic Cardiac
1Nephrology department, Lebanese University, Lebanon Tamponade Apixaban - Induced: A Case Report.
2Cardiology department, Lebanese University, Lebanon
SunText Rev Cardiovasc Sci 1(1): 103.
3Cardiology department, Al Zahraa Hospital University Medical Center, Lebanon
Copyright: © 2021 Badawaki H, et al. This is an open-
4Internal Medicine Department, Lebanese University, Lebanon
*Corresponding author: Chaddad R, Cardiology department, Lebanese University; Lebanon; E- unrestricted use, distribution, and reproduction in any
mail: rimach.9991@hotmail.com
credited.
Abstract
Direct oral anticoagulants (DOACs) are used for many conditions where anticoagulation is needed such as non-valvular atrial
fibrillation, deep vein thrombosis (DVT) and pulmonary embolism (PE). Apixaban is a direct oral anticoagulant (DOAC) that works
by factor Xa inhibition. This agent is associated with a lower risk of bleeding compared with vitamin K antagonists such as warfarin.
Hemopericardium is a lifethreatening bleeding event that is rarely caused by anticoagulants. We describe the case of an 84-year old
male patient who was diagnosed with nonvalvular atrial fibrillation and treated with apixaban, and presented with severe anemia and
hypotension with no apparent bleeding sources. Further diagnostic testing with CT scan and transthoracic echocardiography showed
cardiac tamponade treated urgently by pericardiocentesis.
Keywords: Non valvular atrial fibrillation; Apixaban; Hemopericardium
Introduction
Case Presentation
Inhibitors of factor Xa in the coagulation cascade such as
apixaban become more popular as one of the DOACs due to its An 84 year old elderly patient with known to have atrial
rapid absorption and multiple medical uses [1]. This novel agent fibrillation on apixaban presented with palor, dyspnea and
is preferable over warfarin mainly for its decreased risk of lethargy. Vital signs upon presentation showed blood pressure
bleeding events as well as better facility in follow up with lake to 80/50 mmHg, heart rate 45 beats/min, temperature 36.8 °C and
dosing adjustments according to international normalized ratio oxygen saturation 80%. He was in moderate respiratory distress
(INR) [2]. Despite all apixaban’s benefits, it can still causes major with jugular venous distension, lungs were clear to auscultation,
and non-major hemorrhage complications that may need medical distant and muffled heart sounds. A chest radiograph revealed a
and interventional therapy for stabilization [3]. Hemorrhagic significant cardiomegaly and bilateral minimal pleural effusions,
cardiac tamponade (HCT) is a serious life-threatening condition which were not demonstrated in his previous chest films.
happening in many medical circumstances such as trauma, Laboratory tests showed severe anemia with 4 units drop in
cardiac surgery, acute myocardial infarction, aortic dissection and hemoglobin (compared to his baseline hemoglobin one week ago)
malignancy. To note that anticoagulation related HCT is rarely associated with acute kidney injury and electrolytes disturbance
reported in literature as principal cause of bleed in the absence of .The laboratory and imaging findings (Tables 1,2).
precipitating factors [4]. In this report, we present a case of Medical history is negative for any melena, rectorrhagia or
hemopericardium complicated by tamponade and kidney injury in hematemesis. Stabilization with face mask oxygen, IV hydration
an elderly with chronic atrial fibrillation. Patient developed acute and transfusion immediately started. An urgent TTE showed a
blood loss with hemodynamic instability in the context of use of large circumferential pericardial effusion measuring 2.5 cm and
apixaban 5mg twice daily. evidence of tamponade physiology. The mitral inflow dopplers
Citation: Badawaki H, Awada B, Mokdad R, Tekriti Z, Chaddad R (2021). Hemorrhagic Cardiac Tamponade Apixaban - Induced: A Case
Report. SunText Rev Cardiovasc Sci 1(1): 103.
Badawaki, SunText Rev Cardiovasc Sci (2021), 1:1
showed evidence of more than 25% respiratory variation. The late tamponade [6]. Only a few reports exist concerning
diastolic collapse of the right atrium and early diastolic collapse hemopericardium in patients treated with VKAs [4]. Identified in
of the right ventricular free wall was seen. a systematic review 26 cases of hemorrhagic tamponade with
mean age of 70 years and male predominace of 73% taking
Table 1: Laboratory results.
DOAC .This life threatening complication was seen mainly with
Day 0 Day 5 Day 10 rivaroxaban use (46%) followed by dabigatran and apixaban with
Hemoglobin 6.8 8.9 10.4 37% and 19% successively [7].
Hematocrit 23 27.2 32.4

Creatinine 3.51 2.17 0.85
Sodium 173 153 142
Potassium 4.55 3.81 3.75
Table 2: Pericardial fluid analysis.
RBC LDH PROTEIN ALBUMIN
3552000 295 IU/L 49.3 g/L 25.4 g/L Figure 2: CT scan Chest showed a large circumferential pericardial
effusion.
Plethora of the IVC was also noted. Urgent pericardiocentesis was The highest incidence of hemorrhagic cardiac tamponade in
performed with drainage of 2600 ml of bloody fluid. Patient’s rivaroxaban group may be due to being the most commonly used
hemodynamics improved immediately after drainage of the large DOAC at the time of the reported cases [8]. Multiple risk factors
pericardial effusion along with amelioration of his anemia, renal were noted in the reported cases including old age, male gender,
failure and electrolytes disturbances. Further Computed hypertension, and drug interactions, elevated INR and elevated
tomography scan findings supported the diagnosis of Cr. The patient in our case was free of major risk factors that may
hemopericardium, with no evidence of kidney obstruction, active increase the risk of bleed with the use of DOAC; he had normal
gastrointestinal bleeding or malignancy. Flow cytometry, creatinine before being started on apixaban, not taking any
histopathology, immune staining, and cultures were negative for medications that can interact with this DOAC increasing its level
malignancy or infection. Patient was discharged after ten days in the blood and not taking any NSAID or antiplatelets that can
with return to his baseline (Figures 1,2). increase the bleeding risk. The first case report of
hemopericardium secondary to apixaban treatment of atrial
fibrillation after 6 weeks of therapy. In this study, the
hemorrhagic pericarditis with apixaban may be explained by the
drug interaction with venlafaxine or the decreased GFR which
cause an increase in the apixaban blood levels. Malignancy is a
major cause of hemopericardium as previously reported [9,10]. It
accounts for 65% of the primary etiology of patients presenting
with cardiac tamponade requiring urgent drainage in a 10 years
prospective survey in a single-center, and it may be the first and
only manifestation of non-cardiac primary neoplasm, which is not
the case in our patient; the pericardial fluid cytology was free of
Figure 1: Echocardiography showed large circumferential pericardial malignant cells. In a reported case the reversal of bleeding in
effusion. hemopericardium in patients taking dabigatran has been
Discussion successful with the antidote idarucisumab [11]. For the other
DOAC therapies andexanet alfa is an agent shown to rapidly
Among randomized controlled trials, only five trials have reverse the anticoagulant effects of direct and indirect (enoxaparin
reported pericardial hemorrhage with DOACs (incidence 0.05%) and fondaparinux) factor Xa inhibitors; this agent reverse the
[5]. In the setting of pericarditis the use of anticoagulation mainly effects of rivaroxaban and apixaban and could offer a solution for
heparin has been documented to produce hemorrhagic cardiac the patients presenting with such life-threatening complication
Badawaki, SunText Rev Cardiovasc Sci (2021), 1:1
like our patient, although no phase three clinical trials or head-to- pleural effusion in a patient receiving Apixaban. Cardiol
head trials with usual care are currently available [12,13]. Our Res. 2019; 10: 249-252.
case report adds to the growing evidence for the major bleeding 10. Cornily JC, Pennec PY, Castellant P, Bezon E, Gal GL,
complications with the use of DOACs especially for the life Gilard M, et al. Cardiac tamponade in medical patients: a
threatening hemorrhagic cardiac tamponade that require a high 10-year follow-up survey. Cardiol. 2008; 111: 197-201.
clinical suspicion in any patient presenting with signs of shortness 11. Hsi DH, Krishnamurthy M, Ryan GF, Luo P, Woodlock TJ.
of breath or chest pain or any other manifestation of pericardial Successful management of hemopericardium and cardiac
effusion shortly after starting on any DOAC therapy. tamponade secondary to occult malignancy and
anticoagulation. Exp Clin Cardiol. 2010; 15: 33-35.
Conclusion 12. Song S, Coo.k J, Goulbourne C, Meade M, Salciccioli,
This article aims to alert clinicians to this rare but increasingly Lazar J, et al. First reported case report of hemopericardium
reported side effect of apixaban. A high index of clinical related to dabigatran use reversed by new antidote
suspicion is needed for recognition and diagnosis of spontaneous Idarucizumab. Case Rep Cardiol. 2017; 6458636.
hemopericardium. Caution should be observed especially in 13. Andexxa-an antidote for apixaban and rivaroxaban. JAMA.
elderly patients with declining renal function. With increasing use 2018; 320: 399-400.
of apixaban and other novel anticoagulants and the recent
approval of a new reversal agent, more research are needed to
develop monitoring laboratory parameters to determine and
monitor their therapeutic range.
References
1. Bristol-myers Squibb Company. Prescribing Information.
2018.
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meta-analysis of randomized controlled trials of the risk of
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9. Cinelli M, Uddin A, Duka I, Soomro A, Tamburrino F,
Ghavami F, et al. Spontaneous hemorrhagic pericardial and
Research Article
Volume 1:1
Efficacy of Continuous Local Anaesthetic

Received date: 27 May 2021; Accepted date: 07 June
Infiltration at Sternal Incision Site in Patients 2021; Published date: 10 June 2021
Undergoing Open Heart Surgery Citation: Banerjee A, SenDasgupta C and Goswami

A (2021). Efficacy of Continuous Local Anaesthetic
Banerjee A, SenDasgupta C* and Goswami A Infiltration at Sternal Incision Site in Patients
Undergoing Open Heart Surgery. SunText Rev
Department of Cardiac Anaesthesia, Institute of Postgraduate Medical Education and
Research, Kolkata, India
Copyright: © 2021 Banerjee A, et al. This is an open-
*Corresponding author: SenDasgupta C, Department of Cardiac Anaesthesia, Institute of Creative Commons Attribution License, which permits
Postgraduate Medical Education, India; E-mail: chaitali03@rediffmail.com unrestricted use, distribution, and reproduction in any
credited.
Abstract
Background: Most of the cardiac surgeries are performed through median sternotomy and associated with severe pain which if not
relieved, leads to stress response with detrimental effects on major organ systems with increased postoperative morbidity and
mortality.
Materials and methods: Eighty four patients (18 to 75 years), with modified Parsonnet score < 10 posted for cardiac surgery were
included. Two multi holed, epidural catheters were placed by surgeon, one in sub-fascial plane just above sternum and another just
below skin after sternal closure. Through each catheter, Group I patients received 0.25% levobupivacaine and Group II patients
received 0.25% levobupivacaine and 2 mcg/ml of clonidine at 2 ml per hour in ICU via elastomeric pumps for patient controlled
analgesia.
Results: The pain (VAS Score 24 hours) was significantly lower in Group II than Group I (2.7381+ 0.7005 vs 4.0238 + 0.8968). The
total morphine requirement in 48 hours was significantly higher in Group I than Group II (11.2262 + 1.7455 vs 4.8714 +
2.4111mg).Duration of tracheal intubation and time for mobilisation were similar in both groups. Serum lactate and cortisol levels at
48 postoperative hours were significantly lower Group II than Group I (Lactate 1.39 + 0.613 vs 1.8 + 1.073; Cortisol 22.07 + 9.048 vs
30.73 + 15.666). Patient satisfaction scores in Group II were significantly higher than Group I (78.3095 + 8.4637 vs 72.5238 +
5.2277).
Conclusion: Clonidine as an adjuvant in levobupivacaine infusion at sternal wound site 23 significantly decreases postoperative pain
in cardiac patients.
Keywords: Continuous infusion; levobupivacain; Clonidine; Median sternotomy
Introduction substantial postoperative morbidity and adverse hemodynamic,

metabolic, immunologic, and hemostatic alterations [2-4]. There
The International Association for the Study of Pain (IASP) may be intense pain after cardiac surgery. It originates from many
defines pain as an unpleasant sensory and emotional experience sources, such as the incision site, from intraoperative tissue
associated with actual or potential tissue damage, or described in retraction and dissection, vascular cannulation sites, vein-
terms of such damage. Most of the cardiac surgeries are harvesting sites and site of insertion of chest tubes [5]. Adequate
performed through median sternotomy, it is associated with a pain relief is essential because it results in better patient comfort,
significant amount of pain which patients describe as burning, decreased morbidity and reduced duration of stay in hospital and
aching or shooting unrelieved perioperative pain translates into hence reduced costs. Patient satisfaction has a direct link to
uninhibited surgical stress response [1]. This may have adequate pain relief. It is an essential element that influences
detrimental effects on major organ systems which may lead to clinical activity of Anaesthesiologists. Fast tracking in cardiac
Citation: Banerjee A, SenDasgupta C and Goswami A (2021). Efficacy of Continuous Local Anaesthetic Infiltration at Sternal Incision Site
in Patients Undergoing Open Heart Surgery. SunText Rev Cardiovasc Sci 1(1): 101.
1
Banerjee, SunText Rev Cardiovasc Sci (2021), 1:1
surgery has led to adoption of multimodal analgesia, in order to tracheal intubation, patient mobilization, discharge from ICU,
maximize analgesia and limit the side-effects of any one patient satisfaction , bio-chemical markers of stress response and
particular method of pain relief. Various methods have been used development of chronic pain.
for pain relief after cardiac surgery. They include intravenous
opioids, NSAIDs, intrathecal and epidural techniques, nerve
Materials and Methods
blocks and local anaesthetic infiltration [6]. Opioids are the This double-blinded, randomized, prospective study was carried
commonest agents used for alleviating postoperative pain after out in the Department of Cardiothoracic and Vascular Surgery of
cardiac surgery. They are usually delivered using either patient a tertiary care hospital. After obtaining institutional ethics
controlled analgesia or nurse controlled analgesia. However, committee approval and written informed consent from the
opioids are notorious for causing sedation and respiratory patients, 84 patients of age group 18 to 75 years posted for
depression, causing delayed tracheal extubation. They have other cardiac surgery via median sternotomy were included in the
adverse effects such as nausea, vomiting, constipation and study. Patients with Modified Parsonnet Score > 10, known
urinary retention. Limiting their use results in better adherence to allergy to local anaesthetics, significant liver disease, severe renal
fast-track discharge protocols [7]. Non-steroidal analgesics have dysfunction, any neurological dysfunction or insulin dependent
been shown to be effective in reducing pain after median diabetes mellitus or unable to comprehend Visual Analogue Scale
sternotomy [8]. However, they are sparingly used in patients were excluded from the study. Patients with active bacterial
after cardiac surgery. These groups of patients commonly have infection or those in whom the duration of postoperative positive
associated co-morbidities such as diabetes, hypertension and pressure ventilation was more than 24 hours were also excluded
underlying nephropathy. Non-steroidal analgesics are known to from the study. All the patients underwent a thorough
cause renal dysfunction and bleeding preoperative examination before surgery and all of them were
tendencies.Cyclooxygenase-2 (COX-2) inhibitors possess explained meticulously regarding the procedure and were
analgesic (opioid-sparing) effects and lack deleterious effects on familiarised with the Visual 1 Analogue Scale. After patient was
coagulation (in contrast with nonselective nonsteroidal anti- shifted to operation theatre, five lead ECG, non-invasive blood
inflammatory drugs), because they spare the constitutive COX 1 pressure and saturation probe were attached. An arterial line was
system that confers protective effect. However, current evidence inserted in the left radial artery under local anesthesia and
does not suggest that COX-2 inhibitors provide major advantages invasive arterial blood pressure monitoring commenced from then
over traditional NSAIDs. Furthermore, potential links between on. Induction of anaesthesia was done using intravenous
this class of drugs and cardiovascular complications, sternal injections of fentanyl (5- 10 mcg/kg), midazolam (0.05-0.1
wound infections, and thromboembolic complications need to be mg/kg) and sleep dose of thiopentone sodium (0.5-1 mg/kg).
fully evaluated [9]. Paracetamol infusion as an adjunct to opioids Endotracheal intubation was facilitated using IV inj rocuronium
has shown equivocal results in treating postoperative pain after (1 mg/kg). After securing the airway, the patient was adequately
cardiac surgery [10]. Central neuraxial block using opioids and positioned and a central venous catheter was inserted in right
local anaesthetic infusions have proved to be efficacious in internal jugular vein under strict aseptic precaution. Continuous
reducing postoperative pain after cardiac surgery [11]. Placement monitoring included 5 lead ECG, pulse oximetry, capnography,
of needle and catheters in the presence of systemic invasive arterial blood pressure, central venous pressure, urine
anticoagulation requires strict vigilance. Other adverse effects output, temperature. At the end of surgery, two epidural catheters
associated with neuraxial blockade are hypotension, bradycardia, were inserted at either end of sternotomy wound just after sternal
local site infection, catheter breakage etc. Continuous wound closure with all aseptic precautions, by the surgeon. One catheter
catheters have consistently demonstrated analgesic efficacy as was placed in the sub-fascial plane just above the sternal wound
evident by reduced opioid requirement and decreased pain after apposition of sternal wires. A second epidural catheter was
scores after all types of surgery [12]. Studies of local anaesthetic placed just below the skin incision. The wound was closed and
infusion at the wound site after median sternotomy have produced the patients were shifted to ICU. The patients were randomized
variable results Paul F white and his colleagues demonstrated into two groups by a computer generated randomization chart.
significantly reduced pain scores and earlier return of bowel Group I received 0.25% levobupivacaine at a rate of 2ml/ hour
sounds and removal of urinary catheter in patients receiving through each of the catheters. Group II received 0.25%
local infusion of 0.25% and 0.5% bupivacaine for 48 hours levobupivacaine and 2 mcg/kg of clonidine at 2 ml per hour
postoperatively after cardiac surgery [13]. The present study is through each of the catheters. All the study drugs and syringes
designed to find the efficacy of local anaesthetic infusion at the were prepared by a second anaesthesiologist blinded to study
wound site in reducing postoperative pain measured by the design. After shifting the patients to ICU, infusions were started
amount of rescue opioid required , its effect on duration of after negative aspiration of blood and were delivered through the
Citation: Banerjee A, SenDasgupta C and Goswami A (2021). Efficacy of Continuous Local Anaesthetic Infiltration at Sternal Incision Site in
Patients Undergoing Open Heart Surgery. SunText Rev Cardiovasc Sci 1(1): 101.
conventional bacterial filter present in the epidural kit. The using a PCA pump. No background infusion was used to preclude
infusions were delivered through an elastomeric pump set at 2ml/ accumulation of active metabolite Morphine 6 glucuronide. The
hour. There was no provision for bolus dose because such doses lock out interval between the boluses was 30 minutes and a
would not be effective and would increase the chance of local maximum of four doses were allowed over a period of 24 hours.
anaesthetic toxicity. The mechanism of this modality of analgesia Overall patient satisfaction as described on a 100-point scale with
is presumed to be by the action 1 of cumulative dose of local a score of 1 meaning very dissatisfied and 100 meaning fully
anaesthetic on the nerves carrying afferent pain impulses from satisfied. Incidence of chronic pain 3 months after surgery were
incision site. All the infusions were continued till 48 hours after noted. During discharge, the patients were asked to attend the
shifting to the Intensive Care Unit. In the ICU, hemodynamic Anaesthesia clinic at the end of three months. They were
parameters including heart rate, invasive blood pressure, oxygen interrogated about any burning or shooting pain at the site of
saturation, central venous pressure were monitored continuously sternal wound.
for a period of 48 hours. Pain scores using Visual Analogue scale
were noted 5 at 6, 12, 24, 36 and 48 hours after surgery [14]. The
Result and Analysis
patients who were on ventilator support at the time of recording Out of 84 patient’s one patient in group I and two patients in
of VAS, were asked to nod their head at the number on a scale of group II had sternal wound dehiscence. There was accidental
1 to 10, which indicated the severity of their pain. Sedation score catheter removal in one patient in group I. One patient was lost to
using Ramsay Sedation Scale were noted 8 at 6,12,24,36 and 48 follow up at the end of three months. There was no significant
hours after tracheal extubating [15]. Levels of blood glucose, difference in between the two groups in terms of their age
lactate and cortisol were measured just after shifting the patient to (p=0.44), sex, modified Parsonnet score (p=0.18) 6, type of
ICU, at 24 hours and at 48 hours of stay in ICU. The time surgery, baseline parameters, aortic cross clamp times (p=0.25)
required for first rescue analgesic was noted. The patients were and cardiopulmonary bypass duration (p=0.52). There were no
administered morphine at a dose of 0.05mg/ kg intravenously, significant arrhythmias or hypotension during 48 hours of
when the VAS score was more than or equal to 4. It was delivered infusion [16] (Figures 1 and 2) (Table 1).
Table 1: Demographic Profile.
Pre OP Group 1 n = Group 2 n = 2 Group 1 Mean + Group 2 Mean +

SD SD
Age 42 42 38.64 + 15.62 41.12 + 13.71
Sex Male 25 23
Female 17 19
Weight 42 41 50.36 + 11.15 49.1 + 8.29
Modified Personnet Score 42 42 8.33 + 1.2 8.62 + 0.62
Surgery OPCAB 9 6
MVR 6 7
AVR 7 5
LA Myxoma 2 1
RA Myxoma 0 1
DVR 3 6
ASD 6 6
VSD 3 4
On Pump CABG 0 1
Ebsteins Anomaly 0 1
DCRV 1 1
Pericardiectomy 0 1
ACxcl 42 41 37.7 + 31.94 46.6 + 37.51

Time §
CPB Time 42 42 50.38 + 39.35 56.24 + 42.95
¶
Baseline 42 42 88.71 + 21.5 99 + 14.92
HR ˣ
Baseline 42 42 93.29 + 15.8 107.74 + 16.89
MAP ˢ
Baseline 42 42 98.19 + 1.27 97.26 + 1.38
SpO2
Baseline 42 42 16.76 + 2.65 20.29 + 2.89
RR ̃
§ Aortic Cross Clamp Time; ¶ Cardiopulmonary Bypass ; ˣ Heart Rate ; ˢ Mean Arterial Pressure ; ˜ Respiratory Rate
Table 2: Total postoperative morphine requirement (in mg).
Group Mean Std Minimum Maximum Median p-value

Dev
DOSE Group I 11.2262 1.7455 8.0000 15.0000 11.0000 <0.0001

MORPHI
NE Group II
4.8714 2.4111 0.0000 10.0000 5.0000
Total dose of Morphine required in 48 hours ( in mg)
Pain scores were significantly less in group II as compared to

group I during the postoperative 6 hours (3.5 ± 0.9 vs 5.3 ± 1.6,
p< 0.0001),12 hours (3.4 ± 0.63 vs 4.8 ± 0.9, p<0.0001) and 24
hours (2.7 ± 0.7 vs 4 ± 0.8, p<0.0001). Thenceforth the intensity
of pain as measured by VAS decreased and was found to be
similar between the two groups (Figure 3) (Table 2).
The total dose of morphine required 48 hours postoperatively was
significantly less in group II as compared to group I (4.87 ± 2.4 vs
11.23 ± 1.74 mg, p< 0.0001). There was no statistical difference
in the duration of tracheal intubation between the two groups
(9.76 ± 3.55 vs 11.26 ± 4.76 hours, p=0.089). The time for first
mobilization with assistance was also comparable in the two
groups (23.55 ± 7.48 vs 22.17 ± 6.17 hours, p= 0.37).
Figure 1: Heart rate variation in the postoperative period.
The patient satisfaction score was found to be significantly higher

in group II than in group I (78.3 ± 8.46 vs 72.52 ± 5.220,
p=0.0003). One patient in group I was lost to follow up. Two
(n=41) patients developed chronic pain in group I (7.14%) 1
whereas 3/42 (7.32%) patients developed chronic pain in group II.
None of the patients had 2 catheter breakage, wound dehiscence
or sternal wound infection requiring re-exploration.
Discussion
Pain after cardiac surgery remains a challenge for cardiac
anaesthesiologists. Postoperative pain is an important concern
after cardiac surgery because it is associated with adverse
hemodynamic changes which may be detrimental in these
patients. Undertreated severe pain may have physiological
Figure 2: Mean arterial pressure variation in postoperative period. consequences increasing the stress response to surgery, seen as a
cascade of endocrine-metabolic and inflammatory events that
ultimately may contribute to organ dysfunction, morbidity,
increased hospital stays and mortality. The pain often causes the
patient to remain immobile, thus becoming vulnerable to deep
venous thrombosis, pulmonary atelectasis, and muscle wasting
and urinary retention. Besides, restlessness caused by severe pain
may contribute to postoperative hypoxemia. The peripheral neural
activation, together with central neuroplastic changes, associated
with postoperative pain may in some patients continue into a
chronic pain state [17-19]. Also, unrelieved pain after cardiac
surgery is associated with major organ dysfunction. Patients
undergoing surgery are usually petrified of postoperative pain and
it is listed as one of the main concerns of the patients before
Figure 3: Pain Scores in the postoperative period. surgery [20]. Pain is neglected in the postoperative period
especially because of inadequate reporting and recording. There
The bio chemical markers for stress response at the end of 48 are reservations about administering pain medication especially
hours were significantly lower in group II than in group I. Serum opioids because of fear of development of physical dependence,
lactate was 1.79 ± 0.7 mmol/L in group I vs 1.38 ± 0.61 in group tolerance and side-effects. Pain after cardiac surgery may be
II (p=0.034). Serum cortisol in group I was 30.7310 ± multifactorial in origin. The commonest cause’s incisions,
15.6662µg/dl vs 22.07 ± 9.04 (p=0.003) (Figure 4). intraoperative tissue retraction and dissection, multiple
intravascular cannulations and chest tube insertion sites. The most
excruciating pain is felt on the first two postoperative days. The
intensity of pain decreases as the distance from the operation
increases [21]. The nature of pain also changes from sharp
localized pain to dull osteo-articular pain. Efficacy of a
continuous wound catheters delivering local anaesthetics has been
documented in different group of surgical patients [22]. Similar
studies conducted in cardiac surgery, have shown variable results.
The results of our study are in accordance to those of Paul F
White and his colleagues who used continuous infusion of 0.25%
and 0.5% of bupivacaine and found decreased pain scores and
Figure 4: Serum biochemical markers (Cortisol and Lactate) in better patient satisfaction scores in the postoperative period. They
postoperative period. did not find any significant decrease in the duration of tracheal
intubation and ICU stay [13]. Their study on 37 patients
undergoing cardiac surgery. They used a continuous infusion of
ropivacaine for a period of 4 days and reported a persistently low 2. Weissan C. The metabolic response to stress an overview and update.
pain scores (0-3), faster recovery time and lesser duration of Anaesthesiol. 1990; 73: 308-327.
hospital stay [23]. In a similar study conducted a series of 3. Kehlet H. Surgical stress. The role of pain and analgesia. Br J
Anaesthesiol. 1989; 63: 189-195.
intercostal blocks along with continuous infusion of presternal
4. Xavier M, Mueller, Tinguely F, Hendrick T, Tevaearai , Location P,
0.25% bupivacaine was used. They showed lower morphine
et al. Distribution, and intensity after cardiac surgery. Chest. 2000;
consumption over 48 hours (8.6 ± 0.94 vs 18.83 ± 3.4 mg, 118: 391-396.
p<0.02), earlier time for extubation and better respiratory 5. Zhu F, Lee A, Chee YE. Fast-track cardiac care for adult cardiac
parameters [24]. Levobupi vacaine is L enantiomer of upivacaine surgical patients. Cochrane database syst Rev. 2012; 17: 10.
with better safety profile. The effect of parasternal block and local 6. Boldt J, Thaler E, Lehmann A, Papsdorf M, Isgro F. Pain
anesthetic infiltration with levobupivacaine after cardiac surgery management in cardiac surgery patients, comparison between
with desflurane was evaluated. Patients in the levobupivacaine standard therapy and patient controlled analgesia regimen. J
group used significantly less morphine in the first 4 h after Cardiothorac Vasc Anaesthesiol. 1998; 12: 654-658.
7. Hynninen MS, Cheng DC, Hossain I, Carroll J, Aumbhagavan SS,
surgery (20.8 +/-6.2 mg versus 33.2 +/- 10.9 mg in the placebo
Yue R, et al. Non 5 steroidal anti-inflammatory drugs in treatment of
group; P=0.013); they also had better oxygenation at the time of
postoperative pain after cardiac surgery. Can J Anaesthesiol. 2000;
extubation. The incidence of chronic pain was found to be similar 47: 1182-1187.
in the two groups. Petsikas and his colleagues found that 8. Gilrone I, Milne B, Hong M. Cyclooxygenase 2 inhibitors in
unrelieved pain after cardiac surgery may lead to chronic post postoperative pain management, Current evidence and future
sternotomy pain in as high as 30% of cases [25,26]. In the present directions. Anaesth. 2003; 99: 1198-1208.
study it was found to be around 8% which is significantly less. 9. Lahtinen P, Kokki H, Hendolin H, Hakala T, Hynynen M.
However, since this was studied as a secondary outcome measure, Propacetamol as adjunctive treatment for postoperative pain after
larger population groups need to be considered to establish the cardiac surgery. Anesth Analg. 2002; 95: 813-819.
10. Priestley MC, Cope L, Halliwell R, Gibson P, Chard RB, Skinner M,
actual reduction in incidence of chronic pain. Thus, in this study
et al . Thoracic epidural anesthesia for cardiac surgery, the effects on
we found that the intensity of pain was significantly lower in
tracheal intubation time and length of hospital stay. Anesth Analg.
patients receiving levobupivacaine plus clonidine (p<0.0001) 2002; 94: 275-282.
which led to a significantly lower requirement of morphine 11. Liu S, Richman JM, Thilby RS. Efficacy of continuous wound
(p<0.0001) required in postoperative period. These patients also catheters for delivering local anaesthesia. A qualitatative and
had lower levels of biochemical markers of stress as evident by quantitative systematic review of randomized controlled trials. J Am
significantly lower lactate (p=0.034) and cortisol levels Coll Surg. 2006; 6: 914-932.
(p<0.0003). Also, they were more satisfied with their 12. White PF, Rawal S, Latham P, Markowitz S, Issioui T, Chi L, et al.
postoperative care (p<0.0003). However, the duration of tracheal Use of a continuous local anesthetic infusion for pain management
after median sternotomy. Anesth. 2003; 99: 918-923.
intubation and time required for first mobilization with assistance
13. Jensen MP1, Chen C, Brugger AM. Interpretation of visual analog
were similar in both groups. One limitation of the study was not
scale ratings and change Scores. A reanalysis of two clinical trials of
being able to measure blood levobupivacaine levels as high postoperative pain. J Pain. 2003; 4: 407-414.
performance liquid chromatography for estimation was not 14. Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R. Controlled
available. sedation with alpaxalone-alphadolone. British Med J. 1974; 2: 656-
659.
Conclusion 15. Parsonnet V, Dean D, Berstein ADA. Method of uniform
Subcutaneous and subfascial infiltration of 0.25% stratification of risk for evaluating the results of surgery in acquired
adult heart disease. Circulation. 1989; 79: 13-12.
levobupivacaine and 2 µg/ ml of clonidine produced lesser pain
16. Kamalipour H, Vafaei A, Kazemi AP , Khademi S. Comparing the
scores, decreased postoperative opioid requirements , decreased
prevalence of chronic pain after sternotomy in patients undergoing
surgical stress response and led to better patient satisfaction in coronary artery bypass grafting using the internal mammary artery
cardiac surgical patients Clonidine was found to have analgesic and other open heart surgeries. Anesth Pain Med. 2014; 4: 17969.
sparing effects when combined with levobupivacaine. It is a 17. Kehlet H, Multi-modal approach to control postoperative
simple method which can be easily used and is not associated pathophysiology and rehabilitation. Br J Anaesth. 1997; 78: 606-617.
with any adverse effect. 18. Naughton C, Prowroznyk A, Feneck R. Reasons for prolonged
hospital stays following heart surgery. Br J Nurs. 1999; 8.
References 19. Chiu KM, Wu CC, Wang MJ, Lu CW, Shieh JS, Lin TY, et al. Local
infusion of bupivacaine combined with intravenous patient-
1. Crombie I, Jensen T, Turner J, Hallin ZW. Epidemiology of
controlled analgesia provides better pain relief than intravenous
persistent pain. In Proceeding of the 8th World congress on pain.
patient-controlled analgesia alone in patients undergoing minimally
1999; 80: 539-544.
invasive cardiac surgery. J Thorac Cardiovasc Surg. 2008; 135:

1348-1352.
20. Magnano D, Montalbano R, Lamarra M, Ferri F, Lorini L, Clarizia S,
et al. Ineffectiveness of local wound anaesthesia to reduce
postoperative pain after median sternotomy. J Card Surg. 2005; 20:
314-318.
21. Agarwal S, Nuttall GA, Johnson ME, Hanson AC, Oliver WC. Jr A
prospective randomized blinded study of continuous ropivacaine
infusion in the median sternotomy incision following cardiac surgery.
Reg Anesth. Pain Med. 2013; 38: 145-50.
22. Koukis I, Argiriou M, Dimakopoulou A, Panagiotakopoulos V,
Theakos N, Charitos C, et al. Use of continuous subcutaneous
anesthetic infusion in cardiac surgical patients after median
sternotomy. J Cardiothorac. Surg. 2008; 3: 2.
23. Nasr DA, Abdelhamid HM, Mohsen M, Ali AH. The analgesic
efficacy of continuous presternal bupivacaine infusion through a
single catheter after cardiac surgery. Annals Cardiac Anaesthesia.
2015; 18: 15-20.
24. Elliott S, Eckersall S, Fligelstone L, Jothilingam S. Does the addition
of clonidine affect duration of analgesia of bupivacaine wound
infiltration in inguinal hernia surgery. Br J Anaesth. 1997; 79: 446-
449.
25. Donald SBM, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD,
Salinas F, et al. Parasternal block and local anesthetic infiltration
with levobupivacaine after cardiac surgery with desflurane. The
effect on postoperative pain, pulmonary function, and tracheal
extubation times. Anesth Analg. 2005; 100: 25-32.
26. Bardell T, Petsikas D. Patient knowledge and length of stay after
coronary artery bypass. Chest Meeting Abstracts. 2003; 124: 158.
Opinion Article
Volume 1:1
Two Infant Cases of Tuberculosis Diagnosed

During the Assessment for Cardiac Surgery 2021; Published date: 12 June 2021
Karaagac AT* Citation: Karaagac AT (2021). Two Infant Cases of

Tuberculosis Diagnosed During the Assessment for
University of Health Sciences, Kartal Koşuyolu Research and Training Hospital, Istanbul, Cardiac Surgery. SunText Rev Cardiovasc Sci 1(1):
102.
Turkey
Copyright: © 2021 Karaagac AT. This is an open-
*Correspondingauthor: Karaağaç AT, University of Health Sciences Kartal Koşuyolu Research Creative Commons Attribution License, which permits
And Training Hospital, Pediatry, Istanbul, Turkey; Tel: 0(533)5679965; E-mail: unrestricted use, distribution, and reproduction in any
aysukaraagac@gmail.com medium, provided the original author and source are
credited.
a result of the family screening, his mother was identified as the

Opinion Article
source of infection. The second case, a 9-month-old infant, was
5300 gr and 63cm (both < 3rd percentile). He had been
Two male infants, 5/12 and 9/12 years old, with Down syndrome,
hospitalized 3 times for repeating pulmonary infections. On PE,
congenital heart anomalies, and recurrent pulmonary infections
he had pallor, cutis marmoratus, bilateral crepitations, and the
were referred to our hospital for cardiac surgery. The 5-month-old
signs of congestive heart failure. His transthoracic
infant was 3500gr and 57cm (both <3rd percentile). On physical
echocardiography demonstrated ventricular and atrial septal
examination (PE) he had pallor, fever, bilateral sibilant rales,
defects, mitral and tricuspid regurgitation. Laboratory values were
crackles, and the signs of congestive heart failure. His
normal except for slightly increased acute phase reactants with
transthoracic echocardiography revealed atrioventricular septal
mild anaemia. His chest roentgenogram showed bilateral
defect, pulmonary hypertension, and fibrinous pericardial
paracardiac consolidations and atelectasis in the right lung.
effusion. Laboratory findings were normal except for moderately
Findings didn’t improve despite 3 weeks of large spectrum
elevated acute phase reactants with mild anaemia. Chest
antibiotic treatment. There was no bacterial growth in the sputum
roentgenogram showed bilateral multifocal consolidations.
cultures. Torax CT showed consolidations with air bronchograms
Clinical and radiological findings didn’t improve despite 3 weeks
in the upper posteromedial part of the right lung, atelectatic
of large spectrum antibiotic treatment. There was no bacterial
regions in the upper and lower posteromedial zones of the left
growth in the sputum cultures. His tuberculin skin test was
lung. Therefore, a bronchoscopy was performed. BAL sample
negative, and the quantiferon test result was “indeterminate”. The
PCR and acid-fast bacilli tests were negative. He was operated on
gastric lavage specimens were subjected to smear evaluation for
and discharged from the hospital on the 10th postoperative day.
acid-fast bacilli (AFB) and culture for mycobacteria using
Tuberculosis bacilli were produced in his BAL Lowenstein-
established methods. Computerized thora tomography (thorax
Jensen culture on the 45th day. Treatment was initiated following
CT) showed bilateral diffused ground-glass appearance and
the drug sensitivity test. His parents were also screened for TBC.
reticulonodular shadowing. Therefore, a bronchoscopy was
Pulmonary tuberculosis is still an important cause of morbidity
performed by the paediatric pulmonologist. Since the cardiac
and mortality in children. It was reported that there are more than
surgery of our patient was an emergency, Isoniazid-Rifampicin
1 million new cases of childhood TB annually. Delayed diagnosis
therapy (10 mg/kg/day) was initiated as soon as the broncho
is associated with more advanced disease and worse treatment
alveolar lavage (BAL) sample was obtained. The therapy was
outcomes [1-3]. On the other hand, diagnosis of TBC is
changed to a 4-drug anti-TBC regimen after constricti
challenging due to difficulties in gathering respiratory samples
pericardium was detected during the cardiac operation, which was
from the infant age group, absence of gold-standard diagnostic
approved by pathology. BAL polymerized chain reaction (PCR)
tests, and a wide spectrum of disease symptoms that overlap with
test result was positive for Mycobacterium tuberculosis.
pneumonia, malnutrition, immune deficiencies, and congenital
Unfortunately, the patient died on the 24th postoperative day. As
heart anomaly-related congestive heart failure [4-6]. As a
Citation: Karaagac AT (2021). Two Infant Cases of Tuberculosis Diagnosed During the Assessment for Cardiac Surgery. SunText Rev
Karaagac, SunText Rev Cardiovasc Sci (2021), 1:1
conclusion, TBC should be investigated in children with recurrent

and/or resistant pulmonary infections. It is important to remember
that malnutrition or congestive heart failure symptoms may mimic
and/or mask the symptoms of tuberculosis in children with
congenital heart diseases.
References
1. Newton SM, Brent AJ, Anderson S, Whittaker E,
Kampmann B. Paediatric tuberculosis. Lancet Infect Dis.
2008; 8: 498-510.
2. Johnston N, Sandys N. Delayed diagnosis of pulmonary
tuberculosis in a 13-year-old Malawian boy. Case Reports.
2017.
3. Bafwafwa DN, Mukuku O, MbuliLukamba R, Tshikamba
EM, Kanteng GW. Risk Factors Affecting mortality in
children with pulmonary tuberculosis in lubumbashi, the
democratic republic of the congo. J Lung Pulm Respir Res.
2017; 4: 00151.
4. Adamu AL, Aliyu MH, Galadanci NA, Musa BM, Gadanya
MA, Gajida AU, et al. Deaths during tuberculosis treatment
among pediatric patients in a large tertiary hospital in
Nigeria. Plops One. 2017; 12: 0183270.
5. Pabon CLR, Velez CMP. Tuberculosis exposure, infection,
and disease in children: a systematic diagnostic approach.
Pneumonia. 2016; 8: 23.
6. Gonzalez LHG, Juarez E, Carranza C, Binaghi LEC,
Alejandre A, Gutierrrez C, et al. Immunological aspects of
diagnosis and management of childhood tuberculosis. Infect
Drug Resist. 202; 14: 929-946.
Citation: Karaagac AT (2021). Two Infant Cases of Tuberculosis Diagnosed During the Assessment for Cardiac Surgery. SunText Rev

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Copyright: © 2021 Cakir M, et al. This is an open-

Figure 1: The patient’s electrocardiyography is in normal sinus rhythm.

Herbal Remedies for Management of COVID-19

Ghaffari M* Citation: Ghaffari M (2021). Herbal Remedies for

Hemorrhagic Cardiac Tamponade Apixaban -

Hematocrit 23 27.2 32.4

Table 2: Pericardial fluid analysis.

RBC LDH PROTEIN ALBUMIN

Efficacy of Continuous Local Anaesthetic

Undergoing Open Heart Surgery Citation: Banerjee A, SenDasgupta C and Goswami

Keywords: Continuous infusion; levobupivacain; Clonidine; Median sternotomy

Introduction substantial postoperative morbidity and adverse hemodynamic,

Pre OP Group 1 n = Group 2 n = 2 Group 1 Mean + Group 2 Mean +

Weight 42 41 50.36 + 11.15 49.1 + 8.29

Modified Personnet Score 42 42 8.33 + 1.2 8.62 + 0.62

ACxcl 42 41 37.7 + 31.94 46.6 + 37.51

Table 2: Total postoperative morphine requirement (in mg).

Group Mean Std Minimum Maximum Median p-value

DOSE Group I 11.2262 1.7455 8.0000 15.0000 11.0000 <0.0001

Total dose of Morphine required in 48 hours ( in mg)

Pain scores were significantly less in group II as compared to

The patient satisfaction score was found to be significantly higher

invasive cardiac surgery. J Thorac Cardiovasc Surg. 2008; 135:

Two Infant Cases of Tuberculosis Diagnosed

Karaagac AT* Citation: Karaagac AT (2021). Two Infant Cases of

a result of the family screening, his mother was identified as the

conclusion, TBC should be investigated in children with recurrent

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