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Endovascular repair of abdominal aneurysm (EVAR) has become the main stay of treatment for abdominal aortic aneurysm. Long-term follow-up studies have shown a variety of complications following EVAR, few of which are dangerous with high morbidity and mortality. Open surgery for complications of EVAR poses unique challenges to the surgeon. We present one of the serious complications following EVAR which was successfully managed by open surgery.

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy. Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality. Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality. Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia.

Background: Inflammations resulting from cardiac surgical procedures have traditionally been controlled with corticosteroids such as dexamethasone. However, the use of these medications to attenuate the inflammatory responses from cardiac surgery remains contentious. The aim of this systematic review and meta-analysis was to evaluate the effect of administering dexamethasone intraoperatively on major complications and mortality compared to placebo interventions. Study Design: This was a systematic review and meta-analysis. Methods: The research was conducted on online databases such as PubMed, Google Scholar, EMBASE, and the Cochrane Central Register of Control Trials until August 5, 2022. The studies in the online databases were written between January 1, 2000, and August 1, 2022. The studies that were selected were scanned and analyzed based on an established eligibility criteria for the study. Results: Ten randomized and controlled trials were included in this systematic review and meta-analysis. The incidence of mortality was 2.2% (154 out of 7007 patients) in the dexamethasone group and 2.3% (164 out of 7038 patients) in the placebo group (odds ratio [OR],0.94; 95% confidence interval [CI], 0.75–1.01; P = 0.73; I2 = 0%). Myocardial infarction incidence was 1.88% (88 out of 4685 patients) in the dexamethasone group and 2.12% (100 out of 4708 patients) in the placebo group (OR, 0.88; 95% CI, 0.66–1.18; P = 0.39; I2 = 9%). The incidence of stroke for the dexamethasone group was 1.56% (70 out of 4488 patients) and 1.82% (82 out of 4511 patients) in the placebo group (OR, 0.86; 95%CI, 0.62–1.18; P = 0.34; I2 = 0%). The prevalence of new onset atrial fibrillation was 32.3% (797 out of 2469 patients) for dexamethasone and 34.7% (859 out of 2478 patients) for placebo (OR, 0.90; 95%CI, 0.80–1.01; P = 0.08; I2 = 0%). The incidence of renal failure was slightly higher in the placebo group with 1.58% (108 out of 6857 patients) compared to the dexamethasone group 0.97% (66 out of 6823 patients) (OR, 0.61; 95% CI, 0.45–0.83; P = 0.002; I2 = 0%). Conclusion: According to this review, dexamethasone does not result in a significant decrease in incidences of mortality, myocardial infarction and stroke. However, the medication was associated with decreased incidences of renal failure and atrial fibrillation in a majority of the studies.

Introduction: Surgical management of diffuse coronary artery disease (CAD) requires aggressive techniques for complete revascularization. Coronary endarterectomy (CE) coupled with coronary artery bypass grafting (CABG) is a valuable technique for this subset. The aim is to evaluate the perioperative and early results following CE. Materials and Methods: Three hundred and eighty patients of diffuse CAD undergoing off-pump CABG were included in the study. CE was performed in 204 patients. The mean age of the patients was 62 ± 16.32 years. The male-to-female ratio was 1.43, and the mean SYNTAX score was 33.12 ± 6.42. The mean stay in the intensive care unit was 4.94 ± 2.72 for patients undergoing CABG with CE. The perioperative mortality was 4.9%. The patients were followed up at 3 months, and graft patency was assessed with computed tomography coronary angiography. The average graft patency was 86.725% for the grafts with CE. Patients with left anterior descending (LAD) CE had higher perioperative mortality (5%), overall survival (89.79% at 3 months), and graft patency rates (87%) were favorable. The outcome following single vessel CE was better than multivessel CE. Conclusion: In patients with diffuse CAD, CE is a safe technique with comparable mortality and lesser complication rate if performed adequately. Despite perioperative difficulties, early outcomes are favorable for CE to the LAD artery grafted with the left internal thoracic artery. Single vessel CE yielded a better result as compared to multivessel CE.

Objectives : Adult patients undergoing tetralogy of Fallot (TOF) repair have a higher risk of mortality compared to pediatric patients. Pulmonary regurgitation (PR) further predisposes these patients to heart failure, arrhythmias, and sudden death. Pulmonary valve replacement (PVR) may improve the symptoms in these patients but, fails to reverse the other deleterious effects. Aim of our study was to evaluate the effect of concomitant PVR with TOF repair on right ventricular (RV) parameters, cardiopulmonary exercise capacity, and bioprosthetic valve durability at mid-term. Materials and Methods: Between January 2013 and August 2018, 37 adolescents and adults with TOF who had hypoplastic pulmonary annulus underwent concomitant TOF repair with PVR at our institute. We retrospectively collected the data from the hospital records including follow-up. Results : Mean age of the patients was 18.48 ± 7.53 years. Bioprosthetic valve size ranged from 19 mm to 25 mm. There was no early or late mortality. No patient had developed significant perioperative complications. At a mean follow-up of 53.3 ± 16.4 months, there was no significant change in mean QRS duration, RV function, RV end-systolic and end-diastolic dimensions, RV myocardial performance index, and functional status (including NYHA class and 6-min walk test) compared to at-discharge values. Four patients developed prosthetic valve degeneration with mild PR and without significant increase in gradient. Conclusion : Concomitant PVR with TOF repair in adult provides excellent mid-term outcome, with a minimal rate of pulmonary valve degeneration. It not only eases the early postoperative course but also preserves the RV function as well as functional status at mid-term.

Background: The modification in technique is useful for successful right-sided internal jugular vein (IJV) cannulation on the same side even after intra-arterial puncture without using ultrasound guidance in adult patients. Materials and Methods: This study was carried out in total 160 adult patient from American Society of Anesthesiologists Grade II to III patients male (n = 95) and female (n = 65) who underwent cardiac surgery where cannulation was done on right sided by triple lumen catheter (7 French) using Seldinger technique. Results: Majority of patients were cannulated successfully by Seldinger technique with single or double attempt except for five patients in which arterial puncture occurred. All five patients were cannulated successfully on the same side with this modified technique without any significant major complications. They were managed by application of blocker at the end of arterial needle puncture without removing it. In our routine practice, we were used to removing this needle and applying compression for few minutes to prevent hematoma formation after an arterial puncture. In this study, cannula was used as a marker or guideline for the relocation of IJV on the same side and recannulation was performed by changing the direction of needle on same side lateral to the previous one and without going towards the same direction to prevent the arterial puncture again. Conclusion: Most simple and useful modified technique for institutes where the complications are most common with trainee doctors and in hospitals where there is no advanced facility like ultrasound-guided cannulation available. By this modification, it will be time saving, very comfortable, and user-friendly technique with high success rate.