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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

Chitosan (Cs) as a hemostatic agent has been in use to control hemorrage. Composite hydrogel formed by entrapment of vasoconstrictor-potassium aluminium sulfate (0.25 %PA) and coagulation activator-calcium chloride (0.25 %Ca) into Cs (2 %) hydrogel would enhance the hemostatic property of Cs. In this work, the prepared composite hydrogel was injectable, shear thinning, cyto and hemocompatible. The 2 %Cs-0.25 %PA-0.25 %Ca composite hydrogel caused rapid blood clotting by accelerating RBC/platelet aggregation and activation of the coagulation cascade. Further, in vivo studies on rat liver and femoral artery hemorrage model showed the efficiency of 2 %Cs-0.25 %PA-0.25 %Ca composite hydrogel to achieve hemostasis in a shorter time (20 ± 10 s, 105 ± 31 s) than commercial hemostatic agents-Fibrin sealant (77 ± 26 s, 204 ± 58 s) and Floseal (76 ± 15 s, 218 ± 46 s). In in vivo toxicological study, composite hydrogel showed material retention even after 8 weeks post-surgery, therefore excess hydrogel should be irrigated from site of application. This prepared composite hydrogel based hemostatic agent has potential application in low pressure bleeding sites.

Effective bleeding control is a major concern in trauma and major surgeries. Chitosan (Ch) as hemostatic agent has been widely used and when applied at the site of injury it acts by aggregating blood cells and forming a plug. Our prime interest is to improve the blood clotting property of Ch hydrogel. Incorporation of nanobioglass (nBG) with silica (activate coagulation factor XII), calcium (activate intrinsic pathway) and phosphate (initiates extrinsic pathway) ions into Ch hydrogel (protonated NH2 group) would act at the same time and bring about rapid blood clot formation. Sol-gel method was followed to synthesize nBG particles and its particle size was found to be 14 ± 3 nm. 2%Ch-5%nBG hydrogel was then prepared and studied using SEM and FTIR. The prepared hydrogel was injecable and was also cytocompatible with HUVEC. In in vitro blood clotting study and in vivo major organ injury model, 2%Ch-5%nBG hydrogel formed rapid blood clot than 2%Ch hydrogel. Hence, 2%Ch-5%nBG hydrogel might have great potential to achieve effective bleeding control during critical situations.

This study investigates the unique properties, fabrication technique, and vascular applications of woven nanotextiles made from low-strength nanoyarns, which are bundles of thousands of nanofibers. An innovative robotic system was developed to meticulously interweave nanoyarns in longitudinal and transverse directions, resulting in a flexible, but strong woven product. This is the only technique for producing seamless nanotextiles in tubular form from nanofibers. The porosity and the mechanical properties of nanotextiles could be substantially tuned by altering the number of nanoyarns per unit area. Investigations of the physical and biological properties of the woven nanotextile revealed remarkable and fundamental differences from its nonwoven nanofibrous form and conventional textiles. This enhancement in the material property was attributed to the multitude of hierarchically arranged nanofibers in the woven nanotextiles. This patterned woven nanotextile architecture leads to a superhydrophilic behavior in an otherwise hydrophobic material, which in turn contributed to enhanced protein adsorption and consequent cell attachment and spreading. Short-term in vivo testing was performed, which proved that the nanotextile conduit was robust, suturable, kink proof, and nonthrombogenic and could act as an efficient embolizer when deployed into an artery.

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.

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.

Background This retrospective study was designed to study the clinical profile, indications, postoperative complications and long-term outcome of pulmonary aspergilloma operated in our institute. Methods From 1985 to 2003, 60 patients underwent surgery for pulmonary aspergilloma at Sree Chitra Tirunal Institute for Medical Sciences and Technology. Results The group consisted of 36 male patients and 24 female patients with a mean age of 42.7 ± 11.8 years. The most common indication for surgery was hemoptysis (93.3%). The common underlying lung diseases were tuberculosis (45%), bronchiectasis (28.3%), and lung abscess (11.6%). Fourteen patients (23%) had simple aspergilloma (SA) and 46 (77%) had complex aspergilloma (CA). The procedures performed were lobectomy (n = 55), pneumonectomy (n = 2), segmental resection (n = 2), and cavernoplasty (n = 2). One patient underwent bilateral lobectomy at 14 months interval. The operative mortality was 4.3% and 0% in CA and SA, respectively ( p = 1.0). Major complications occurred in 26.1% patients of CA, whereas none occurred in SA ( p = 0.052). The complications included bleeding (n = 2), prolonged air leak (n = 4), empyema (n = 4), repeated pneumothorax (n = 1), and wound dehiscence (n = 1). Three patients needed thoracoplasty. The mean follow-up period was 40 ± 24 months. The actuarial survival at 10 years was 78% and 92% for CA and SA, respectively. There was no recurrence of disease or hemoptysis. Conclusions Surgical resection of pulmonary aspergilloma prevents recurrence of hemoptysis. Complex aspergilloma resection was associated with low mortality but significant morbidity, whereas SA had no associated early mortality and morbidity. Long-term outcome is good for SA and satisfactory for CA.

Objective This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. Methods A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. Results In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2 %), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. Conclusion Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

Objective: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches. Methods: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7G8.2 years; mean time interval for development of aneurysm was 3.6G4.2 years; mean age at aneurysm surgery was 16.9G8.8 years. Residual left to right shunt was detected in 6 (46%) patients. Results: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6G5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up. Conclusion: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-rightlateral positioning of the patient. q 2004 Elsevier B.V. All rights reserved.

A 32-year-old female underwent mitral valve replacement with total chordal preservation (Miki's technique) using 26mm (1M) Starr-Edward prosthesis (SEP) in 1988. The patient was in NYHA class-I until 2001. She progressed to NYHA class-III with paroxysmal nocturnal dyspnoea. Transthoracic echocardiogram showed increased prosthetic valve gradient, and cardiac catheterization confirmed the findings. Intraoperatively, the poppet movement in the cage was found to be restricted due to the preserved subvalvular apparatus entrapping the poppet inside the prosthetic valve cage.

Adults with congenital cardiac abnormalities surpass the number of children because of better assessment of cardiac anatomy and function, monitoring, operative options, patient outcomes, and increased survival into adulthood.1 Partial anomalous pulmonary venous return may present in adulthood, particularly if asymptomatic with small shunt fraction. One or more pulmonary veins, most commonly an anomalous right upper pulmonary vein, connect to a systemic vein or the right atrium; this accounts for 0.5% of congenital cardiac defects. Cardiovascular imaging continues to evolve rapidly for accurate preoperative evaluation and operative planning. Although transthoracic echocardiography is the first-line tool for diagnosis, suboptimal acoustic windows may preclude adequate inspection of pulmonary veins or atrial septal defect to assess for appropriate baffling. Disadvantages of computed tomography include an inability to calculate shunt fraction, ionizing radiation, and a greater risk of nephrotoxicity than with gadolinium with cardiac magnetic resonance imaging (MRI).2 Anatomically, MRI provides noninvasive volumetric anatomic data and enables evaluation of systemic veins, as well as the number, origin, course, and drainage of all pulmonary veins, including anomalous connections or obstruction. Detection rate for each pulmonary vein is 57% for the right superior pulmonary vein, 62% in the left superior pulmonary vein, 76% in the right inferior pulmonary vein, and 86% in the left inferior pulmonary vein. MRI …

Primary percutaneous transluminal coronary angioplasty (PTCA) with the insertion of a stent is a well-established procedure for management of coronary artery disease. Infected pseudoaneurysms following PTCA and stenting are very rare and have poor outcomes if not managed properly. We are presenting a case of a man aged 50 years with infected pseudoaneurysm of the left anterior descending artery following multiple percutaneous interventions for coronary artery disease. In this paper, we have described the presentation, diagnosis and management of this patient and have discussed the aetiology and management options of infected pseudoaneurysm affecting coronary arteries.

Venous aneurysms arising from the mediastinal systemic veins are rare. There are only 27 reported cases of such aneurysms. Majority arise from the superior vena cava. We are reporting a saccular aneurysm of superior vena cava in a 58-year-old male. The chest radiogram suggested superior mediastinal mass and the computed tomogram was suggestive of aortic arch aneurysm. Aortography and venography confirmed the diagnosis as saccular aneurysm arising from the superior vena cava. A 7 cm saccular aneurysm arising from the distal half of superior vena cava was resected through median sternotomy. The surgery was done to prevent pulmonary thrombo-embolism.

Gastrointestinal bleeding due to angiodysplasia of the large intestine associated with calcific aortic stenosis is a well-known entity. Angiodysplasias are artero-venous malformations and they form one of the common causes of occult gastro-intestinal bleeding in the elderly. A 59-year-old man underwent aortic valve replacement for severe aortic regurgitation, developed severe gastro intestinal bleeding. Selective angiography was inconclusive. Exploratory laparotomy revealed angiodysplasia of the terminal ileum, which was resected. We report this case to draw attention to this rare cause of gastro intestinal bleeding and the difficulty in arriving at a diagnosis by the usual investigations. q 2003 Elsevier B.V. All rights reserved.

A rare and previously unreported combination of Holt-Oram syndrome, atrial septal defect, patent ductus arteriosus, isolated left atrial isomerism and inferior vena caval interruption with hemiazygous continuation to the left superior vena cava is described.

Objective: This study was designed to assess the use of 100% oxygen or 50% oxygen in air or nitrous oxide after cardiopulmonary bypass (CPB) on atelectasis, as evidenced by the oxygenation index (PaO 2 /F I O 2 ), after coronary artery bypass graft (CABG) surgery. Design: Prospective, randomized clinical study. Setting: University teaching hospital. Participant: Thirty-six adult patients undergoing CABG surgery. Interventions: Patients either received 50% O 2 in air (50% O 2 group), 50% O 2 in N 2 O (50% N 2 O group), or 100% O 2 (100% O 2 group) after CPB. Measurements and Main Results: Apart from demographic and perioperative clinical data, extubation time, mediastinal drainage, and pulmonary complications were also recorded. After CPB, arterial blood gases done at various time points until 3 hours postextubation and oxygenation index were calculated. No significant differences were noted in demographic and perioperative data except preoperative hemoglobin and fluid use. Significant deterioration in arterial oxygenation was noted in the 100% O 2 group from the baseline value, whereas significant improvement was seen in the 50% O 2 group at 4 time points from baseline value and at all time points from the 100% O 2 group. After initial deterioration in oxygenation, no further change was evident in the 50% N 2 O group. Furthermore, there was a greater increase in the oxygenation index as compared with the 100% O 2 group. Time to extubation was also longer in the 100% O 2 group than the 50% O 2 group. Conclusion: Significant deterioration in arterial oxygenation and an increase in the extubation time occurred with the use of 100% O 2 after CPB, whereas better oxygenation was evident with the use of 50% O 2 in air.

m s t p a i i v t a t t m i t g a t 1 c o t 1 N ATRIAL SEPTAL DEFECT (ASD) is usually repaired through a midline sternotomy under general anesthesia nd cardiopulmonary bypass (CPB). Device closure of ASDs in he catheterization laboratory is another alternative; however, here are limitations.1 Presence of bilateral multiple emphyseatous bullae and chronic obstructive pulmonary disease COPD) in a patient with an ASD can pose various problems in he perioperative period including perioperative hypoxemia; ypercarbia; bronchospasm2; spontaneous rupture of bulla; neumothorax3; difficulties in separation from CPB because of ulmonary vascular disease; cor pulmonale; unfavorable pulonary mechanics; and the likelihood of postoperative respiatory failure and prolonged mechanical ventilation.2 The isues of concern to the anesthesiologist are secondary to the ecision whether to operate on the emphysematous bullae, the SD, or both lesions and whether to operate on them simultaeously or separately and in what order. A search in the iterature did not reveal any report that addresses these issues. n this report, the anesthetic management of a patient who resented for simultaneous surgical treatment of multiple emhysematous bullae and an ASD is discussed.

D S s HE OCCURRENCE OF malignant ventricular arrhythmias after aortic valve surgery may be a cause of failure to ean patients from cardiopulmonary bypass (CPB). Electrical ardioversion or defibrillation and antiarrhythmic drugs may ail to treat arrhythmias and establish sinus rhythm. Controlled aortic root perfusion with infusion of warm carioplegia has been used as a strategy for intraoperative myoardial management during cardiac surgery. In 3 patients oprated on in 2001 and 2002, aortic root perfusion was useful hen refractory ventricular arrhythmias developed after reoval of the aortic cross-clamp. All of them failed to respond o conventional treatment, but controlled aortic root perfusion ed to establishment of sinus rhythm and successful weaning ff CPB.

Left ventricular pseudoaneurysms (LVPAs) arise from contained myocardial rupture after acute myocardial infarction. Their propensity to rapid enlargement and rupture mandates expeditious surgical management.' We report a case of LVPA repair through an endocavitary transmitral approach in a patient undergoing concomitant mitral valve surgery.

Since the initial report in 1991, the maze procedure performed surgically (cut and sew) has been widely accepted worldwide as a treatment for atrial fibrillation (AF) with or without associated structural heart disease. In an effort to reduce the number of incisions, an irrigated radiofrequency (RF) device has been used to create the majority of the required lesions. We report postoperative sinus node dysfunction complicating polymorphic ventricular tachycardia (VT) in 2 patients who underwent the maze procedure by means of RF ablation along with valve replacements.

Cor triatriatum is an uncommon but surgically correctable cause of pulmonary venous hypertension and congestive cardiac failure, with a reported incidence of 0.1% among children with congenital heart diseases. Association with partial atrioventricular canal defect (PAVCD) is even rarer, with only anecdotal reports appearing in the literature. In the classic form, cor triatriatum is characterized by the presence of a fibromuscular diaphragm that subdivides the left atrium into a proximal accessory chamber and a distal true chamber.