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Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2 ), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™ , PreSep™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.

Thirty seven year old asymptomatic male underwent routine medical examination which revealed an abnormal mass in the right atrium. Family history was not suggestive of any cardiac or malignant disease. Detailed investigation detected deficiency of protein S, which is a vitamin K dependent protein and a cofactor for activated protein C mediated cleavage of factor Va and VIIIa. The deficiency of protein S predisposes to venous thrombosis. Further investigation revealed that it was an organized calcified thrombus in right atrium occupying almost whole of the cavity. Various approaches including surgical excision, thrombolysis and anticoagulation has been used to manage such thrombosis. However therapeutic approach is still a question of debate. Atriotomy and excision of mass was done using cardiopulmonary bypass.

A seventy eight year old male patient was admitted in our hospital with headache, vomiting, irritability and confusion. Initially he was diagnosed as a case of pyogenic encephalitis. Further investigations revealed that patient had cerebrospinal fluid rhinorrhea and coronary artery disease. He successfully underwent coronary artery bypass grafting and cerebrospinal fluid leak repair.

Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management.Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2 ), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™ , PreSep™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study.Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study.Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of - 0.331, -0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB. [ABSTRACT FROM AUTHOR]

To the Editor, A 50-year-old male patient with hypertension, diabetes, and end-stage renal failure on regular dialysis was admitted to our hospital for acute coronary syndrome. Critically ill patients, who are on dialysis, require frequent determination of arterial blood gas composition. [Extracted from the article]

The article is a letter to the editor which presents a case study regarding a 63-year-old female, with known hypertensive and diabetic, who was diagnosed as a case of acute anterior wall myocardial infarction. Thrombolytic treatment with streptokinase was provided. Echocardiography revealed ejection fraction of 45–50 percent and 12 mm long muscular ventricular septal defect. Doppler study of upper and lower limb arteries was normal. High total leukocyte count was detected.

A seventy eight year old male patient was admitted in our hospital with headache, vomiting, irritability and confusion. Initially he was diagnosed as a case of pyogenic encephalitis. Further investigations revealed that patient had cerebrospinal fluid rhinorrhea and coronary artery disease. He successfully underwent coronary artery bypass grafting and cerebrospinal fluid leak repair. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about the clinical case of a 60-year-old woman who underwent off-pump cardiac surgery following leech therapy.

The article reports on the genetic syndrome which is a major concern for anesthesiologists and is present to patients with heart diseases. Discussed is the Down syndrome which is the most common example of genetic syndrome. It states that Down syndrome patients have congenital heart disease which characterized by endocardial cushion defects, ventricular septal defects, patent ductus arteriosus and other heart abnormalities.

A letter to the editor is presented in response to the article "Comparative study between the effects of dexmedetomidine and propofol on cerebral oxygenation during sedation at pediatric cardiac catheterization" by Murat Cetin, and colleagues, that was published in the previous issue.

A response from the authors of the article "Necklace shadow in the neck after surgery" in volume 16, 2013, which discusses chest radiography, is presented.

The article describes the case of a 72-year-old female coronary artery bypass graft patient who had necklace shadow in the neck following surgery. The patient underwent post-operative chest radiography, but medical personnel failed to find a necklace. According to a radiologist, the necklace shadow was calcification of tracheal rings.

Thirty seven year old asymptomatic male underwent routine medical examination which revealed an abnormal mass in the right atrium. Family history was not suggestive of any cardiac or malignant disease. Detailed investigation detected deficiency of protein S, which is a vitamin K dependent protein and a cofactor for activated protein C mediated cleavage of factor Va and VIIIa. The deficiency of protein S predisposes to venous thrombosis. Further investigation revealed that it was an organized calcified thrombus in right atrium occupying almost whole of the cavity. Various approaches including surgical excision, thrombolysis and anticoagulation has been used to manage such thrombosis. However therapeutic approach is still a question of debate. Atriotomy and excision of mass was done using cardiopulmonary bypass.