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The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings—increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.

We present two patients who turned positive for coronavirus disease 2019 (COVID-19) after elective cardiac surgery, developing postoperative pericardial effusion with tamponade. One of the patients who presented with tamponade had no other symptoms of COVID-19 infection. COVID-19 can rarely present with cardiac manifestations including pericardial effusion and tamponade. In the post cardiac surgery setting, this effect of the virus may be accentuated. Hence, a high index of suspicion and prompt management are the keys for a successful outcome.

Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01240-y.

One of the major risks of cardiac surgery is the occurrence of infection at the sternal wound site. Sternal wound infections are primarily classified into superficial infection and deep sternal wound infection or mediastinitis. A patient is diagnosed with mediastinitis if microorganisms are present in their mediastinal tissue/fluid or with the observation of sternal wound infection during operation and with characteristic symptoms including chest pain, fever, and purulent drainage from the mediastinum. It is usually caused by Staphylococcal organisms in 75.8% of cases and the rest is caused by gram-negative bacteria. Currently, in cardiac surgery, hemostasis is achieved using electrocautery and bone wax, and the sternum is closed using wire cerclage. Several studies show that bone wax can act as a nidus for initiation of infection and the oozing blood and hematoma at the site can promote the growth of infectious organisms. Many research groups have developed different types of biomaterials and reported on the prevention of infection and healing of the sternum. These materials are reported to have both positive and negative effects. In this review, we highlight the current clinical practices undertaken to prevent infection and bleeding as well as research progress in this field and their outcomes in controlling bleeding, infection, and enhancing sternal healing.

The indications for mitral valve repair extend across the entire spectrum of degenerative mitral valve disease, ranging from fibroelastic degeneration to Barlow’s disease. Collaboration between the surgeon and anesthesiologist is essential for ensuring optimal results. Echocardiographic assessment of the repair can be challenging but is essential to the success of the procedure, as even mild residual mitral regurgitation can portend poor patient outcomes. In addition to determining the severity of residual regurgitation, the anesthesiologist must elucidate the mechanism of disease in order to inform appropriate re-intervention measures. Finally, there are unique complications of mitral valve surgery for the anesthesiologist to understand and assess by echocardiography. This review describes a systematic pathway for a comprehensive intraoperative assessment of the mitral valve following surgical repair.

Trans-aortic septal myectomy is the gold standard for septal reduction therapy. This technique has low peri-procedural mortality and excellent long-term survival. Moreover, it relieves the heart failure symptoms and improves the quality of life. Secondary chordal cutting along with septal myectomy has shown to improve the outcome but can potentially cause deterioration of left ventricular function. In patients with relatively thin inter-ventricular septum, abnormalities of mitral valve apparatus may be the main reason for systolic anterior motion and left ventricular outflow tract obstruction. These patients may require additional procedures on the mitral valve to shift the coaptation plane away from outflow tract. Mitral valve replacement should be performed only in patients with intrinsic mitral valve abnormalities that are not suitable for repair and its routine use along with limited septal myectomy should be discouraged. Minimal access surgery although attractive in concept requires more robust data before universal application.

Abnormalities of the mitral valve apparatus are a phenotypical expression of hypertrophic cardiomyopathy and can contribute to systolic anterior motion and left ventricular outflow tract obstruction. In patients with significant abnormalities of the mitral apparatus, adjunct procedures like plication of the anterior mitral leaflet and/or release of papillary muscles may be required to obtain sufficient relief of obstruction. Very rarely, an elongated posterior mitral leaflet is the main culprit for systolic anterior motion. In such cases, plication of the posterior mitral leaflet is a useful technique, in addition to septal myectomy, to abolish left ventricular outflow tract obstruction. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01213-1.

Background Sepsis is caused by a dysregulation of immune response to infection that results in very high mortality. Current laboratory tests and clinical criteria are inadequate to diagnose sepsis due to limited sensitivity and specificity. Circulating monocytes are important players in immune homeostasis and their altered HLA-DR expression indicate immune dysregulation. HLA-DR is an MHC Class II cell-surface receptor that can present foreign antigens to helper T cells and mount an inflammatory response. Therefore, we analyzed the variations in HLA-DR expression and the concentration of monocyte subsets for diagnosing post-surgical sepsis. Methods In this double-blinded prospective cohort study, we adopted immunophenotyping and quantification of antigen expression by flowcytometry to detect the changes in circulating monocyte subsets in patients undergoing cardiac surgery. Statistical analysis was performed to identify significant changes and based on the predictive potential of measured variables ROC curve analysis was done. ROC curve permitted the choice of appropriate cut-off values using which a diagnostic protocol was developed. Results We observed that the monocyte subset concentrations in circulation varied differently after surgery. There was a significant downregulation of monocytic HLA-DR on both intermediate (p = 0.0477) and non-classical monocytes (p = 0.0333) at 48 h post-surgery. The monocyte subset analysis clearly showed that the patients with reduced pre-surgical non-classical monocyte count (p = 0.0430) coupled with post-surgical down-regulation of HLA-DR expression on the same subset had a higher incidence of developing sepsis after cardiac surgery. Conclusions Here we are reporting for the first time, the significant influence of non-classical monocytes in inducing dysregulated host response and sepsis after cardiac surgery. Using multiple biomarkers associated with this monocyte subset, we established an algorithm for the diagnosis of sepsis at 48 h post cardiac surgery with 100% sensitivity and 69.23% specificity.

Background :The aim of this study was to validate whether pulmonary capillary wedge pressure estimated using transoesophageal echocardiography in anaesthetised patients receiving mechanical ventilation can be comparable to gold standard method of estimating PCWP by using pulmonary artery catheter. Methods : A cross sectional validity study conducted in a tertiary care cardiac centre in south India over a period of 6 months from February 2016 – August 2016 among 100 patients undergoing cardiac surgery where intraoperative TEE and pulmonary artery catheter used. In anesthetised patients, after the insertion of TEE probe, the following echocardiography ratios were calculated: 1) SF = S ⁄ S + D (systolic fraction of pulmonary venous flow 2) Systolic ⁄ diastolic (S ⁄ D ratio) 3) E ⁄ Ea 4) E ⁄ Vp 5) E ⁄ A ratio , for three consecutive cardiac cycles and averaged by two independent and blinded observers. All the echo measurements were taken pre cardiopulmonary bypass at end expiration and during a stable period of hemodynamics. Simultaneously PCWP was recorded from PAC. The ability of these variables to predict PCWP was tested for previously determined cutoffs as per extant guidelines and validity parameters such as sensitivity, specificity, predictive value of positives, predictive value of negatives & accuracy were computed. Conclusion : Use of E/A,DT,S/D,SF ratio & E/Vp reveal poor predictive capacity for detecting high left sided filling pressures. The use of E/Ea is reasonable to predict an elevated PCWP especially if the cohort predominantly comprises of patients with normal ejection fraction

PURPOSE: Despite advances in medical care, infective endocarditis (IE) has high mortality. Surgery for IE though recommended for complications of the disease is still not commonly offered due to conflicting reports in the literature. We reviewed our results of surgery for IE from the last 5 years to assess their outcome. METHODS: A retrospective review from a single center of consecutive patients who underwent surgery for infective endocarditis from September 2014 to December 2019 was done. Data was collected from hospital records and follow-up done up to May 2020. Outcomes evaluated were mortality, follow-up survival, and postoperative complications. Factors affecting mortality and survival were analyzed. RESULTS: Ninety-seven patients underwent surgery for IE during this period. Seventy-nine had native valve endocarditis (NVE) and 18 had prosthetic valve endocarditis (PVE). The overall postoperative mortality was 13%, with mortality for native valve endocarditis being 11% and that for prosthetic valve endocarditis being 22%, which was not statistically significant. Three-year survival for the overall group was 88.7% with 88.1% for NVE and 91.7% for PVE. Multivariate predictors of operative mortality were a high EuroSCORE II, diabetes mellitus, and the presence of Staphylococcus organism. CONCLUSION: Surgery for infective endocarditis has a very acceptable early outcome and intermediate-term survival.

In patients with a small aortic annulus, the clinical benefits of aortic valve replacement depend on avoidance of patient-prosthesis mismatch as it is associated with reduced overall survival. Aortic root widening or enlargement is a useful technique to implant larger valve prosthesis to prevent patient-prosthesis mismatch. Posterior annular enlargement is the commonest technique used for aortic root enlargement. Consistent enlargement of the aortic root requires more extensive procedures like Manouguian or Konno-Rastan techniques. The patients commonly selected are younger patients with good life expectancy. However, caution is advised in applying this procedure in elderly patients, patients with heavily calcified annulus and when performing concomitant procedures. There is no definitive conclusion on the best material to use for the reconstruction of aortic annulus and aorta in aortic root enlargement procedures.

Embolization of a transcatheter aortic valve is a rare complication. Surgery is required if percutaneous retrieval is not possible. We present a case of embolization of an Evolut R device (Medtronic, Minneapolis, MN) into the ascending aorta. This device, owing to its taller profile, presents unique surgical challenges in retrieval with respect to arterial access and cross clamping of the aorta. Prior knowledge of the profile of the various devices is critical to ensure a safe retrieval and smooth conduct of the operation.

Hemorrhage is the leading cause of death in combat settings, trauma injury, and during surgical procedures. Hemostatic agents and tissue sealants are required when body’s coagulation cascade is not able to control hemorrhage effectively. Chitosan because of its hemostatic and tissue adhesive property has gained popularity as a topical hemostatic agent. Chitosan and derivatives of chitosan in different forms such as sponge, hydrogel, dressing, and particles have been extensively studied as hemostatic agent. This chapter provides an overview of the basic hemostatic property of chitosan and also reviews the recent progress on different forms of chitosan and its derivatives as hemostatic agents and tissue sealants.

Left atrial clots are occasionally seen in patients with long-standing atrial fibrillation who come for valve surgery. Once identified on echocardiogram, intraoperative identification and retrieval of the clot are essential in order to prevent the possibly devastating complication of embolism and stroke. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01154-9.

Uncontrolled bleeding can lead to many complications that might cause multiple organ failures and even death. Of all the hemostatic agents used, chitosan has been reported to show better hemostatic potential. It acts through one mechanism involved in hemostasis that is plug formation by adhering to the injured site. Hence our focus is to enhance the hemostatic potential of chitosan (Ch) hydrogel by incorporating nano whitlockite (nWH: Ca

PURPOSE: Ticagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3 months after off-pump surgery. METHODS: Three hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization. RESULTS: Patients in the ticagrelor group had more incidence of re-exploration for bleeding (p = 0.042), pericardial effusion requiring drainage (p = 0.007), readmissions (p

BACKGROUND: In spite of general decline worldwide, off-pump coronary artery bypass grafting (CABG) surgery is performed in more than 60% of patients undergoing CABG in India; mainly because of shorter operative time and reduced procedure cost. However, paucity of data exists in literature about early outcomes following off-pump CABG from India. METHODOLOGY: We conducted a prospective observational study of 800 consecutive cases that underwent off-pump CABG (OPCAB) from August 2015 to October 2017. Primary end point of the study was the 30-day/in-hospital mortality from any cause. RESULTS: On multivariate analysis, emergency surgery (OR 9.72; CI 1.96–48.21, p value 0.005), severe left ventricular dysfunction (OR 2.28; CI 1.25–4.76, p value 0.026), postoperative atrial fibrillation (OR 9.95; CI 3.12–32.01, p value 0.05), and dialysis-dependent renal failure (OR 29.7, CI 10.02–87.99, p value 0.006) were the factors associated with mortality. The observed mortality was 1.6%, and the expected mortality by EuroSCORE II was 2.6%. The median EuroSCORE II of expired patients was 3.03 and of entire cohort was 1.54 (p value 0.001). Stroke rate was 0.9%. Deep sternal wound infection occurred in 0.9%, and 3.8% patients were readmitted to the hospital after discharge. CONCLUSION: Early outcome of off-pump CABG was excellent in this study. Increased incidence of deep sternal wound infection remains a concern. Multicenter study with a larger sample size is required for a dependable evaluation of the efficacy of off-pump CABG in Indian population.

Mediastinitis occurs after cardiac surgery and is a major threat to patient’s life due to postoperative bleeding and deep sternal wound infection. Major challenge in treating this condition is that it demands a material that should adhere to the applied site and act as both a hemostatic and an antibacterial agent. On the basis of this we have developed an in situ forming tissue adhesive chitin–fibrin (CH-FB) gel with tigecycline loaded gelatin nanoparticles (tGNPs) for controlling bleeding and preventing bacterial infection. Spherical shaped tGNPs (231 ± 20 nm) were prepared and characterized. In situ forming tGNPsCH-FB gel was formed using a dual syringe applicator in which one syringe was loaded with a mixer of fibrinogen solution, chitin gel, and tGNPs; the other syringe was loaded with a mixture of thrombin solution, chitin gel, and tGNPs. Both these mixtures were injected together. In situ gel formed within a minute and exhibited excellent tissue adhesive property. tGNPsCH-FB gel was found to be cyto...

Introduction: Bacillus cereus is a gram positive bacilli found commonly in the soil and environment. It is a bacteria rarely associated with endocarditis. Case History: Intravenous drug abuse, presence of valvular defects, pacemakers, immunodeficiency are some of the known risk factors for B.cereus endocarditis. We present here a case series of two patients with B.cereus endocarditis along with a review of the literature. Conclusion: This is the first report of B.cereus endocarditis from India to the best of our knowledge.

INTRODUCTION Sepsis caused by a dysregulated host response to infection, is a serious healthcare problem that results in very high mortality every year-round the globe. When left untreated, sepsis can potentially turn fulminant, making early diagnosis and intervention an essential component of the therapeutic strategy. Proinflammatory cytokines are necessary for initiating an effective inflammatory response against infection, whereas their excess production has been associated with tissue injury in multiple organ systems leading to increased mortality. In contrast, anti-inflammatory cytokines seem to be a prerequisite for controlling and down regulating the initial inflammatory response. But a sustained release of these biomolecules leads to a turn-down of immune activation within the host organism. In the clinical conundrums associated with sepsis, it was often observed that pathogen-responsive cells were exposed to a complex cytokine milieu. The excess production of proinflammatory cytokines is essential for the survival, replication and activation of phagocytic and cytotoxic immune cells. In conjunction with this proinflammatory activity, anti-inflammatory cytokines are also released which are involved in the occurrence of cellular anergy and impaired response to aetiologic agents, causing a compensatory anti-inflammatory response syndrome (CARS). Current practice in cardiac surgery is to review laboratory test results (CRP, PCT, blood culture) and clinical criteria (SOFA and STS) 48 h after surgery to diagnose sepsis. CRP and PCT lack sensitivity and specificity, whereas blood culture requires a long turnaround time and lacks sensitivity. Sepsis being an interplay between pro and anti-inflammatory response, the relative expression of immune biomarkers may provide a useful criterion for early diagnosis of sepsis. Thus, we aimed at investigating the variations in circulating levels of prominent cytokines and their potential use as a diagnostic marker of adult sepsis post cardiac surgery. MATERIALS AND METHODS In this double-blinded cohort study, blood samples of adult patients undergoing cardiac surgery were collected before surgery (D -1), and on the post-operative day 1 (D +1) after the approval from the appropriate Institutional Ethics Committee. Patients who were deemed risky by EuroSCORE II risk stratification were included and immuno-compromised as well as patients with active infection before surgery were excluded. Plasma levels of IL-1β, IL-5, IL-6, IL-10, IL-17A and TNFα were determined using cytometric bead assay by flow cytometry and the results were analyzed using FCAP Array™ software. The data sets were analyzed (GraphPad Prism 5.02) and a p value of < 0.05 was considered statistically significant. RESULTS The study was conducted with 34 patients (n=34) and un-blinded after retrieval of data. The cohort has 8 patients diagnosed with sepsis and 26 without sepsis based on STS criteria. Demographic details for both groups are summarized in Table 1. Cytokine and other biomarker expression levels before (D-1) and after (D+1) Surgery is summarized in Table 2. At D +1, IL-1β, TNF-α, IL-17A and IL-10 showed significantly higher concentration in sepsis group compared to non-sepsis group (Fig 1B). CRP, PCT, WBC and differential blood count were not showing any discriminatory potential between sepsis and non-sepsis patients at D +1. The ROC curves of the above four cytokine expression levels at D+1 was analyzed between sepsis and non-sepsis groups. A plasma IL-1β level of 0.25 pg/ml had a sensitivity of 87.5 % and a specificity of 53.8 % and a plasma IL-17A level of 1.78 pg/ml had a sensitivity of 75 % and specificity of 46.2 %. In addition, IL-10 level of 8.99 pg/ml in plasma showed a diagnostic sensitivity of 87.5 % and a specificity of 53.8% (Fig 1C). Based on the current observation we proposed a model of inflammatory cytokine dynamics involving IL-1β, IL-17A and IL-10 suggesting their role, which may lead to the development of sepsis (Fig 1D). CONCLUSION We identified a significant up regulation of circulating inflammatory cytokines at 24 h in patients who developed sepsis after cardiac surgery, earlier than any noticeable changes in conventional sepsis biomarkers. These results suggest the possibility of inflammatory cytokines as a diagnostic marker and may be a potential therapeutic target as well. The study needs to be validated further on a larger cohort of patients. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. Aims and Objectives: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. Methods: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. Results: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. Conclusions: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.

Background: The female gender is considered as a risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Aim: In this analysis, we assessed the impact of female gender on early outcome after CABG. Study Design: This is a retrospective analysis of data from our center situated in South India. Statistical Analysis: Patients were categorized according to gender and potential differences in pre-operative and post-operative factors were explored. Significant risk factors were then built in a multivariate model to account for differences in predicting gender influence on surgical outcome. Methods: 773 consecutive patients underwent first time CABG between January 2015 and December 2016. 96.77% of cases were performed using off-pump technique. 132 (17.07%) patients were females. These patients formed the study group. Results: The in-house/ 30-day mortality in females was similar to that of males (3.03% vs. 3.12%, p value 0.957). Mediastinitis developed more commonly in females (5.35% vs. 1.30%; p value 0.004) compared to males. There were more re-admissions to hospital for female patients (21.37% in females vs. 10.14% in males, p value

Objective Post-operative atrial fibrillation (POAF) increases hospital stay, resource utilization, morbidity, and mortality. However, there is paucity of data about its effect in Indian patients undergoing off-pump coronary artery bypass grafting (CABG). Methods Seven hundred forty-eight patients underwent off-pump CABG from January 2015 to December 2016 (24 months). One hundred twenty-seven patients (16.7%) developed POAF. In an effort to mitigate the effects of wider risk factors on perioperative outcomes, a separate sub-analysis of patients based on risks quantified by EuroSCORE II (<> 3) was also performed. Results Age > 60 years and development of sepsis were the independent predictors for the development of POAF. Thirty-day/mortality rate was higher in the POAF group (7.1% vs. 1.4%; p value

Ischemic mitral regurgitation (IMR) is a frequent complication of left ventricular (LV) global or regional pathological remodeling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces and reduced closing forces. IMR is defined as mitral regurgitation caused by chronic changes of LV structure and function due to ischemic heart disease and it worsens the prognosis. In this review, we discuss on etiology, pathophysiology, and mechanisms of IMR, its classification, evaluation, and therapeutic corrective methods of IMR.

Anomalies of the mitral valve apparatus in hypertrophic cardiomyopathy are an important cause of systolic anterior motion. Patients with significant residual obstruction due to systolic anterior motion after myectomy and anterior mitral leaflet plication may end up having mitral valve replacement. We describe the case of a 52-year-old man who underwent posterior mitral leaflet plication to correct residual systolic anterior motion after anterior mitral leaflet plication.

Preoperative risk scores are essential tools for risk assessment, cost–benefit analysis, and the study of therapy trends. Various scoring systems have been developed to predict mortality and morbidity after cardiac surgery. Risk stratification will inform patients and clinicians of the likely risk of death for a group of patients with a similar risk profile undergoing the proposed operation. This information is useful and should form part of the basis on which the patient and surgeon decide whether to proceed or not. Risk models were also applied for quality improvement programs comparing year-to-year outcomes, as well as allocation of healthcare resources through the prediction of length of stay and postoperative complication rates. In this review, we focus on the various risk score models used in adult and pediatric cardiac surgery.

Background: In orthodontic diagnosis assessment of sagittal skeletal discrepancy has greater importance and it aids in treatment planning. Aim: To establish cephalometric norms for sagittal dysplasia using four parameters WITS, ANB, Beta and YEN in Andhra population. Materials and Methods: Sample consisted of 90 pretreatment conventional lateral cephalograms and WITS, ANB, Beta, YEN were measured. Statistical analysis included mean, standard deviation, reciever operative characteristic (ROC) analysis. Results: ROC analysis shows range for WITS: −3 mm to +2.5 mm; ANB: 0° to 4.5°; Beta: 27° to 37° and YEN: 120° to 127°. Conclusion: Subjects with straight profile and class I occlusion showed higher range of values for all the four parameters. These values can be considered while assessing sagittal skeletal discrepancies which help in better orthodontic diagnosis and treatment plan of subjects residing in Andhra.

Large databases give an insight into patient characteristics and outcomes of patients undergoing coronary artery bypass grafting (CABG) in western populations. However, there is paucity of data in Indian population. This study was designed to understand the clinical characteristics and short-term outcomes of patients undergoing CABG at our institute. All the patients who underwent isolated CABG from January of 2001 to December of 2011 were included in the study. Those who underwent re-operative CABG and concomitant valve surgery were excluded. A total of 4,024 patients underwent CABG during the 11-year period. Mean age of patient population was 57 ± 9.6 years. The incidence of female patients undergoing surgery was 12.6 %. Diabetes mellitus was present in 58.4 % of patients. A total of 1,972 (49 %) patients had prior myocardial infarction. Thirty percent of patients had anterior and anterolateral wall infarction. Nineteen percent of patients had inferior wall infarction; 10.6 % had ischemic cardiomyopathy. Incidence of significant left main disease was 10.9 %. Majority of patients (66.4 %) presented with triple vessel disease. Ninety patients (2. 23 %) died in the early post-operative period. Post-operative stroke rate was 0.15 %. Acute renal failure requiring dialysis and mediastinitis occurred in 0.5 and 0.75 % of patients, respectively. Compared to Western population, this cohort of patients who underwent coronary artery bypass grafting had higher incidence of diabetes mellitus and ischemic cardiomyopathy and low incidence of significant left main disease. Post-operative stroke rate was significantly lower compared to 1–2 % stroke rate reported in western population.

INTRODUCTION Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection. Early detection of sepsis is very crucial in its management, as there is an increase of 8% mortality for every hour delay in commencing therapy (Kumar et al., 2006). A wide variety of diagnostic techniques proposed, could not be clinically translated due to poor sensitivity & specificity, high levels of heterogeneity and complexity of assay preparation. Currently most clinical settings depend on Procalcitonin (PCT) and C-reactive protein (CRP) for diagnosis, which also lack sensitivity and specificity. The objective of our study was early detection of sepsis in patients undergoing cardiac surgery. Blood stream infection, confirmed by blood culture (the gold standard), requires large turnaround time and is less sensitive here due to prophylactic antibiotics. SOFA score overestimate the probability of sepsis due to the impaired cardiovascular parameters and inotrope support (Howitt et al., 2018). The Society of Thoracic Surgeons (STS) criteria to detect sepsis need positive blood culture to identify sepsis within the first 48 hours post-surgery. Since none of the above can cater early diagnosis, the most appropriate way is to target dysregulated host response. It has been reported that increased expression of CD64, on neutrophil surface (nCD64) is associated with proinflammatory response and down-regulation of HLA-DR expression on circulating monocytes (mHLA-DR) is associated with anti-inflammatory response in humans. Citing this interplay between pro and anti-inflammatory response in sepsis, we hypothesized that the relative expression of these antigens may detect dysregulated host immune response and thereby may provide a criterion for early diagnosis of sepsis MATERIALS AND METHODS A flowchart of the experimental steps is shown in Fig1. Adult patients, who underwent cardiac surgery, were selected for this double-blinded study after the approval from the appropriate Institutional Ethics Committee. The study was un-blinded after the initial set of experiments, with biochemical and clinical outcome of the patients. The data sets were analyzed (GraphPad Prism v8.1.1) and a p value of < 0.05 was considered statistically significant RESULTS Out of the total patients (n=33), 7 patients were diagnosed with suspected sepsis and 1 with proven sepsis as per STS criteria, substantiated by longer ICU and hospital stay (Table1). The optimized Flowcytometry panel and gating strategies is shown in Fig.2 The expression of nCD64, mHLA-DR and SI (Sepsis Index) in all patients before surgery did not show any statistically significant difference with that of healthy controls [Figure-3A]. At 24 hours post-surgery, all patients had significant up-regulation of nCD64 and down-regulation of mHLA-DR. A similar significant elevation was observed in CRP and PCT [Figure-3 B-D], but insignificant difference exists between sepsis and non-sepsis patients (p values in Table1). Therefore the diagnostic efficacy of all this measurements and scoring scheme, in identifying sepsis at 24 hours was poor (Table2) A useful diagnostic criterion is obtained by calculating the fold increase in nCD64 (I64) & SI (ISI) and fold decrease in mHLA-DR (DHLA) at 24 hour. It was observed that many patients had ISI≥10, due to I64 approximately 2 and DHLA 5. Based on this observation, a diagnostic criterion able to detect 'dysregulated host immune response' at 24 hour post-surgery is identified. The criterion is: 10 fold or more increase in SI combined with either ≤1.8 fold increase in nCD64 or ≤5.2 fold decrease in mHLA-DR. CONCLUSION The data obtained from this pilot study was analysed based on different criteria to identify the best possible way to detect the onset of sepsis post-cardiac surgery. The discriminative power of many tests to differentiate sepsis and SIRS is inadequate. We propose a combination of fold changes in antigen expression, which could so far, identify all sepsis patients, since the measurements detect the underlying biological mechanism, picking up both exacerbated proinflammatory response and immunoparalysis. The significance of the result is that the proposed diagnostic criteria could potentially pre-empt diagnosis of sepsis at 24 hours post-surgery, before the onset of any clinically identifiable symptoms of the disease. This needs to be substantiated by extending the study on a larger patient cohort. Disclosures Mony: BD Biosciences: Research Funding. Jain:BD Biosciences: Employment.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease with many genotype and phenotype variations. Earlier terminologies, hypertrophic obstructive cardiomyopathy and idiopathic hypertrophic sub-aortic stenosis are no longer used to describe this entity. Patients present with or without left ventricular outflow tract (LVOT) obstruction. Resting or provocative LVOT obstruction occurs in 70% of patients and is the most common cause of heart failure. The pathology and pathophysiology of HCM includes hypertrophy of the left ventricle with or without right ventricular hypertrophy, systolic anterior motion of mitral valve, dynamic and mechanical LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia, and fibrosis. Thorough understanding of pathology and pathophysiology is important for anesthetic and surgical management.

Rheumatic mitral stenosis (MS) is common in India. Ventricular septal defect (VSD) is the commonest congenital heart disease seen clinically. The incidence of right coronary artery (RCA) arising from the left aortic sinus is 0.17 %. The presence of all the three lesions in a patient is likely to be extremely rare. We present a patient who had all the three lesions, and to the best of our knowledge, this is the first such case to be reported.

Modified Bentall's procedure done as part of the primary repair in Laubry-Pezzi syndrome is very rarely described in the literature. We present a case of a 33-year-old man with a subpulmonic venticular septal defect, aneurysmal dilatation of the aortic root and ascending aorta, with an associated patent ductus arteriosus, corrected by the incorporation of Yacoub's techique for ventricular septal defect closure with a modified Bentall's procedure and transpulmonary patent ductus arteriosus ligation. The postoperative course was unremarkable. Early follow-up reports show good biventricular function without residual ventricular septal defect or iatrogenic ventricular outflow tract obstructions.

Superior vena cava syndrome is one of the rare adverse events associated with pacemaker leads. We describe a 47-year-old woman with a pacemaker implanted 10 years earlier who presented to us with superior vena cava syndrome managed surgically. We report the presentation, diagnosis, and treatment of this patient and the causes and management options of superior vena cava obstruction associated with pacemaker leads.