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Byline: Anita. Malik, Monica. Kohli, Jayashree. Sood, Baljit. Singh, Balakrishnapillai. Radhakrishnan, Muralidhar. Kanchi The primary objective of postgraduate medical education is to produce specialists who provide highest quality of health [...]

Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.

Byline: Srinath. Damodaran, Anuja. Kulkarni, Vikneswaran. Gunaseelan, Vimal. Raj, Muralidhar. Kanchi Background and Aims: The incorporation of artificial intelligence (AI) in point-of-care ultrasound (POCUS) has become a very useful tool [...]

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient′s outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of "Fellowship" is by way of conducting IACTA - TEE fellowship (F-TEE) examination. This has been done annually for the past 7 years using well-established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F-TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F-TEE certification process.

In 1980, Transesophageal Echocardiography (TEE) first technology has introduced the standard of practice for most cardiac operating rooms to facilitate surgical decision making. Transoesophageal echocardiography as a diagnostic tool is now an integral part of intraoperative monitoring practice of cardiac anaesthesiology. Practice guidelines for perioperative transesophageal echocardiography are systematically developed recommendations that assist in the management of surgical patients, were developed by Indian Association of Cardiac Anaesthesiologists (IACTA). This update relates to the former IACTA practice guidelines published in 2013 and the ASE/EACTA guidelines of 2015. The current authors believe that the basic echocardiographer should be familiar with the technical skills for acquiring 28 cross sectional imaging planes. These 28 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination and adds 5 more additional views, introduced for different clinical scenarios in recent times. A comparison of 2D TEE views versus 3D TEE views is attempted for the first time in literature, in this manuscript. Since, cardiac anaesthesia variability exists in the precise anatomic orientation between the heart and the oesophagus in individual patients, an attempt has been made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

Byline: Kirubanand. Senniappan, Salome. Jeyabalan, Pradeep. Rangappa, Muralidhar. Kanchi The coronavirus disease 2019 (COVID-19) is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although 85% of infected [...]

Perioperative anaesthetic management of the VentrAssist TM left ventricular assist device (LVAD) is a challenge for anaesthesiologists because patients presenting for this operation have long-standing cardiac failure and often have associated hepatic and renal impairment, which may significantly alter the pharmacokinetics of administered drugs and render the patients coagulopathic. The VentrAssist is implanted by midline sternotomy. A brief period of cardiopulmonary bypass (CPB) for apical cannulation of left ventricle is needed. The centrifugal pump, which produces non-pulsatile, continuous flow, is positioned in the left sub-diaphragmatic pocket. This LVAD is preload dependent and afterload sensitive. Transoesophageal echocardiography is an essential tool to rule out contraindications and to ensure proper inflow cannula position, and following the implantation of LVAD, to ensure right ventricular (RV) function. The anaesthesiologist should be prepared to manage cardiac decompensation and acute desaturation before initiation of CPB, as well as RV failure and severe coagulopathic bleeding after CPB. Three patients had undergone implantation of VentrAssist in our hospital. This pump provides flow of 5 l/min depending on preload, afterload and pump speed. All the patients were discharged after an average of 30 days. There was no perioperative mortality.

Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

An acute coronary syndrome due to mast-cell activation in the presence of an allergen is known as Kounis Syndrome (KS). This relatively new entity of KS is being increasingly recognized among allergists, cardiologists, and emergency physicians; however, it is not well-known among anesthesiologists. We report here, a case of type 2 KS due to antibiotic administration causing sudden perioperative cardiac arrest. [ABSTRACT FROM AUTHOR]

There has been considerable controversy regarding the use of pulmonary artery catheter (PAC) in clinical practice. Some studies have indicated poor outcome in patients who were monitored with PAC. However, these studies, which have condemned the use of PAC, were conducted on patients in intensive care units, where the clinical scenarios with regard to patients′ status are somewhat different as compared to those of a cardiac operating room. This study was designed to identify the indications of PAC use in cardiac operating rooms. A questionnaire was mailed to anasthesiologists in cardiac centers and the response was analyzed.The practicing cardiac anesthesiologists recommended the use of PAC for following indications in cardiac surgery: coronary artery bypass grafting (CABG) with poor left ventricular (LV) function, LV aneurysmectomy, recent myocardial infarction (MI), pulmonary hypertension, diastolic dysfunction, acute ventricular septal rupture and insertion of left ventricular assist device (LVAD).The analysis of responses from practicing anesthesiologists clearly indicates that use of a PAC cannot be recommended as a matter of routine, but a definite role is suggested in selected groups of patients undergoing cardiac surgery.

Background: Quantification of urinary tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein (IFGBP-7), which is commercially known as NephroCheck™(NC) test have been suggested as promising tools for the early detection of acute kidney injury (AKI) after cardiac surgery involving cardio-pulmonary bypass (CPB). Objectives: The aim of the present study was to test the hypothesis that single value of postoperative NC test performed at 4 hours after surgery can predict AKI in off-pump coronary artery bypass grafting (OPCABG) surgery. Setting and Design: This prospective single-center study was conducted at the tertiary cardiac center in India from December 2017 to November 2018. Methods: Ninety adult patients of both sex undergoing elective OPCABG were included. Anesthesia was standardized to all patients. Urine samples were collected preoperatively and at 4 hours after surgery for NC test. Urine output, serum creatinine, estimated glomerular filtration rate (eGFR) were also measured. AKI staging was based on kidney disease improving global outcomes (KDIGO) guidelines. Statistical Analysis: To assess the predictability of NC test for the primary endpoint, area under the receiver operating characteristic curve (ROC), was calculated. Results: Thirteen patients developed AKI in the study cohort (14.4%) out of which 7 patients (7.8%) developed stage 2/3 AKI and the remaining stage 1 AKI. Baseline renal parameters were similar between AKI and non-AKI group. The area under curve (AUC) of NC test at 4 hours after surgery was 0.60 [95% confidence interval (CI): 0.42-0.77]. Postoperative NC test performed at 4 hours after surgery did not predict AKI in this study population (P = 0.24). There were no significant differences in duration of mechanical ventilation, length of intensive care stay and hospital stay between the two groups (P > 0.05). Conclusion: NephroCheck™ test performed at 4 hours after surgery did not identify patients at risk for developing AKI following OPCABG surgery. [ABSTRACT FROM AUTHOR]

Protective lung ventilation is the mainstay ventilation strategy for patients on extracorporeal membrane oxygenation (ECMO), as prolonged mechanical ventilation increases morbidity and mortality; the technicalities of ventilation with ECMO have evolved in the last decade. ECMO on the other end of the spectrum is a complete or total extracorporeal support, which supplies complete physiological blood gas exchanges, normally performed by the native lungs and thus is capable of delivering oxygen (O2) and removing CO equal to the metabolic needs of the patient, it requires higher flows, is more complex, and uses bigger cannulas, higher dose of heparin and higher blood volume for priming. This review describes in detail carbon dioxide removal on ECMO. [ABSTRACT FROM AUTHOR]

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE. [ABSTRACT FROM AUTHOR]

Objective A significant number of conditions may mimic acute myocardial infarction when patients present to acute emergency care (AEC) with chest pain. A proportion of such patients may exhibit ST segment abnormality on the electrocardiogram (ECG) which is due to conditions other than acute coronary syndromes (ACS) or myocardial infarction. The American Heart Association/American College of Cardiology guidelines (2015) algorithm for ACS does not include echocardiographic evaluation in the assessment of chest pain. Patients with chest pain may be subjected to investigations and interventions based on ECG leading unwarranted invasive procedures, which may prove unnecessary, futile, and even detrimental. This study was performed to determine if a bedside echocardiography would help identify the conditions that do not need intervention and might possibly change the treatment pathway at the right time. Materials and Methods In a prospective observational study design, adult patients presenting to AEC with chest pain were included in the study. After the assessment of airway, breathing and circulation, and initiation of bed side monitoring, a 12-lead ECG was obtained. Patients exhibiting a significant ST change on ECG were subjected to bedside echocardiography, that is, two-dimensional (2D) transthoracic echocardiography (2D-TTE) with a cross reference to a consultant cardiologist for the precise assessment and diagnosis. The findings of echocardiography were correlated with electrocardiogram for possible diagnostic coronary angiography and percutaneous coronary intervention. The results of ECG, echocardiography, and coronary angiography (if done) were analyzed to determine the sensitivity and specificity of echocardiography for ACS. Results Among 385 patients in the study, 312 were suspected to suffer acute coronary syndrome; among these patients, eight patients turned out to have chest pain due to non-ACS. Of the 73 patients, the chest pain was suspected to be not of cardiac ischemia origin; among these patients, 66 patients were true negative and 7 patients were false positive. Echocardiography was the predictive of ischemic chest pain with a predictive value of 97.7%. The specificity of echocardiography calculated from the above confusion matrix was 90.4% and sensitivity was 97.4%. The positive predictive value of 2D-TTE was 97.7% and negative predictive value was 89.1%. The overall accuracy of bedside 2D-TTE was 96.1%. Conclusion Echocardiography was found to be an effective tool in aiding diagnosis of a patient presenting to AEC with chest pain and ST-T changes in ECG. A significant percentage of patients (18.7%) presented to AEC with chest pain, ST-T changes and found to have causes other than ACS, and screening echocardiography (2D-TTE) was able to identify 90.4% of those cases. From this study, we conclude that bedside echocardiography had high specificity (90.4%) and sensitivity (97.43%) in identifying regional wall motion abnormality due to ACS. Hence, bedside echocardiography is recommended in patients with chest pain and ST-segment abnormality to avoid unnecessary delay in diagnosis and invasive interventions in non-ACS. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease-2019 (COVID-19) causes various cardiopulmonary manifestations. Bedside ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend™ (GE, Wauwatosa, WI, USA) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and the number of healthcare workers exposed to COVID-19. This is a prospective observational study comparing the cardiorespiratory parameters and time duration for assessment between Vscan Extend™ and the conventional ultrasound machine. Materials and methods: Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend™ device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used clinical examination, X-ray chest, ECG, and conventional echocardiogram for assessment. The agreement between the findings and the time duration required in both the methods was compared. Results: The use of handheld ultrasound has significantly decreased the duration of bedside examination of patients than the conventional method. The median duration of examination using handheld ultrasound was 9 (8.0-11.0) minutes, compared to 20 (17-22) minutes with the conventional method (P < 0.001). The Cohen's kappa coefficient was 1.0 for left ventricular systolic function, most of the lung fields, and diaphragmatic movement. Conclusion: Vscan Extend™ helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety. [ABSTRACT FROM AUTHOR]

Background: This study was undertaken to determine the effects of dexmedetomidine on pulmonary artery pressure (PAP) in children with congenital heart disease (CHD) and pulmonary hypertension (PH) undergoing cardiac catheterization with and without a planned intervention during monitored anesthetic care using midazolam and ketamine.Materials and Methods: Children (<18 years) with known CHD and PH who were scheduled for cardiac catheterization and interventional procedures were included in the study. The procedures were performed under monitored anesthesia. After obtaining baseline PAPs, an intravenous (IV) infusion of dexmedetomidine (1 μg/kg) was given for over 10 min. During infusion, heart rate (HR), blood pressure (BP), respiratory rate (RR), and peripheral arterial oxygen saturation (SPO2) were recorded every 2 min until completion of dexmedetomidine infusion, 15 min later, and when the procedure was completed. In addition, pulmonary artery systolic and diastolic pressures, and mean pulmonary artery pressure (MPAP) were recorded and the pulmonary artery systolic pressure (PASP)/systolic blood pressure (BP) ratio was calculated.Results: All children tolerated the procedure without adverse events. The HR decreased significantly over time during dexmedetomidine infusion. The changes in systemic systolic BP and PAPs were not significantly different from the baseline value at all points of measurement as was the ratio between the systolic pulmonary artery and systolic systemic BPs.Conclusions: Administration of dexmedetomidine in a dose of 1 μg/kg over 10 min did not significantly alter the PAP in children with CHD and PH. There was a decrease in the HR that was not clinically significant. The children tolerated dexmedetomidine without adverse events. [ABSTRACT FROM AUTHOR]

National cardiac life support training program initiated in October 2016, it is a systematic approach to management of a victim of cardiac arrest. The program aimed to address the training needs of a junior physician such as the one undergoing postgraduate medical education and other health-care professionals. It is a 2-day "hands-on" course that recommends an instructor-candidate ratio of 1:6 and limits the number of candidates to 30 per session to maintain adequate mentee-mentor interaction, monitoring, and evaluation. This program is developed in collaboration with Society for Emergency Medicine in India, Indian College of Anesthesiologists, Indian College of Cardiology, and Association of Healthcare Providers India. In addition, this program has been endorsed by West Bengal University and National Board of Examinations, New Delhi. Currently, The Simulation Society which deals with online teaching simulation has lent its support by endorsing this program. [ABSTRACT FROM AUTHOR]

Byline: Muralidhar. Kanchi, Hema. Nair, Sanjay. Banakal, Keshava. Murthy, C. Murugesan Endotracheal intubation involving conventional laryngoscopy elicits a haemodynamic response associated with increased heart and blood pressure. The study was [...]

Background and Aims: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality and economic burden. This study was designed to determine the benefit of sodium bicarbonate (NaHCO3) supplementation in patients with stable chronic kidney disease (CKD) undergoing off-pump coronary artery bypass grafting (OP-CABG). Material and Methods: We prospectively studied 60 non-dialysis CKD patients with glomerular filtration rate (GFR) ≤60 ml/min/1.73 m2 requiring elective OP-CABG. They were randomly allocatted to one of the two groups. One group received NaHCO3 infusion at 0.5 mmol/kg first hour followed by 0.2 mmol/kg/h till the end of surgery and the other group received 0.9% NaCl. A third group of 30 patients without renal dysfunction undergoing OP-CABG was included. The serum creatinine was estimated prior to surgery, immediately after surgery and on postoperative days 1, 2, 3 and 4. Results: Ten patients (33.3%) in NaCl and 6 (20%) patients each in NaHCO3 and normal groups developed Stage-1 AKI. None of our study patient required renal replacement therapy and no mortality was observed in any of the groups during the perioperative and hospitalization period. Conclusion: Perioperative infusion of NaHCO3 in OP-CABG reduced the incidence of Stage-1 AKI by about 40% when compared to NaCl. The incidence of Stage-I AKI in NaHCO3 group was similar to that in patients with normal renal function undergoing OP-CABG. A larger group of patients may be required to suggest a significance of renal protective benefit of NaHCO3 in patients undergoing OP-CABG. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality, and economic burden. In this study, we assessed the usefulness of estimating serum neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker in predicting AKI in patients with stable chronic kidney disease (CKD) and undergoing off-pump coronary artery bypass grafting (OP-CABG).Patients and Methods: We prospectively studied sixty nondialysis-dependent CKD patients with estimated glomerular filtration rate <60 ml/min/1.73 m2 who required elective OP-CABG. Patients were randomized into two groups, Group D received dopamine infusion at 2 μg/kg/min following anesthesia induction till the end of the surgery and Group P did not receive any intervention. Serum creatinine, NGAL, brain natriuretic peptide, and troponin-I were estimated at specified intervals before, during, and after surgery. The results of the study patients were also compared to a simultaneous matched cohort control of thirty patients (Group A) without renal dysfunction who underwent OP-CABG.Results: No patient required renal replacement therapy, and no mortality was observed during perioperative and hospitalization period. Six patients from control group (n = 30), ten patients from placebo group (n = 30), and 12 patients from dopamine group (n = 30) developed stage 1 AKI. However, we did not observe any stage 2 and stage 3 AKI among all the groups. There was a significant increase in serum NGAL levels at the end of surgery and 24 h postoperatively in placebo and dopamine groups as compared to the control.Conclusion: The measurement of NGAL appears to predict the occurrence of AKI after OP-CAB surgery. However, large multicentric studies may be required to confirm the findings of this study. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing coronary artery bypass graft (CABG) procedures have higher incidence of difficult laryngoscopy and intubation than general surgery population. Accurate prediction of difficult laryngoscopy in CABG patients is desirable to reduce the hemodynamic response and myocardial oxygen requirements. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway. We, in our prospective observational study, evaluated the accuracy of the TMHT in predicting difficult laryngoscopy.Methodology: A total of 345 patients undergoing CABG of either sex, in the age group of 35-80 years, American Society of Anesthesiologists 111, undergoing CABG, were studied. Airway assessment was performed with modified Mallampati test with the addition of thyromental distance, sternomental distance, and TMHT. Intraoperatively, direct laryngoscopy was done in accordance with Cormack and Lehane grade of laryngoscopy. The preoperative data and laryngoscopic findings were used together to evaluate the accuracy of TMHT. The sensitivity, specificity, positive and negative predictive values of other three tests were calculated according to standard formula.Results: A total of 345 patients were in the group with mean age of study population at 56.7 (standard deviation 9.1) years (35-80 years). This study showed that almost all tests had good specificity, but sensitivity was poor. However, sensitivity of TMHT was 75% with accuracy of 95%. Receiver operating characteristic curve analysis of TMHT-derived cutoff was 52.17 which increased sensitivity to 81.25% and specificity to 92.3%.Conclusion: TMHT had a higher sensitivity compared to other tests along with good positive and negative predictive value and a very high specificity. [ABSTRACT FROM AUTHOR]

Aims and Objectives: Perioperative optic neuropathy (PON) is a rare, but devastating complication following coronary artery bypass graft surgery (CABG). We performed a retrospective study of PON associated with off-pump CABG (OPCABG) to identify possible risk factors. Materials and Methods: 1442 patients underwent OPCABG over a 10-month period from October 2008 to August 2009; PON was identified in four (0.28%) patients. A retrospective review of the charts was done to identify the patient characteristics, pre-operative status, intra-operative details, and ophthalmic examination details. Friedman test was used to compare the hematocrit (Hct) and the mean arterial pressure (MAP) values across the three time periods: Pre-, intra- and post-operative periods. Results: All four patients were male, diabetic, and in the age range 51-69 years. All patients noted unilateral or bilateral severe visual loss in the immediate post-operative period, which was permanent. All the four patients had statistically significant decrease in the Hct (P < 0.039) and mean arterial blood pressure (P < 0.018) in the intraoperative and post-operative period when compared to pre-operative value. Conclusions: PON is a rare but definite possibility in patients undergoing OPCABG. Diabetes mellitus may be a risk factor. Perioperative hemodynamic abnormalities like decrease in MAP and anemia may play a role in the development of PON in OPCABG. [ABSTRACT FROM AUTHOR]

Background: The initial insights from the studies on COVID-19 had been disappointing, indicating the necessity of an aggravated search for alternative strategies. In this regard, the adjunct potential of yoga has been proposed for enhancing the effectiveness of the standard of care with respect to COVID-19 management. We tested whether a telemodel of yoga intervention could aid in better clinical management for hospitalized patients with mild-to-moderate COVID-19 when complemented with the standard of care., Methods: This was a randomized controlled trial conducted at the Narayana Hrudyalaya, Bengaluru, India, on hospitalized patients with mild-to-moderate COVID-19 infection enrolled between 31 May and 22 July 2021. The patients ( n = 225) were randomized in a 1:1 ratio [adjunct tele-yoga ( n = 113) or standard of care]. The adjunct yoga group received intervention in tele-mode within 4-h post-randomization until 14 days along with the standard of care. The primary outcome was the clinical status on day 14 post-randomization, assessed with a seven-category ordinal scale. The secondary outcome set included scores on the COVID Outcomes Scale on day 7, follow-up for clinical status and all-cause mortality on day 28, post-randomization, duration of days at the hospital, 5th-day changes post-randomization for viral load expressed as cyclic threshold (Ct), and inflammatory markers and perceived stress scores on day 14., Results: As compared with the standard of care alone, the proportional odds of having a higher score on the 7-point ordinal scale on day 14 were ~1.8 for the adjunct tele-yoga group (OR = 1.83, 95% CI, 1.11-3.03). On day 5, there were significant reductions in CRP ( P = 0.001) and LDH levels ( P = 0.029) in the adjunct yoga group compared to the standard of care alone. CRP reduction was also observed as a potential mediator for the yoga-induced improvement of clinical outcomes. The Kaplan-Meier estimate of all-cause mortality on day 28 was the adjusted hazard ratio (HR) of 0.26 (95% CI, 0.05-1.30)., Conclusion: The observed 1.8-fold improvement in the clinical status on day 14 of patients of COVID-19 with adjunct use of tele-yoga contests its use as a complementary treatment in hospital settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Majumdar, Manjunath, Nagarathna, Panigrahi, Kanchi, Sahoo, Nagendra, Giridharan, Reddy and Nayak.)

Extracorporeal membrane oxygenation (ECMO) is a modality utilized for partially or completely supporting the cardiac and/or pulmonary function. There are multiple vascular access techniques depending upon the necessity and the mode of ECMO used. ECMO has evolved over the years as an integral part of the cardiac care discipline. Historically, this lifesaving modality began as an extension of cardiopulmonary bypass and was associated with adverse outcomes. Currently, ECMO has evolved as an accepted and viable solution to patients with severe cardiac/respiratory/cardiorespiratory failure that is refractory to conservative management. The outcomes of patients on ECMO are dependent on multiple factors originating from demographic and pathophysiological status of patients as well as the control of homeostasis during ECMO within the acceptable range. Various studies have been published by many practitioners over past decades since the dawn of ECMO era. A brief review of such experience is summated, and a conclusion is derived about the clinical course of the patients on ECMO, while adding the author's experience about the same in a tertiary care large-volume center., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Association of Surgeons of India 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background Off-pump coronary artery bypass grafting (OP-CABG) is an accepted surgical option in treating ischemic heart disease and has proven safer than traditional on-pump CABG in terms of reducing perioperative bleeding, coagulopathy, avoiding cardiopulmonary bypass machine and its related morbidity. However, there is evidence that shows the risk of bleeding in OP-CABG due to surgical trauma, heart manipulations, and heparin-protamine exposure. We aim to evaluate the effectiveness of tranexamic acid (TxA) in reducing blood loss and related perioperative complications in patients undergoing OP-CABG. Method An individual matched cohort study was conducted at a cardiac centre over a period of one year. We enrolled a total of 60 patients undergoing OPCABG in our study. The basic strategy was to enroll every possible intervention patient until the desired sample size (30 in each group) was achieved and then to select and enroll controls, using a prospective individual matching strategy. Preoperative cardiac risk evaluation was done using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) in both groups. The intervention group (I) received TxA 10 mg/kg over 10 minutes at the time of induction while the control group (C) did not receive any TxA. Postoperative blood loss was measured by observing chest drain output 24 hourly till the chest drain tube was removed. Perioperative complications were also recorded. Results Demographics and baseline characteristics were comparable among groups (p > 0.05). The mean volume of postoperative blood loss in the I group at 24 hours and 48 hours were 352.67 ml and 86.83 ml, respectively. On the other hand, in the C group, the mean volume of postoperative blood loss was 602.00 ml and 166.3 ml. The data showed a statistically significant difference in the postoperative chest drainage output between the groups (unpaired t-test, p < 0.05) and exhibiting a significant reduction in postoperative blood loss in the I group. However, there was no significant difference in blood transfusion requirements in both of the groups (Mann Whitney U test, p > 0.05). The mean duration of postoperative complications, inotropic support, intermittent positive pressure ventilation, intensive care, and hospital stay were also comparable depicting no significant effect of TxA on reducing the perioperative morbidity. Conclusion This study showed the significance of TxA in reducing bleeding in the postoperative period in patients undergoing OP-CABG., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Khadanga et al.)

Background: Genome-wide polygenic scores (GPS) integrate information from many common DNA variants into a single number. Because rates of coronary artery disease (CAD) are substantially higher among South Asians, a GPS to identify high-risk individuals may be particularly useful in this population., Objectives: This analysis used summary statistics from a prior genome-wide association study to derive a new GPS CAD for South Asians., Methods: This GPS CAD was validated in 7,244 South Asian UK Biobank participants and tested in 491 individuals from a case-control study in Bangladesh. Next, a static ancestry and GPS CAD reference distribution was built using whole-genome sequencing from 1,522 Indian individuals, and a framework was tested for projecting individuals onto this static ancestry and GPS CAD reference distribution using 1,800 CAD cases and 1,163 control subjects newly recruited in India., Results: The GPS CAD , containing 6,630,150 common DNA variants, had an odds ratio (OR) per SD of 1.58 in South Asian UK Biobank participants and 1.60 in the Bangladeshi study (p < 0.001 for each). Next, individuals of the Indian case-control study were projected onto static reference distributions, observing an OR/SD of 1.66 (p < 0.001). Compared with the middle quintile, risk for CAD was most pronounced for those in the top 5% of the GPS CAD distribution-ORs of 4.16, 2.46, and 3.22 in the South Asian UK Biobank, Bangladeshi, and Indian studies, respectively (p < 0.05 for each)., Conclusions: The new GPS CAD has been developed and tested using 3 distinct South Asian studies, and provides a generalizable framework for ancestry-specific GPS assessment., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

An alternative method of maintaining carotid perfusion during combined carotid endarterectomy and off-pump coronary artery bypass grafting involves insertion of a cannula in the ascending aorta after a median sternotomy. This cannula is connected to a perfusion cannula, the distal end of which is inserted into the carotid artery beyond the carotid arteriotomy. This technique of aortico-carotid shunting and carotid perfusion was utilized in nine patients who underwent successful combined carotid endarterectomy and off-pump coronary artery bypass grafting.