IJTCVS 2003; 19: 2 IJTCVS, Jan–Mar, 2003 IJTCVS 2003; 19: 2 Abstracts

Results of 'Off-pump' bypass surgery in 175 Methods: Data were collected from 100 consecutive patients. consecutive unselected patients-including 1 Patients were randomised into two groups. Group A in which LIMA a high risk subset-A prospective study in to LAD anastomosis was done first followed by obtuse marginals a new cardiac centre anastomosis, Group B in which obtuse marginals were done first S Roy Chaudhuri, MB Das, B Roy, P Mukherjee, followed by LIMA to LAD. There were 50 ptients in each group. P Roy, T Bag, S Bagchi, Tapas Raychaudhuri Patients were evaluated for perioperative hemodynamic parameters, Anandalok Hospital, Salt Lake, Kolkata ECG changes, regional wall motion changes on transesophagial Introduction: After a reasonable experience in Off-pump coronary echocardiography (TEE), cardiac enzymes and clinical outcome. artery bypass grafting (OPCAB) since February, 1996, we decided to Results: There was no difference in hemodynamic parameters study prospectively all consecutive isolated CABG patients over a in both the groups statistically. Perioperatively there were statistically period of 6 months in a new cardiac centre, where all patients were significant ECG changes in anterior leads and regional wall motion offered OPCAB regardless of their pre-operative clinical or abnormalities on TEE in terms of hypokinesia of left ventricular haemodynamic status, LV function, coronary anatomy or intra- anterior wall and interventricular septum in patients in whom the operative findings, including intra-myocardial or diffusely diseased LAD anastomosis was done first (Group A) as compared with the native vessels. Our objectives were to determine a) the proportion of patients in whom the obtuse marginal were anastomosed first patients who would require CPB support, b) completeness of (Group B) especially in patients in whom LIMA length was short or revascularisation and c) general outcome. the site of anastomosis of LAD was quite distal. Cardiac enzymes Patients and Method: Out of 175 consecutive patients 15 were and clinical outcome were comparable in both the groups. following acute myocardial infarction (8.5%) of which 9(5%) were in Conclusion: Significant perioperative myocardial ischemia cardiogenic shock. Thirty (17%) had LVEF less than 25% with grade 1 occurs in patients in whom LIMA to LAD anstomosis is done first to 2 mitral regurgitation. Intraoperatively seven LAD arteries were especially when length of LIMA is short or site of anastomosis of deep intra-myocardial, 45 recipient vessels were diffusely diseased LAD is distal. and 11 had critical left main lesion. Protocol for starting CPB were a) persistent mean BP less than 60 mm. Of Hg. b) failure to dissect important intra-myocardial target vessel and c) refractory arrhythmia. Right pleura was opened during all posterior grafting and in case of large hearts with or without application of Star-fish (Medtronic) device. Median stemotomy was used in all patients. All data were processed in a CABG software and were analyzed by an independent statistician. Results: Only two patients (1.1%) needed CPB support due to Evaluation of hemodynamic parameters with or refractory arrhythmia. There were 3 thirty days mortality (1.7%), one without "starfish" in off pump coronary artery 3 cardiac (due to early graft failure), another following acute on chronic bypass (OPCAB) surgery during laterial renal failure and the third from intra-cerebral hemorrhage. All 7 intra- displacement of the heart myocardial LAD arteries could be safely dissected on beating heart Vijay Kohli, Rajesh Malhotra, Yugal Mishra, ZS Meharwarl, and received IMA grafts. Average graft per patient was 3.6 (one to Ramesh Bapna, Rajesh Chouhan, Yatin Mehta, Naresh Trehan eight) and only 17 of 647 target vessels (2.6%) could not be grafted for Escorts Heart Institute and Research Centre, New Delhi various reasons. Average stay was 7.5 days and average blood Introduction: During cardiac displacement for OPCAB surgery consumption was 3.5 units per patient. One hundred and sixty of 172 maintenance of stable hemodynamic remains a challenge. The current survivors (90%) are in NYHA class I. study investigated the effects of cardiac displacement on left Conclusion: Nearly 99% of all surgical revascularisations, ventricular (LV) hemodynamics during surgical exposition of obtuse including patients with poor LV, cardiogenic shock and intra- marginal artery during OPCAB surgery with or without 'starfish"TM myocardial target vessels, can be performed on a beating heart with device. good result. However, in our result, there was no improvement in the Methods: One hundred patients were randomly divided into 2 average blood comsumption per patient or in the duration of hospital groups called "starfish" (using both starfish and octopus, n=50) and stay. control (using only octopusTM, n=50). Heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), pulmonary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance Which graft to do girst: Obtuse marginals or left (SVR) were evaluated in both the groups during obtuse marginal anterior descending artery: Sequence of distal 2 awastomosis (lateral displacement). anastomoses in OPCAB surgery Results: Rajneesh Malhotra, Vivek Gupta, Yugal Mishra, Vijay Kohli, Starfish Control p value ZS Meharwal, RK Bapna, Yatin Mehta, Naresh Trehan Both starfish (Only octopusTM Escorts Heart Institute and Research Centre, New Delhi & octopus n=50) n=50) Introduction: More and more cardiac surgeons are converting to Heart Rate (HR) 82±10 88±13 <0.05 MAP 104±22 86±20 <0.05 OPCAB surgeons from conventional onpump surgeons and the CVP 8±2 6.2±1.4 NS percentage of OPCAB surgeries is steadily increasing. But there are Stroke volume 113±17 94±13 0.015 still few debatable questions in OPCAB surgery. The aim of this study PCWP 6.6±3.3 7.7±2.6 <0.05 was to answer one such question: which vessel to bypass first left CI 2.4±0.6 1.8±0.8 <0.05 anterior descending (LAD) artery or obtuse marginals? Left internal SVR 1428±268 1626±248 NS mammary artery (LIMA) grafted to LAD can become stretched while Conclusions: The results demonstrate that the "Starfish" allows doing distal anastomosis of obtuse marginals and can cause more hemodynamic stability in lateral positions, as compared with hemodynamic and ECG changes. patients done using only octopus stabilizing device.

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Reduced incidence of atrial fibrillation with off in New York Heart Association class I or II. Only 8 patients had residual pump coronary artery bypass surgery 4 had mitral regurgitation on late follow up. Long term survival and ZS Meharwal, R Bapna, Y Mishra, V Kohli, N Trehan, excellent functional recovery can be achieved in patients undergoing TS Kler, V Arora correction of VSD at appropriate time. Escorts Heart Institute and Research Centre, NewDelhi Introduction: Atrial fibrillation (AF) is associated with an increased incidence of stroke and a prolonged hospital stay after coronary artery bypass graft surgery (CABG). The harmful effect of cardiopulmonary bypass (CPB) is one of identified variable to predict the occurrence of atrial fibrillation during the post-operative period. The purpose of this study was to determine if the incidence of post-operative AF is reduced with off pump coronary artery bypass (OPCAB). Off pump coronary artery bypass surgery in Methods: Between January 1997 and April 2002, 4953 patients patients over 75 years-An analysis of outcome 6 underwent CABG without CPB (OPCAB group). They were compared Dinesh RS, Avery Matthew, Rao PV, Pravin Kumar, with 7133 patients who underwent conventional CABG on pump Sanjay Banakal, Devi Prasad Shetty (CCAB group) during the same period. All patients were operated Narayana Hrudayalaya Institute of Medical Sciences, Bangalore through median sternotomy. Octopus was used as the mechanical Introduction: The rapid expansion of the elderly population in stabilizer and intracoronary shunts were used in most of the patients. our country has led to a dramatic increase in the number of patients Results: Mean age of the patient was 59±9 yrs in OPCAB group as over 75 years requiring coronary artery bypass grafting (CABG) compared to 57±9 yrs in CCAB group (p<0.001). The LVEF was surgery. According to the published literature, CABG in the elderly comparable in both the groups. (over 75 years) has an increased mortality and morbidity, which may Postop AF Stroke ICU stay Hospital stay Mortality be a consequence of cardiopulmonary bypass (CPB). The aim of this OPCAB 10.9% 0.8% 23±6 5±2 0.97% study is to analyse the potential benefit of CABG without CPB for CCAB 18.9% 1.2% 34±8 8±3 1.86% patients over 75 years. P value <0.001 0.043 <0.001 <0.001 <0.001 Methods: Off pump CABG was performed in 40 patients aged 75 Conclusions: OPCAB is a safe and effective procedure which is years and above at our institution between May 2001 and September associated with reduced incidence of AF, which may contribute to 2002. 5 more patients had CABG on CPB over the same period. One reduced postoperative morbidity and decreased hospital stay. patient had left main coronary artery disease. However, large randomized studies with long term follow-up are Results: There was no death after off-pump CABG while 2 out of required to show the renal benefits of OPCAB over CABG on CPB. the 5 cases done using CPB died (mortality rate 0% versus 40%). The off-pump CABG group also had a significantly shorter post-operative length of stay in hospital and lower requirement for blood transfusions. Conclusion: Our data demonstrate off-pump CABG to be a safe and efficacious method of myocardial revascularisation in the elderly, and is superior to CABG using CPB in this group of patients. Outcome after surgical repair of post infarct ventricular septal defect 5 Vijay Kohli, Rajneesh Malhotra, OP Sharma, R Gupta, Anil Karlekar, Yatin Mehta, Naresh Trehan Escorts Heart Institute and Research Centre, New Delhi Introduction: Post infarct VSD comprises 1% of all deaths from acute myocardial infarction. Most patients experience abrupt or rapid deterioration manifesting as cardiogenic shock if appropriate surgical Management of pseudoaneurysms of the left ventricle management is not timely. 7 Ravindra Setty, Sanjay Dhaded, Rao PV, Pravin Kumar, Objective: Of the study is to identify the patients with post infarct Neeti Chandra, Devi Prasad Shetty VSD and to make an assessment of the clinical factors, the presence Narayana Hrudayalaya Institute of Medical Sciences, Bangalore or absence of cardiogenic shock and the location of VSD in fnfluencing the final outcome of the patients. Introduction: Pseudoaneurysms of the left ventricle are rare, but Material and Methods: 38 patients (mean age 57.9±9.3 years) with the introduction of aggressive thrombolysis of acute myocardial underwent surgical correction of post infarct VSD between January infarction it is being seen more often today. We present our experience 1990 to July 2002 at Escorts Heart Institute and Research Centre, New with two cases managed surgically. Delhi. 23 patients had anterior infarct and 15 patients had inferior Methods: 2 patients presented with shortness of breath and angina. infarct. Mild mitral regurgitation (Grade II/IV) was present in 10 Coronary arteriography revealed triple vessel coronary artery disease. patients while 8 patients had moderate mitral regurgitation (Grade Echocardiography revealed poor left ventricular function. On opening III/IV) at the time of admission. IABP was required in 22 patients. 26 the chest the pericardium was found to contain blood stained fluid patients had concomitent coronary artery disease. VSD repair was and a small left ventricular anterior wall pseudoaneurysm was seen. carried out on CPB through ventriculotomy. VSD correction was This was repaired and coronary artery bypass surgery was done. carried out with placement of a Dacron Patch. Observations: Both patients had uneventful post-operative Results: There were six early (hospital) deaths. Factors responsible recovery. Echocardiography revealed improvede left ventricular for early mortality were: 1. Old age (>65 years). 2. Site of infarct ejection fractions. (inferior). 3. Time interval between post infarction VSD and surgical Conclusion: For better quality of life for these patients proper pre- correction. 4. Cardiogenic shock. 5. Pre-operative renal dysfunction. operative diagnosis and aggressive repair of the left ventricle restores Conclusion: Of the 32 long term survivors 25 patients (78%) are its function to near normal.

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Modified technique of left ventricle (3.9 in starfish as compared to 3.2 in the control group. P=<.05) is restoration 8 increased. Ravindra Setty, Vivek Dharwad, Sanjay Dhaded, Rao PV, Conclusions: These results demonstrate that starfish allows better Pravin Kumar, Muralidhar K, Devi Prasad Shetty visibility, provides the operating comfort, more grafts in less time per Narayana Hrudayalaya Institute of Medical Sciences, Bangalore patient. "Starfish" allows haemodynamic stability especially in the Introduction: Left ventricular aneurysms are seen in 10 to 25% of lateral positions. patients with trans-mural myocardial infarctions mainly in the Left Anterior Descending (LAD) coronary artery territory. Early surgical management of this condition enables the ventricle and the patient to regain near normal function. We present our modified technique that Coronary artery bypass grafting in female is employed in our center with excellent results. patients-Risk factors and outcome 10 Patients and Methods: Between May 2001 and October 2002, 14 NR Ravishankar, AK Sibal, R Jaganathan, P Srinivasa Reddy, patients undergoing coronary artery bypass grafting (CABG) at our BR Jagannath center had left ventricular aneurysms. 12 had anterior aneurysms and Chennai 2 had inferior wall aneurysms. Mean age was 58 years (range 48-72 Background: A study was conducted to know the results of CABG years). There were 12 males and 2 females. in female patients compared with male patients. It is a retrospective Operative technique employed was an internal Aneurysmorraphy analsysis. with Dacron patch at the junction between infarcted and viable Methods: 240 female patients underwent CABG from January 1997 myocardium to maintain geometry. Linear suturing outside the to December 2001. A total of 2022 male patients had CABG in the ventriculotomy using Teflon strips in two layers was used to complete same period. For analysis only 240 male patients are randomly taken. the repair. This provides additional security to the geometric repair Associated comorbid medical conditions were identical in both the and is haemostatic. groups, except that none of the women smoked. Results: There was no mortality. Two patients required intra-aortic Mean age was 55.5 vs 50.5 years, average NYHA class 2.87 vs 3, balloon pump (IABP) support post-operatively for 48 hours and diabetes 140 vs 63, previous myocardial infarction 72 vs 146, eventually recovered. Respiratory and renal failure occurred in one hypertension 74 vs 110, hyperlidemia 168 vs 55. There were 47 peri patient each. Both did well after treatment. Two patients had post- menopausal and 193 post menopausal patients. Average ejection operative ventricular arrhythmias requiring short-term ejection fraction was 58.6 vs 56, mean number of grafts 3.19 vs 2.72, pharmacological management. All patients had post-operative use of lima 168 vs 189 pts, mean aortic cross clamp time 54.2 vs 52, echocardiography showing improved left ventricular function CPB time 90 vs 88 minutes. Mean blood loss was 477 vs 660 ml, compared to preoperative status. inotrope usage 102 vs 157 pts. Conclusion: Our modified technique of left ventricle Results: Average icu stay 2.66 vs 3 days. IABP used in 3 vs 20 aneurysmorraphy is an excellent surgical option for post-infarction patients, re-exploration 2 vs 15 patients, major wound infection 3 vs aneurysms and can be done with a very low risk. Our experience 17 pts. Early mortality 8 vs 7 patients, died because of low cardiac suggests that all cases of left ventricular aneurysms should be worked output and sepsis. 90% of patients attended the first year follow up. up and offered surgical management as modality of treatment. Conclusions: This study does not support the view that women carry higher surgical risk in comparison to men.

Off pump coronary artery bypass surgery Reduction in post operative blood loss and blood with and without "star fish"– A prospective 9 transfusion requirement after multi vessel 11 analysis of haemodynamic changes OPCAB: A prospective study Vivek Jawali, Murali Chakravarthy, KN Srinivas, Murali Manohar, Lokeswara Rao Sajja, Gopichand Mannam, Sriramulu Sompalli Gilbert, Das CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Bangalore Hyderabad Objective: Off pump coronary artery bypass (OPCAB) surgery Background: Coronary artery bypass grafting (CABG) without causes significant haemodynamic changes during displacement of the using cardiopulmonary bypass (CPB through median sternotomy is heart. The purpose of this study was to define the haemodynamic increasingly accepted as an alternative for conventional coronary changes in patients undergoing OPCAB using two different techniques artery bypass grafting. A prospective study was designed to of heart stabilization. investigate the effect of coronary artery bypass grafting with or Method: 26 patients operated by a single surgeon were randomly without CPB on post operative blood loss and transfusion divided into 2 groups called, "Star Fish" (n=14) and "control" (n=12). requirement. The parameter recorded were, heart rate (HR), mean arterial pressure Methods: Six hundred and forty two patients between February (MAP), central venous pressure (CVP, pulmonary wedge pressure 2000 through October 2002 requiring multi vessel coronary artery (PCWP), cardiac index (CI) systemic vascular resistance index (SVRI) bypass were prospectively studied. They were grouped into two. were collected. The time per graft and the grafts per patients were Group A: Off-pump CABG on beating heart through median also noted. sternotomy (n-124), group B: On pump CABG with CPB and using Results: The positions were emperically classified as anterior, intermittent ischemic fibrillatory arrest technique (n=518). The post oblique, lateral and inferior depending on the location of the grafted operative blood loss as indicated by the total chest tube drainage, coronary artery. The heart rate, MAP, CI and SVRI did not change requirement for homologus blood and transfusion costs were significantly in the anterior, oblique, and inferior positions but there analysed. was a statistically significant change (p<.05) in the lateral in the Results: There was no difference between the groups with respect "control" group. The time per graft is reduced (7 min in star fist as to preoperative and intraoperative patient variables. The mean post compared to 9.5 minutes in control group. P=<.05) and graft per patient operative blood loss was 410ml (260-760 ml) and 760 ml (range 380-

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1260 ml). Post operative blood loss was 1.8 times higher in on-pump was to determine whether off-pump coronary artery bypass grafting group compared to the off-pump group. Forty two patients in group might decrease the operative mortality and morbidity in a select group A did not require a blood transfusion and 16 patients in group B of high risk patients with multi vessel coronary artery disease. required blood transfusion. (P<0.001) and seventy patients in group Methods: Utilizing Cleveland clinic foundation risk stratification A required transfusion of one unit only. Six patients in group B required score, we analysed prospectively collected data on a cohort of high fresh frozen plasma and platelet tranfusion where as none in group A risk coronary patients, who were operated on beating heart by a single required these transfusions. Transfusion costs per patient in was higher team of surgeons between 1998 through September 2002. High risk in group B compared to the patients in group A (Indian Rupees Rs. patients were defined as the patients with a score of 5 or more. 9000/- verses 3000/-). Reexploration for bleeding was done in one A total of 376 patients underwent multivessel OPCABG by our patient in group A and 5 patients in group B. team, where 145 patients had high scores (>5) underwent coronary Conclusion: Off-pump CABG is associated with a significant artery bypass grafting on a beating heart. CCF scores ranged between reduction in post operative blood loss, requirement for homologous 5-13. Twenty six patients were > 65 years of age, 70 patients were blood transfusion and transfusion related cost when compared to the diabetics needing oral hypoglycemic agents or insulin, severe LV myocardial revascularization using cardiopulmonary bypass and is dysfunction (LVEF < 35%) was seen in 42 patients, 14 patients ischemic fibrillatory arrest technique. underwent emergency/urgent revascularization, reoperation was done in 3 patients, serum creatinine was > 1.6 mg/dL in 22 patients, 12 patients had associated peripheral vascular disease, 16 patients had associated cerebro vascular disease, 36 patients had chronic obstructive pulmonary disease, weight was < 65 Kg in 14 patients, anemia (Hct < 34%) was seen in 4 patients, significant atherosclerotic changes of ascending aorta was seen in 10 patients. An average of 3.4 Left anterior descending endarterectomy, vein patch reconstruction and internal mammary artery 12 grafts were performed per patient. bypass in diffuse coronary artery disease Results: There was no incidence of peri-operative myocardial SK Nair, SR Rajagopal, AK Rafeeq, AK Baburaj, V Vaghela, SG Nair infarction based on ECG and cardiac enzyme changes. The in hospital Deptt of Cardiovascular and Thoracic Surgery, Amrita Institute of mortality was 0.3%. Two patients (0.6%) needed re-exploration for Medical Sciences and Research Center, Cochin bleeding. No patient had neurological or pulmonay problem. All these patients except one patient were discharged from the hospital between Introduction: Saphenous vein reconstruction following extensive 5 and 9 days. Left anterior descending artery (LAD) endarterectomy facilitates Conclusion: OPCAB can be performed with an acceptable internal mammary artery grafting which is a determinant for long morbidity and mortality in a select group of high risk patients with term survival. We present our experience in 39 patients using this multi vessel coronary artery disease. It is a safe and reproducible and technique. at time the preferred method of surgical strategies in the high risk Method: Between August 1999 and September 2002, 39 patients group of coronary patients. underwent extensive LAD endarterectomy with vein patch reconstruction and internal mannary bypass. 9(23.1%) of these patients also required endarterectomy of their right coronary artery and 6(15.4%) of the branches of the left circumflex system. 3(7.7%) patients required endarterectomy of both the left and right coronary arteries. There were 35 males and 4 females. Their age ranged from 37 to 73 years. 28(71.8%) patients had previous MI and 6(14%) had severe LV Myocardial revascularization in severe LV dysfunction. Risk factors included diabetes 23(59.9%), Smoking dysfunction. Does OPCAB make a difference? 14 29(74.35%) and Hyperlipidemia 21(53.8%). Follow up ranged from Harpreet Singh, Surya Mishra, Deepak, Sanjula, SK Sinha one to 36 months. Department of Cardio Thoracic & Vascular Surgery, Batra Hospital, Results: There was no hospital mortality. 2 patients required intra New Delhi aortic balloon pump support. 4 patients required Amiodarone/DC Objectives: The Present study evaluates our experience with conversion for atrial or ventricular arrhythmia. One patient had a coronary bypass grafting in patients with a left ventricular ejection reversible neurologic deficit. Follow up information is available for fraction (EF) <25%. Myocardial revascularization in this setting 34 patients. 29(85.3%) are symptom free and 5(14.7%) are in Canadian remains controversial because of concerns about operative mortality cardiovascular society class II or III. An improvement in ejection and morbidity and lack of functional and survival benefit. fraction was seen in all cases on echocardiography. Methods: 141 patients with coronary artery disease and EF <25% Conclusion: Extensive LAD endarterectomy with reconstruction underwent coronary artery bypass grafting between October 1999 and using saphenous vein patch and internal mammary artery grafting August 2002. Mean age at operation was 63.3 years and 81.4 were provides excellent early and intermediate term clinical outcome. male. The major indication for surgery was angina (114 Patients, 80.8%). Ejection fraction, left ventricular end diastolic pressure and cardiac index was used to assess left ventricular function. The number of grafts was 2.7±1.6/patient. Internal mammary artery was used in 141 patients (100%). Intra aortic balloon pump was placed The role of multi vessel Off pump coronary preoperatively in 12 patients (8.5%). Five operative risk factors were artery bypass grafting in a selected group 13 associated with a higher mortality: emergency, female sex, LVEDP, CI of high risk patients and NYHA class IV. Lokeswara Rao Sajja, Gopichand Mannam, Sriramulu Sompalli Results: Care Hosptial, The Institute of Medical Sciences, Banjara Hills, The operative mortality was 6 Another 2 died within first Hyderabad year of follow up due to CCF. Left ventricular ejection fraction (assessed postoperatively in 135 pts.) improved from 22.2% Objectives: The ideal indications for off-pump coronary bypass preoperatively to 33.5%. Postoperatively (p<0.001), mean end diastolic grafting (OPCAB) still alludes the surgeon. The objective of this study volume index fell from 98 to 83 m1/m2 following surgery. Two

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variables were associated with increased long-term survival absence Results: The quality of the harvested graft was excellent and of congestive heart failure (NYHA class lower than IV, p<0.05) and comparable to the graft harvested through open technique. No post cardiomegaly (p=0.05). operative hematoma occurred in our cases. Conclusion: In patients with left ventricular dysfunction, Conclusion: 'Watch band' incision gave good cosmetic results and myocardial revascularisation can be performed relatively safely with patient satisfaction, though the procedure is technically demanding good medium term survival and improvements in quality of life and and initially takes more time. in ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection when considering these patients for operation should assess Surgical remodelling of the left ventricle potentially reversible dysfunction. Sanjay BS, Sreedhar Reddy, Prabhakar R 17 Sagar Apollo Hospital, Bangalore Introduction: Generalized dilatation of the Left Ventricle or a Sutureless aortic connector for proximal vein localized dyskinetic segment that is a left ventricular aneurysm graft anastamosis-An initial experience 15 contribute to a poor functioning left ventricle and progress to cause Sanjay Kumar, Ganeshakrishnan Iyer, D Renuka Rao, heart failure. We have tried to remodel the left ventricle for its better Vijay Dikshit performance. Dept. of Cardio-Thoracic Surgery, Apollo Hospitals, Jubilee Hills, Methods: Between September 1999 to September 2002 we have Hyderabad had 21 cases of which one case was a dilated cardiomyopathy and the remaining 20 were left ventricular aneurysm. The case of dilated Morbidity during Coronary artery bypass surgery is known to be cardiomyopathy was a 23-year-old gentleman who was in congestive caused by Cardiopulmonary bypass, full median sternotomy and cardiac failure, in which case we performed a Batsista Operation. The manipulation of aorta. Clampless aortic anastamosis can reduce the remaining 20 cases of left ventricular aneurysm were of ischemic potential risk factors of CNS injury by avoiding the aortic etiology with ages ranging from 38 yr to 65 years to which 16 were manipulation. male and 4 were female. We have used cardiopulmonary bypass in During last 2 months period, we have used aortic connector in 4 all patients. Excision and suturing was done in 5 cases and autologous patients under going CABG. In all cases, Saphenous vein was pericardial patch and reinforcement and plication was done in 15 cases. harvested from upper thigh and loaded to connector. Thus the aortic Coronary artery bypass graft was performed in all cases. hole was made and proximal anastamosis done with connecting Results: Mean age of follow-up was 19 months (range 6-35 device. All patient underwent CABG without CPB and LIMA was months). The patient with the dilated cardiomyopathy died on the 15 used in all cases. postoperative day. All other patients are NHYA class I or II. 10 patients Complete revascularization was done in all cases and mean grafts were restudied with an informed consent, which consisted of coronary were 2.7. The mean age of patient was 56.2 years. Total of four Aortic and LV angio. MRI and echo assessment of LV wall motion showed Connector device were used in four patinets. Haemostasis was improvement of ejection fraction in all patients. instantaneous in all cases. No patient presented with neurological Conclusion: Surgical remodeling of the left ventricle is of immense complication in early experience. Early clinical experience using a benefit to the patient with localized LV distortions with improved mechanical proximal Saphenous anastamosis demonstrates safety and ejection fraction and better quality of life but of questionable value in efficacy. The reduction in manipulation of aorta promises reduction case of generalized dilatation of the left ventricle. in mortality and morbidity in a high risk population but long term patency of anastamosis is yet to be evaluated. Details of technique and result will be presented. "Early results of 45 patients using Off pump coronary artery bypass surgery technique 18 through left anterolateral thoracotomy Endoscopic radial artery harvesting – Initial (Last) procedure" experience 16 Sanjeev Kalra, Ajay Saraswat, Milind Umre, HC Sachdeva, RP Singh, D Renuka Rao, Ganeshakrishnan Iyer, Sanjay Kumar, Kishan Kumar, Jagdish Prasad Vijay Dikshit Department of Cardio Thoracic & Vascular Surgery,Vardhman Dept. of Cardio-Thoracic Surgery, Apollo Hospitals, Jubilee Hills, Mahavir Medical College & Safdarjang Hospital, New Delhi Hyderabad Objective: To study and assess the role and status of this approach Background: With the present preferred practice of Total Arterial we performed in 45 patients of coronary artery disease. Revascularisation, there is resurgence in the expanded use of Radial Method: Forty five cases were operated for coronary artery bypass Artery (RA) as a bypass conduit. An Endoscopic radial artery grafting (CABG) using left anerolateral thoractomy via fifth intercostal harvesting method was used to improve esthetics and possibly to space from December 1998 to August 2002. Twenty five patients had decrease neurological complications in the hand. single vessel disease, 18 had double vessel and 2 had triple vessel We present the initial experience with first 6 patients. disease. Methods: Radial artery exposed through a 3 cms vertical incision Results: In all patients operated at our centre LITA to LAD artery 1 cm proximal to radial styloid process. 30º 5 mm telescope, was placed. Twenty five patients had single vessel grafting. Eighteen subcutaneous ultraretractor and ultrasonic harmonic coagulating patients had double vessel grafting and out of that 16 patients had shears, endobook were used for dissection. A proximal counter incision second graft to Obtuse marginal (OM) and two had to Posterior of 2 cms was made in the cubital fossa and proximal end of radial deceding artery (ODA). To patients had triple vessel grafting a graft artery ligated under vision and transected. RA pulled through tunnel each to LAD, OM and PDA. In all patients of double vessel and triple and distal end ligated and transected. Endoscope was used to check vessel grafting cell saver was used. Average blood requirement was bleeding spots. Both incision were closed using subcuticular 3/0 1.3 units. Sixteen patients of single vessel disease did not require any monocryl. blood transfusion. There was no mortality or re-exploration.

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Conclusion: Off pump CABG techniques are used in majority of in six patients. Annuloplasty ring was used in four patients. Four the patients undergoing coronary surgery these days. Various surgical required mitral valve replacement using either prosthetic or tissue options are there in for Off pump technique like MIDCAB (Minimally valves. Age group varied from 63-76 years. invasive direct coronary artery bypassgrafting), Thoracoscopic Results: One patient with MVR died seventh post op day. LV approach and LAST procedure. LAST procedure is an easy and function improved 10-15% in others. Reduction in MR by echo reproducible procedure, how ever in our experience we found that it evaluation was seen from severe to mild in half the patients and to should be used preferably in patients with left sided lesions and with trivial in others. Recurrent admissions to CCU ceased in four of these good coronary anatomy. 12 patients remained in NYHA Class I-II. Conclusion: Mitral Valve reconstruction with posterior reduction annuloplasty in patients with ischemic MI and poor LV function is a safe procedure. Early and midterm results are satisfactory. OPCAB in patients with low EF Pawan Kumar, D Kulkarni, Pranav SK, Raghvendra C, 19 Uday Jadhav, AG Tendolkar LTMMC & LTMGH, Sion, Mumbai Modified distal carotid artery perfusion for Introduction: Low EF has been defined as an EF less than 20-30%. combined carotid endarterecromy and off pump 21 The mortality associated with CABG in this subgroup of patient's coronary artery bypass surgery demands higher requirements of ionotropes & IABC. We present our Avery Mathew, Gulam Ali, Jayashankar Marla, Rao PV, experience with patients undergoing OPCAB with an EF between 25 Pravin Kumar, Sanjay Banakal, Devi Prasad Shetty to 30% & the techniques adopted by us for the same patients. Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Material & Methods: Total patients=330, 16 patients (5% of total) Conventionally patients requiring combined coronary artery of EF less/equal too 30% where operated for CABG with a primary bypass grafting (CABG) and carotid endartrectomy (CEA) needed an intention of performing OPCAB. on-bypass procedure, with carotid endartrectomy done before Male/Female= 14/02 Age=42-70 years No. Of vessels grafted=2.5 coronary artery bypass grafting. We describe a technique using Technique: All the surgeries were performed using the Octopus modified distal carotid artery perfusion and off-pump coronary artery 2+ or 3. Anortic purse string was taken in all the patients (for the ease bypass grafting. of aortic cannulation, if required). Extensive opening of the right pleura Methods: Between May 2001 and September 2002 three patients was performed, along with vertical splitting of the pericardium, for underwent a combined CABG + CEA procedure utilizing an alternate the OM's & high diagonals. Hitching up of pericardium was as with method of cerebral perfusion. There were 2 males and 1 female, and all cases of OPCAB. Intracardiac shunts were used for all coronaries. mean age at presentation was 66.3 years. All the three patients in this Ionotropic infusion was initiated at the slightest doubt of series had symptoms of cerebral ischaemia and had carotid duplex hemodynamic compromises (this in our experience prevents sudden scanning and carotid angiography in addition to the regular cardiac collapse, more common in this subgroup of patients). If there was work-up. All 3 patients had unilateral carotid artery disease and the persistent hemodynamic compromise, the patient was put on a CPB stenosis was more than 70%. All underwent carotid endartrectomy on a semi elective basis. On CPB the surgery would be performed on and repair of the artery using Poly-tetra fluoroethylene patch (Gore- a beating heart, without cross clamp, using the octopus stabilizer & tex) with alternate cerebral protection followed by off-pump CABG. intracoronary shunts. Results: There were no early deaths or peri-operative Result: Number of grafts/patient=2.5 Intraoperative arrhythmias, complications. The average number of coronary bypass grafts was Atrial fibrillation=5 (31.3%), ventricular fibrillation=1 (6.3%): (all three. Left internal mammary artery was used in two patients. All 3 cardioverted) patients had an uneventful recovery. The average hospital stay was 8 Hypotension (<80 mm Hg) seen during positioning for any days. On follow-up these patients showed an improved quality of vessel=9 (56.3%) life and were asymptomatic. Conversion to CPB=4 (25%) ST elevation=4 (25%) Conclusion: The combined off-pump coronary artery bypass Mortality=4 (25%), 3 conversion to CPB Fresh MI=(18.8%) grafting and carotid endartrectomy using our alternate technique of Ionotropes required in post operative period=5 (31.3%) cerebral perfusion is a safe procedure which is also easily reproducible Conclusion: OPCAB in patients with a lower EF is a safe procedure and cost effective compared to expensive carotid artery shunts. if extra caution is exhibited.

Coronary bypass with mitral valve repair in OPCAB through full sternotomy in awake ischemic mitral valve disease 20 patients without general anaesthisia 22 James Thomas, Sanjiv Kalra, BK Mohanty, Amit Chandra, Vivek Jawali, Murali Chakravarthy, KN Srinivas, TA Patil, VK Sinha, S Sharma, HK Agarwal, T Roy, AP Arora, LC Gupta, Jaya Prakash, Shivanand, Murali Manohar, Gilbert, Das S Padmavati Bangalore National Heart Institute, East of Kailash, New Delhi Objectives: The feasibility of the use of high thoracic epidural Background: Optimal treatment of patients with ischemic mitral anesthesia as a sole anesthetic in patients undergoing beating heart insufficiency with reduced left ventricular function is a matter of coronary revascularization, avoiding general anesthesia was studied. debate. We have used posterior reduction annuloplasty in addition A prospective study. to CABG in these patients Early and midterm results are evaluated. Interventions: Fifteen patients underwent beating heart coronary Methods: Patients with more than moderate mitral regurgitation artery revascularization without endotracheal general anesthesia, with recurrent congestive failure and angina, underwent CABG using between October 2001 to May 2002, using high thoracic epidural arterial (LIMA, radial) and saphenous vein grafts. A posterior anesthesia and analgesia. All the patients underwent epidural reduction annuloplasty using a 4 mm flattened PTFE graft was done catheterization on the evening before the surgery.

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Measurement and Main Results: 2 patients underwent improving coronary perfusion, optimizing subsystem functions, helps anterolateral thoracotomy and underwent grafting from Left internal in safe anaesthetic induction and avoids crash bypasses, reduces rates mammary artery to left anterior descending artery. The patients in all of perioperative myocardial infarction, reduces and prevents spasm received 36 grafts (single n=5, double n=3, triple n=3, quadruple n=4). of native coronary artery and spasm of arterial conduits. There were 3 female patients and 12 male patients with mean age of Material and Methods: Retrospective analysis of a group of high- 60.6±5.9 years. There was no conversion to general anesthesia, risk patients of coronary artery disease who underwent cardiopulmonary bypass, perioperative morbidity or mortality. Mean revascularisation between January 2000-May 2002. An IABP was length of stay in the intensive care unit was 18±4.2 hours and hospital placed percutaneously before the operation under fluoroscopy. The was 3.2±1.2 days. time in hours before institution of cardiopulmonary bypass was noted. Conclusion: Our experience confirms the feasibility of performing The complications related to IABP and surgery were noted. Patients multiple coronary artery bypasses in conscious patients without underwent CABG, whether conventional or on beating heart was endotracheal general anesthesia. recorded. Doses and duration of inotropes and duration of IABP support were recorded. The events occurring postoperatively and perioperative MI, low cardiac output status and other organ dysfunction were recorded. Predictors of atrial fibrillation in post-CABG 90% of the patients were male, High-risk included in the study patients: A retrospective study 2423 LMCA stenosis >50%, diffuse coronary artery disease 85%, LV S Vengal Reddy, N Nageswara Rao, DS Bhaskar Raju, dysfunction 65%, presence of preoperative refreactory arhythmias A Dharma Rakshak 10%, and 2 or 3 above risk factors in the same patient. 55% underwent Department of Cardiothoracic Surgery, Nizam's Institute of Medical elective operation and rest urgent operation. 90% of the patients Sciences, Hyderabad underwent CABG on beating heart with CPB support. Duration of Aim: To determine incidence of postoperative atrial fibrillation, insertion of IABP prior to CPB was 9 hours. IABP removed 60 hours identify the risk factors, whether non-use of CPB with cardioplegic after the postoperative period of augmentation. arrest will decrease the incidence of postoperative atrial fibrillation Results: In-hospital mortality was 10%. Preoperative IABP is in CABG patients. modality of choice in high--risk patients without less cost and without Atrial fibrillation is a common arrhythmia seen in post CABG additional IABP related complications. patients. Classic risk factors are advanced age, male gender, hypertension, presence of LV Dysfunction and Cardioplegia. Material and Methods: Patients admitted between June 2001- March 2002 for coronary revascularisation were included in study. Thoracotomy approach for RE-DO coronary Complete history, related to coronary heart disease were noted artery bypass grafting without cardiopulmonary 25 including risk factors, CPB time and cross clamp time. Patients bypass requiring CABG and valve replacement were excluded. Patients who Dinesh RS, Kuldeep CKK, Julius Punnen, Colin John, Rajesh Sharma, were in sinus rhythm without any conduction block only were taken Muralidhar K, Devi Prasad Shetty into study. Continuous ECG monitoring as and when required till Narayana Hrudayalaya Institute of Medical Sciences, Bangalore discharge. All patients' characters and their relation to arrhythmias Introduction: Sternotomy approach for re-do CABG in the were also analyzed. presence of a patent graft to the left anterior descending (LAD) 139 males and 11 females. Male-female ratio was 12.64:1. Median coronary artery carries high risk. We present out experience with 3 age in AF group was 54 years and in non-AF group 52 years. No cases of re-do CABG which required re-grafting to the circumflex female patients had developed AF. marginal coronary artery. Results: Incidence of development of AF in this study was 10.67%. Methods: From may 2001 to September 2002, re-do CABG without In OPCAB group it was 13.64%. Age >60 years, hypertension, prior cardiopulmonary bypass (CPB) was performed on 3 patients using a β MI, -blocker usage, presence of LV dysfunction, were the significant left postero-lateral thoracotomy approach. The radial artery was the predictors for the development of AF. 13.64% of the OPCAB group bypass conduit. The proximal anastomosis was done onto the developed postoperative AF but not statistically significant for descending thoracic aorta. All patients had a patent left internal development of AF. mammary artery graft to the LAD but required grafts to the left Conclusions: Diabetes mellitus, prior angioplasty, presence of circumflex (LCX) coronary system. chronic obstructive pulmonary disease and patients on calcium Results: All patients were operated upon without CPB. A total of channel blockers and ACE inhibitors, were not predictors for the 1 graft per patient was performed. There was no peri-operative development of postoperative AF. cerebrovascular accident or myocardial ischaemia/infarction. There were no intra-operative or early deaths. Conclusion: Re-do CABG without CPB to revascularise selected coronary artery targets can be safely performed using a posterior thoracotomy approach. Evaluation of preoperative IABP support in high-risk coronary surgery patients 24 S Vengal Reddy, KV Ramana, DV Ramana, RC Mishra, RV Kumar, P Rajagopal 75 consecutive cases of Off pump coronary Department of Cardiothoracic Surgery, Nizam's Institute of Medical bypass surgery for critical left main coronary 26 Sciences, Hyderabad artery disease without mortality Binoy C, Ahmed Aziz, Sanjay Dhaded, Rao PV, Pravin Kumar, Aim: Evaluation of results and efficacy of pre-operative IABP in Rajnish Garg, Devi Prasad Shetty high risk patients who underwent coronary revascularisation. Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Introduction: Strategies for management of high-risk coronary patients include postcardiotomy IABP, centrifugal pumps, and Introduction: Left main coronary artry disease is considered to be different myocardial protection techniques. Elective IABP helps by an incremental risk factor for off pump coronary artery bypass

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(OPCAB) surgery. The purpose of this study is to assess the safety Conclusions: Severe atheromatous disease of aorta, critical carotid and efficacy of OPCAB in patients with left main coronary artery artery stenosis, history of stroke or TIA and perioperative hypotension disease. are strong risk in patients undergoing CABG. TEE and carotid Doppler Methods: Between May 2001 and August 2002, 101 patients with evaluation helps in modifying the surgical technique to reduce the critical left main coronary artery disease underwent revascularisation. risk of stroke. Of these 14 patients were operated using cardiopulmonary bypass (CPB) support electively. In 87, OPCAB revascularisation was attempted but in 12 patients (13.7%), OPCAB had to be abandoned CABG on CPB without aortic cross clamp and conversion to CPB support was necessary for a variety of reasons. Anil Kumar, P.N. Rao, Sushil Chandran, Mahmoud H, 28 Results: There were no in-hospital deaths (mortality rate = 0%). Salam Ali, AK Dhir, DK Saxena, AS Pillay, VR Pillai, The mean duration of post-operative ventilation was 13.4 hours in CG Venkitachalam, M Saeed, MA Fikree, Sultan Abdul A, YA Nazer the OPCAB group as compared to 24.8 hours in the on-bypass group. Departments of Cardiology and Cardiac Surgery, Mafraq Hospital, Blood and inotrope requirements were also significantly less in the Abu Dhabi, UAE OPCAB group. 2 out of 75 patients (2.6%) in the OPCAB group and 1 Background: In severely deprerssed ventricular function associatd out of 26 patients (3.8%) in the on-bypass group developed peri- with dilated left ventricle and haemodynamic instability, of pump operative ischaemia. The duration of ITU stay (mean 2.44 versus 3.5 CABG may be not feasible. Also, in badly diseased ascending aorta days) and hospital stay (mean 7.09 versus 9.03 days) was lesser in the with extensive calcific plaques, avoiding aortic x-clamp during OPCAB group. conventional CABG on CPB may be a useful technique. Conclusion: Off-pump coronary artery bypass surgery can be Methods: We have used this technique in 18 patients. On safely performed even in patients with critical left main coronary conventional CPB, the grafting was done on beating heart without artery disease and is significantly better than on-bypass surgery in aortic cross clamp using a stabilizer, maintaining normothermia several aspects. An open mind to conversion to CPB support, and throughout. The patient profile included 14 males and 4 females with being prepared to establish CPB if required in an emergency, will help a mean age of 60 years (range 50-72 years). Six patients had emergency optimise outcome. surgery for unstable angina, but associated with severe LV dysfunction with high LVEDP. Ten patients had recent myocardial infarction with dilated left ventricle with a mean ejection fraction of 25%. All of the above had unstable haemodynamics, two of them inspite of pre Predictors of strokerisk in patients undergoing operative IABP. In two other elderly patients the indication for the coronary artery bypass surgery-A prospective 27 technique was enormously thickened and diseased aorta with study 2001-2002 extensive plaques. The average number of grafts per patient was 3+/ Anand Agarwal, P Mruthyunjaya Kumar, Subhash Kaul, - per patient. A Dharma Rakshak Results: There was no oprative mortality. Two patients required Department of Cardiothoracic Surgery, Nizam's Institute of Medical IABP support pre operatively, and in two others IABP had to be Sciences, Hyderabad instituted post operatively due to low cardiac output. In one patient Introduction: Strokes remain a major source of morbidity who had an ejection fraction of 15%, methylene blue had to be used following Coronary Artery Bypass Graft surgery. Various risk factors post operatively for severe vasoplegia that had not responded to have been atributed for postoperative stroke, the most important being maximum inotropes. All patients showed symptomatic and advanced age, atherosclerotic disease of the ascending aorta, carotid echocardiographic evidence of improvement of venricular function occlusive disease, severe left ventricular dysfunction, long standing post operatively. diabetes mellitus, protracted cardiopulmonary bypass time, severe Conclusion: We have found this technique very useful in a subset perioperative hypotension, and history of previous stroke. This study of patients with severe LV dysfunction with unstable haemodynamics was undertaken to evaluate the predictors of stroke risk in patients associated with coronary artery disease, requiring CABG; in elderly undergoing CABG. patients, this would be more useful in the presence of a badly diseased Meterial and Methods: A prospective cohort of100 patients aorta. undergoing CABG between November 2001 to March 2002 and a retrospective group of 100 patients between July to October 2001 formed the subject material of study. All the patients in the prospective Off pump CABG in high risk patients - group had preoperative TEE and carotid Doppler evaluation to assess AIMS experience 29 the aortic atheromatous disease and carotid occlusive disease R Mahadevan, P Manoj, AP Chandrasekharan, V Satya Prasad respectively. Detailed postoperative neurological assessment was done Departments of Cardiovascular and Thoracic Surgery Amrita to identify and focal deficits and if any was confirmed by CT scan. Institute of Medical Sciences and Research Center, Cochin Statistical analysis was done using Minitab software for Windows. Off Pump CABG in high-risk patients constitutes a challenging Results: 3 of the 100 patients in each group developed stroke. There procedure in terms of technical feasibility, and high morbidity when was equitable distribution of age in both groups. Statistical analysis done by conventional techniques. in the prospective group produced an odds ratio of 48000 for critical Methods: 30 high-risk patients who underwent OPCAB from 18th carotid stenosis as revealed in Doppler study and 23.7500 for Grade July 2002 to 20th October 2002. IV atheromatous plaques on TEE, indicating that these patients were Patient selection: All patients who had an ejection fraction <30% at a higher risk of developing stroke. The corresponding p values were selected for these study. The other co-morbid factors were derived by the chi square test were p<0.00009 and p<0.002 respectively preoperative renal dysfunction (14 patients, 46.6%), bilateral carotid which were statistically very significant. In the retrospective group stensosis (4 patients, 43%), uncontrolled diabetes (17 patients, 56%). patients with history of TIA (odds ratio 15.6667) and perioperative The male: female ratio was 26: 4. IABP was used in 15 patients (50%). hypotension (odds ratio 9.200) were found to be a higher risk of stroke. The average number of grafts received were 4. The incidence of The corresponding p values derived by chi square test were p<0.009 dyslipedemia was: 35% (17), hypertension - 40% (12), smoking - 50% and p<0.05. (15), previous MI - 73.3% (22). The mean duration of ventilation was

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24 hours. The average duration of IABP used was 36 hours. 2 patients in 124, both radials in 184 and the LIMA was used in all, single radial were converted to conventional CABG. in 124, both radials in 184 and the RIMA in 14. There was 1 Results: There were no perioperative deaths. One late death was perioperative infarct, 1 stroke and 8 deaths. 2 patients had a positive due to mediastinitis. Mean duration of hospital stay was 5 days. There Treadmill at 12 months. was no perioperative MI, no re-exploration and the use of blood Conclusions: TAR is possible in most patients presenting for CABG products were minimal. by using various strategies like 'Y' grafts, pure grafts and combinations. Conclusion: Thus OPCAB in high risk patients no only reduces the morbidity of CPB but also reduces post operative complications like renal failure, bleeding and hospital stay. Off pump coronary artery surgery in high risk subgroups 32 Srirup Chatterjee, Satyajit Bose, Sushan Mukherjee, Bilateral radial arteries – Helps achieve total Bishnu Kr. Deka, Saikat Sangupta, Tanmoy Das, Simran Gupta arterial revascularisation 30 Suraksha Hospital, Salt Lake City, Kolkata Sanjeeth Peter, Mahpaekar Mashhadi, Manoj Subramaniam, Aim of study: This study reviews the experience of 'off pump' David Thomas DDMM Institute of Cardiology and Cardiovascular Surgery, CABG in the high risk group. Nadiad Materials and Methods: From April 1999 onwards, 1232 patients have been subjected to OPCAB in our unit. Pre-and intra-operative Background: The accessibility and availability of artrial conduits variables as identified by the Parsonnet scoring system and the become important when attempting to achieve TAR. The radial artery Euroscore system were used to segregate the 230 high risk patients. has proven itself in the above qualities. In consequence, when more Data was entered into a locally modified European Cardiac Registry conduits in addition tothe LIMA are required, we have followed a database and then analyzed. Results were analyzed in the following policy of using one or both radial arteries. The aim of this study is to subsets: 75 years of age or more (67), prior neurological event (9) or see the morbidity, clinical outcome and hand function when both chronic renal failure (12), chronic obstructive airway disease (34), re radial arteries are used. operations (6), left ventricular ejection fraction <30% (24), diffuse Materials and Methods: The study period was between July 2000 coronary artery disease requiring endarterectomy (36), left main and October 2002. The Allen's test clinically and with pulse oximetry, coronary artery disease >80% (24), LV Aneurysms requiring was used to assess the feasibility of harvesting the radial artery. Pulse aneurysmorrhaphy (14), deep intra myocardial coronaries (14) and oximetery, sensory and motor function was measured in all patients compared with a similar clinical subset of patients, randomly selected before surgery and 10 days post operatively. from the data base, who underwent ONCAB procedure previously. Results: A total of 338 CABGS were done during the study period. Post operative clinical parameters (ventilation time, number of Both radial arteries were used in 184 patients. Among these, there transfusions, inotropic requirement, metabolic acidosis) and outcome were 3 in-hospital deaths. No motor weakness was noted in the 181 data (Total ITU and hospital stay, peri - operative MI, atrial fibrillation, patients studied. Sensory loss of the lateral cutaneous nerve was seen stroke, re-entry for bleeding and mortality) were analyzed. in 22 (12.1%), 1 patient had a haematoma which needed evacuation Results: Comparing with similar risk group undergoing on pump and 1 had a superficial wound infection. There was no visible spasm CABG, it became very apparent that there was marked improvement in any of the radial arteries. in both clinical parameters and outcome data. Average ventilation Conclusion: Harvesting of both radial arteries is safe and does time was 2.4 hrs (6.3 hrs in ONCAB), average transfusion per patient not compromise hand function. It helps achieve TAR when more was 1.8 (4.1/pt in ONCAB), inotropic requirement was comparatively conduits are required. lower. Mean total ITU and hospital stay was 1.9 & 6.3 days respectively (compared to 3.1d and 9.8 d in ONCAB). There were less number of re-explorations. Peri–operative MI occurred in 2 patients in OPCAB Strategies to achieve total arterial (3 in the ONCAB). There was minimal diference in the incidence of revascularisation for all CABG patients 31 atrial fibrillation, especially in the older age group. There was no Sanjeeth Peter, Mahpaekar Mashhadi, Manoj Subramaniam, incidence of neurological deterioration (5% in ONCAB). The mortality David Thomas in the high risk group was 9 (4%), (9% in ONCAB, 21 pts). 3 died of DDMM Institute of Cardiology and Cardiovascular Surgery, total bowel ischaemia, one of post operative acute pancreatitis, two Nadiad patients of severe chest infection, four of primary cardiac failure. Conclusions: Advances in coronary stabilization and developing Background: The Gold Standard for Coronary revascularization a mindset for OPCAB has improved the results of this form of this is the LIMA to LAD whose long term patency is considered to be due surgery even in the high risk group as far as immediate and mid term to the use of an arterial conduit. Duplicating such results in all results are concerned. territories involves using different arterial conduits. The aim of this study is to see if this is possible in all patients undergoing CABG Surgery. CABG in women: Are the results better Methods: The 343 patients for CABG between July 2000 and with OPCAB October 2002 were assesse to see if Total Arterial Revascularisation 33 A Sharda, S Dubey, R Ghadiok, A Chandra, OP Yadava (TAR) was possible. All underwent a transthoracic echocardiogram Department of Cardiac Surgery Dharma Vira Heart Centre, and Tread mill test at 3, 6 and 12 months postop. Sir Ganga Ram Hospital, New Delhi Results: Of 343 patients, TAR was possible in 338 (98.5%). 2 were in cardiogenic shock pre operatively and 3 had bilaterally delayed Introduction: Women carry a higher risk of mortality and Allen's with uncontrolled Diabetes. 338 patients received 1152 distal morbidity as compared to men in most reported series. We anastamoses (Ave. 3.4). 151 (44.6%) had Off Pump surgey with 408 retrospectively analysed our data of 236 women who underwent (Ave. 2.7) grafts. Of 338 patients, 172 received pure grafts, 89 'Y' grafts CABG from Feb. 99 to Sept. 02 and compared the results of and 77 received a combination. The LIMA was used in all, single radial conventional CABG (n=133) with OPCAB (n=103).

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Methods: 39.8% were diabetic and 49.7% hypertensive. 33.1% had of off pump coronary artery bypass in patients with significant left unstable angina, 5.1% patients presented with failure 3.4% patients main disease. had recent MI with cardiogenic shock. 10 (4.2%) patients were Patients and Methods: From August 2001 to August 2002, sixteen asymptomatic. The angiographic profile revealed 21 (8.9%) had left patients with significant left main disease were taken up for OPCAB. main stenosis, 179 (75.8%) had TVD. The co morbidities were carotid Significant left main disease was defined as more than 50% narrowing artery disease, renal impairment, peripheral vascular disease, thyroid of the vessel diameter in any one of the views on angiography. There dysfunction and COPD [24(10.2%); 41 (17.4%); 12 (5.1); 8(3.4%); were 10 males and 6 females. The mean age was 54.5 years and the 22(9.3%)]. mean ejection fraction was 46%. Pre-operative IABP was inserted in Results: Average number of total grafts and arterial grafts in the two patients with ejection fraction of less than 30%. Left anterior CPB group vs OPCAB group were 3.6±1.4; 1.2±0.7/2.9±1.2; 1.2±0.7 desending (LAD) artery was revescularised first followed by other respectively. Post op. ventilation, ICU stay and total hospital stay were vessels. 10.2±2.9 hrs; 28.4±10.2 hrs; 8.6±3.4 days in the CPB group as compared Results: OPCAB could be accomplished in 13 (81.25%) patients. to 6.3±2.4 hrs; 24.6±8.4 hrs; 7.4±2.1 days in the OPCAB group. 4 (1.7%) Two patients became hemodynamically unstable and had neurological complications in the CPB group. IABP support, post revascularisation was completed on cardiopulmonary bypass. Both op. arrhythmias, mediastinitis, pulmonary complications were seen these patients became unstable while positioning the heart for the in 17(13.5%); 25(18.8%); 3(2.3%); 11(8.3) in the CPB group vs 20 (19.4%); left anterior descending graft. In the other cease, left internal mammary 19(18.1%); 2(1.9%); 4(3.4%) in the OPCAB group. The in hospital to lad graft was done off pump. During the construction of saphenous mortality was also lower in the OPCAB group 2.9% vs 5.2% in the vein to obtuse marginal graft, the patient became unstable and further pump group. revascularisation was accomplished on bypass. There was no Conclusion: OPCAB can be safely performed in women with mortality. reduced morbidity and mortality. Conclusion: In our experience, OPCAB can be safely performed in patients with left main disease. Those patient who show signs of hemodynamic instability while positionimg for LAD graft should probably be performed on cardiopulmonary bypass. Thus the benefits Can transit time flowmetery of bypass grafts of beating heart surgery can be safely offered to patients with left improve the outcome of beating heart surgery 34 main disease. Pankaj Goel, Arvind Makker, Vivek Gupta, Dinesh Garg, Rajesh Arya, Sanjay Kaistha, Rajneesh Malhotra. Hero DMC Heart Institute, Ludhiana, Punjab Although the results of this technique have improved considerably after the advent of stabilisers, concerns still remain regarding the quality of anastamosis. Transit time flowmetery (TTFM) is a simple Coronary artery bypass surgery in young non-invasive method of assessing graft patency per-operatively. This adults (<40 yrs) 36 study was undertaken to study the efficacy of TTFM in detecting graft S Dubey, S Juneja, A Sharda, R Ghadiok, OP Yadava related problems during off-pump coronary artery bypass (OPCAB) Department of Cardiac Surgery, Dharma Vira Heart Centre, surgery. Sir Ganga Ram Hospital, New Delhi Patients and Methods: From August 2001 to August 2002, 133 OPCAB surgeries were performed at our centre. A total of 372 (2.8 Introduction: An increasing number of young adult (<40 yrs) are grafts per patient) anastomoses were constructed. All grafts were affected by coronary artey disease representing an interplay of evaluated with TTFM using a fixed protocol. The graft flows, genetics, modern lifestyles and stress. We report out experience of pulsatility index and waveform were evaluated to decide whether to coronary artery bypass in young adults from 1993 to Oct. 2002. revise a graft or not. Methods: A total of 107 patients underwent coronary artery Results: Abnormal flowmeter indices were detected in 9 grafts surgery during the period, and there were two women in the group. (2.%). In one case LIMA spasm was responsible and flow indices Seventy seven (72%) of the patients presented with acute coronary returned to normal after topical papaverine. Eight of the grafts were syndrome. Forty three (40%) of the patients had suffered a myocardial revised. Flowmeter indices returned to normal in 7 grafts. In one graft, infarction. The risk factor profile revealed 46 (43%) smokers, 41 (38%) the indices remained abnormal despite revision. This vessel were small hypertensives, 22 (20%) diabetics, 21 (19%) with dyslipidaemias and 1 mm in size. The hospital mortality was 0.75% (n=1). There was no 24 (23%) obese (BMI >27%) and 13 patients had family history of death related to graft malperfusion. coronary artery disease. Majority (65%) of the patients undergoing Conclusions: In our experience, TTFM is a useful tool in detecting CABG had triple vessel disease and 43% patients had left ventricular graft related prolems during OPCAB surgery. These problems can be dysfunction (LVEF <50%). Arterial conduits were obvious choice in rectified before chest closure thus reducing mortality and morbidity. this subset of patients. One hundred and five patients received left The sensitivity of TTFM needs to be determined especially cases with internal mammary artery, of which 29 had bilateral internal mammary small sized coronary arteries. artery. Other preferred conduits were radial artery (20 patients), Gastroepiploic artery (32 patients) and inferior epigastric artery (2 patients). Results: There was no early mortality in the group. Two patients required Intra aortic balloon pump for post op low output. Two Off-pump coronary artery bypass grafting in patients had deep wound infection and 3 had minor pulmonary patients with left main disease – Initial experience 35 complications. Pankaj Goel, Arvind Makker, Vivek Gupta, Dinesh Garg, Conclusion: In conclusion, coronary artery disease in young is Rajesh Arya, Sanjay Kaistha, Rajneesh Malhotra. Hero DMC Heart Institute, Ludhiana, Punjab essentially a disease of the male sex and the commonest presentation is acute coronary syndrome. Use of arterial grafts and total arterial Most of the cases of bypass grafting can be performed on the revascularisation is recommended with no detrimental influence of beating heart. This retrospective analysis was done review our results & early post operative morbidity and mortality.

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Hybrid revascularisation for management of acute Redo coronary artery bypass surgery mi with haemodynamic instability 37 Jagmohan Singh, S Dubey, G Shivnani, A Prakash, S Yadav, 39 S Juneja, GR Shivnani, S Dubey, KK Sethi, R Jain, OP Yadava R Ghadiok, OP Yadava Department of Cardiac Surgery, Dharma Vira Heart Centre, Department of Cardiac Surgery, Dharma Vira Heart Centre, Sir Ganga Ram Hospital, New Delhi Sir Ganga Ram Hospital, New Delhi Introduction: Urgent coronary artery bypass grafting (CABG) in Introduction: In the present era, an increasing number of patients patients presenting with acute myocardial infarction (MI) with are referred for redo coronary surgery. Re-operative coronary artery cardiogenic shock, evolving MI, refractory post MI angina, experience surgery on CPB is associated with significant morbidity and mortality. a higher rate of mortality and morbidity. Methods: We retrospectively analysed our experience of redo Methods: We retrospectively reviewed, 9 such patients who coronary surgery (n=20) from Feb. 1999 to Oct. 2002 and compared underwent urgent CABG after rescue percutaneous transluminal results of redo OPCAB (Group A, n=7) with redo CABG on CPB coronary angioplasty of the culprit vessel. 5 patients presented with (Group B, n=13). cardiogenic shock, out of which 4 required ventilatory support. All Results: It was observed that patients in Group B required more patients had severe triple vessel coronary artery disease with severely blood transfusion (3 units vs. 1 unit), required a longer period of imparied LV function. Intra aortic balloon pump and inotropic support ventilation. (>24 hrs) (7.7% in Group B Vs Nil in Group A), an increased were necessitated for stabilisation of all patients before angioplasty use of ionotropic support. However, IABP use was more common in of the culprit vessel. Group A (33.3% Vs 15.3%). Patients in Group A had a shorter stay in Urgent CABG had to be done, within 12 hours of angioplasty in 3 the intensive care unit and hospital (5±2 Vs 9±2 days). In hospital patients, and other six patients underwent staged CABG after an initial mortality was higher in Group B (7.7%) against no mortality in period of stabilisation but within 2-7 days of PTCA. 2 patients were Group A. revascularised without the use of cardiopulmonary bypass (OPCAB) Conclusions: In conclusion off pump redo coronary surgery is and seven patients underwent conventional CABG. technically feasible and safe. No patient in Group A needed to be Results: There was one mortality resulting due to persistent lactic converted to on pump CABG. However, the use of IABP was more in acidosis secondary to unresponsive renal failure. Group A and in our opinion IABP provided crucial haemodynamic Conclusion: The hybrid revascularisation has proved to be a useful stability and averted the possibility of a conversion to CPB. Though strategy for management of haemodynamically compromised patients the number is small, there is a trend suggesting that off pump redo with acute MI after an initial period of stabilisation whenever possible. coronary surgery is associated with lower morbidity & early hospital discharge.

Off pump bypass grafting in patients with left main coronary disease 38 S Juneja, S Dubey, G Mahajan, R Ghadiok, OP Yadava Department of Cardiac Surgery, Dharma Vira Heart Centre, Sir Ganga Ram Hospital, New Delhi Combined OPCAB and carotid endarterectomy Introduction: Because of a concern about the ability to tolerate D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, 40 P Balasubramanian, Ajit K Tharakan, PSN Raju beating heart grafting, patients with left main coronary artery stenosis Vijaya Heart Foundation, Chennai, India have usually been excluded from off pump bypass. We reviewed our experience with off pump CABG for patients with left main coronary Aims: Cardiopulmonary bypass has several associated deleterious artery disease. effects that include a systemic inflammatory response, coagulopathy, Methods: 115 such patients underwent bypass grafting from Feb. central nervous system complications and a variable degree of end- 1999 to Sept. 2002. 51 patients were revascularised without the use of organ damage. The recent upsurge in interest in “beating-heart” cardiopulmonary bypass (OPCAB) and compared with a similar surgery attempts to avoid these deleterious effects. This study aims cohort of 64 patients who underwent conventional CABG (CCAB) to analyse the possibility and safety of OPCAB and combined carotid with cardiopulmonary bypass. All patients had multi vessel grafting endarterectomy. performed through a sternotomy. Though CCAB patients received Methods: 18 patients over a period of five years underwent significantly more grafts per patient than OPCAB patients (3.7 Vs 2.9, combined coronary artery bypass and carotid endarterectomy. Age p<0.01), the number of arterial grafts were similar to both groups group ranged between 52–75 years. All patients were males. (OPCAB 1.8 Vs CCAB 2.1). Unilateral carotid disease was present in 16 patients and insignificant Results: There was no death in the group undergoing off pump contralateral disease (less than 50%) lesion in 2. In patients with grafting as compared with a in hospital mortality of 4.7% in the on bilateral disease, distal stump pressure was measured. Heparin 1 pump group. Two patients (5.4%) required conversion to mg. Per kg was given to maintain ACT around 300. Carotid shunts cardiopulmonary bypass due to haemodynamic instability. Univariate were not used. Carotid occlusion time ranged between 12–20 analysis established that patients revascularised with minutes. In all patients vein patch was used. Carotid endarterectomy cardiopulmonary bypass were significantly less likely to require was followed by OPCAB. ionotropic support (31.4% Vs 65.5%, p<0.01) and transfusion (40% Vs Results: None of the patients developed cardiac instability during 76.5%, p<0.01). The requirement of temporary post operative pacing carotid endarterectomy. There were no transient or permanent (5.7% Vs 9.4%, p<0.05) and post operative length of stay (5.6 Vs 8.3 neurological sequelae or cardiac complications observed. days, p<0.05) was also less in off pump patients. Conclusions: Combined OPCAB with carotid endarterectomy Conclusion: Coronary artery bypass grafting using off pump is a safe and effective procedure without added morbidity or technique is safe and effective in left main coronary artery disease. mortality.

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Management of proximal anastomosis during Successful repair of left ventricular free wall CABG–The two in one technique 41 rupture using VHF modification of endo 43 D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, ventricular patch plasty – A case report P Balasubramanian, Ajit K Tharakan, PSN Raju D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, Vijaya Heart Foundation, Chennai P Balasubramanian, Ajit K Tharakan, PSN Raju Vijaya Heart Foundation, Chennai Aims: Multiple proximal anastomoses on an atherosclerotic and short aorta have always been a problem during CABG. Moreover, the Background: Ventricular free wall rupture and cardiogenic shock use of bilateral mammary arteries for OPCAB reduces the anastomotic are now the leading causes of death following acute myocardial space on the aorta. We have tried this novel technique for proximal rupture and together account for about two-thirds of the death from anastomosis to obviate these problems. acute myocardial infarction. Usually the sequence of events following Methods: 3200 patients have undergone coronary artery bypass acute free wall rupture is so rapid that there is no time for surgical over the last 5 years. Out of these over 1700, patients underwent veno- intervention. More over, the surgical options available are also limited venous hood (VVH) for the proximal anastomosis. 30% of patients and the operative techniques difficult. We present a case of acute were above the age of 60.90% were males and 10% were females. In a ventricular free wall rupture who underwent the VHF modification single aortic partial clamp and a single aortic punch, the initial graft of the endoventricular patch plasty. anastomosis is completed in a side-to-side fashion using 6–0 Case report: A 58-year-old male who presented to us with features polypropylene suture. The distal end of the graft is then beveled and of acute antero-lateral myocardial infarction later developed severe spatulated adequately. The second graft is then anastomosed to this congestive cardiac failure on the second day which was not responsive graft in an end-to-end fashion using 6–0 polyproylene suture. to maximum medical therapy. Investigations revealed an impending Results: There was no compromise in the graft flow with no graft free wall rupture with free blood in the pericardial cavity. He occlusion or kinking. None of the patients developed any neurological underwent immediate surgery, which revealed impending rupture or aortic complications. One patients who has associated carotid of the ventricular free wall. After instituting cardiopulmonary bypass, disease developed T.I.A and had complete postoperative recovery. the left ventricular was opened at the border zone between the necrotic Conclusions: The use of VVH is a simple technique during and normal myocardium, an appropriate sized Gore-Tex patch was coronary bypass surgery to manage a difficult aorta. This reduces the sutured between the infarcted myocardium and the free edge of the need for repeated cross clamping thereby reducing neurological and viable myocardium excluding the septum. He recovered well in the aortic complications. postoperative period and was discharged home on the eighth postoperative day. Conclusion: Endoventricular patch plasty is viable surgical option for this major complication of acute myocardial infarction and with careful and prompt action we can save this large subgroup of patients.

EVPP–VHF technique D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, 42 Harmonic scalpel in cardiac surgery P Balasubramanian, Ajit K Tharakan, PSN Raju D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, 44 Vijaya Heart Foundation, Chennai P Balasubramanian, Ajit K Tharakan, PSN Raju Vijaya Heart Foundation, Chennai Background: Ventricular remodelling following myocardial infarction produces akinetic and dyskinetic segments in the Objective: We would like to share our experience with harmonic myocardium depending on the extent of reperfusion and scalpel instrument in cardio thoracic surgery at the Vijaya Heart revascularisation. Traditional surgery for ventricular restoration Foundation. reduced the long axis making the heart more spherical and less Methods: 3262 patients have undergone coronary artery bypass effective as a pump and increasing incidence of mitral regurgitation. operations at the Vijaya Heart Foundation from July 1996 to Sep. 2002. We hypothesize that maintenance of the conical shape of the left 2972 (91%) were males and the remaining 290 (9%) were females. Most ventricle is essential for improved long-term results. Towards this patients were between 40 and 70 years of age. 1278 (39%) were by objective we formulated a modification of the traditional beating heart surgery (OPCAB) and 1984 (61%) were done on pump endoventricular patch plasty to maintain the long axis of the left (ONCAB). We have been using Ultra Cision Harmonic Scalpel (HS) ventricle. (Ethicon Endo-Surgery, Inc., Cincinnati, OH) since 1998. Technique: We perform endoventricular patch plasty (EVPP - the Results: In redo surgeries and pericardiectomy for constrictive Vijaya Heart Foundation technique), whereby the left ventricle is pericarditis it significantly reduces the surgical time, inadvertent opened at the border zone between the scar and normal myocardium, surgical trauma, per and post operative bleeding. Electroutery has a an appropriate size Gore-Tex patch is sutured between the infarcted potential risk of serious pacemaker dysfunction in patients with septum and the free wall, thus restoring the conical shape of the left implanted pacemaker. The harmonic scalpel is also very safe and ventricle and reducing left ventricular volumes. Mitral valve can be useful in these patients. In internal mammary artery dissection, there repaired or replaced through the left ventriculotomy when indicated. is a significant reduction in the dissection times with the need of less The modification lies in the site of incision on the scar and the suturing clips and possibly a reduction in the incidence of wound problems in of the patch to the lateral wall in such way that a gentle curvature is the post operative period. This is particularly true in the patients where maintained towards the septum. A total of 230 patients have bilateral internal mammary artery has been harvested. Earlier, the undergone EVPP from 1998 till date including those who had dissection of the intramyocardial coronary arteries involved bleeding emergency surgery, mitral regurgitation, ventricular septal defect and with obscurement of vision in the operating field. The harmonic scalpel ventricular free wall rupture. has also been of significant benefit in this clinical scenario. Results: Marked clinical improvement was seen in these patients Conclusions: The use of harmonic scalpel is very useful in redo with low mortality with negligible use of IABP and decreased surgeries, pericardiectomy and intramyocardial coronary artery incidence of ventricular arrhythmias. Overall 30–day mortality was dissection. However, the cost – effectiveness of this instrument needs 5%. to be evaluated.

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The use of intra-coronary shunts during OPCAB There were 6 cases of superficial wound infectin (3%). 2 patients D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, 45 died, mortality (1%), the causes being resistant tachyarrhythmia and P Balasubramaniam, Ajit K Tharakan, PSN Raju low cardiac output respectively. Vijaya Heart Foundation, Chennai Conclusion: Thus, combining TAR which is an established strategy, for long term graft patency along with off pump methods ensures Aims: Off-pump coronary artery bypass (OPCAB) operations are fast tracking, less requirement of blood, lesser post operative evolving rapidly and becoming established in many cardiac centers. complications. Long term results of this strategy are awaited. Advances in surgical technique, such as the use of intracoronary shunts and the Octopus retractor, have made beating-heart coronary bypass surgery a reality. Earlier, the management of the coronary arteriotomy was done using slings and other occlusion devices. The drawbacks with these occlusion device include myocardial ischemia, Can Euro SCORE predict direct costs of distal embolism and compromise of the anastomosis. We share our Off pump CABG 48 experience with using intracoronary shunts during OPCAB. Srirup Chaterjee, Sushan Mukherjee, Satyajit Bose, Methods: 1278 patients have undergone OPCAB at Vijaya Heart Bishnu Deka, Simran Gupta, Saikat Sengupta, T Das, V Kumar Foundation over the last three years. Flexible, soft, bulbous ended Vijaya Heart Foundation, Chennai, India shunts (Medtronic) were used. Most common size was 1.5 mm, 2 mm Objectives: The aim of this study is to determine if a pre-operative used and rarely 2.5 mm & 1.25 mm. The length of the coronary risk stratification model can identify different surgical costs. arteriotomy was around 1 cm. If necessary, the bulbous ends were Methods: 200 consecutive patients undergoing off-pump CABG trimmed. Continuous hemodynamic monitoring using Swan Ganz between July 2002 and October 2002 were classified with the Euroscore catheter was done on all patients. model. Patients were grouped into 2 categories according to euroscore, Results: Since shunts maintain distal coronary flow, there was no the first being Euroscore 0-4, and the second being >4. Direct variable perioperative myocardial infarction. Bloodless field and scaffolding costs were prospectively collected, excluding the fees of the surgical of arterial lumen allows accurate anastomosis. In five patients on- team. pump conversion was required. Time taken for each distal Results: The relationship between risk group/Euroscore and cost ananstomosis varied between 8-15 minutes (mean 12 minutes). is shown Peroperative blood loss was negligible. Postoperative transfusion was also minimal. Conclusions: Intracoroanry shunt is a valuable tool in the Euroscore Number ITU stay (days) Hospital stay (days) Av. Cost (Rs) armamentarium of cardiac surgeons during OPCAB. 0—4 154 2.37±SD 0.67 7.90±SD 1.96 51,595 > 4 46 3.71±SD 0.91 10.42±SD 2.42 78,343

Conclusions: From our data the Euroscore model developed to Total artreial revascularisation using bilateral internal mammary arteries joined in a "Y" manner 46 predict 30 day post operative mortality could be used to direct on a beating heart experience in 479 cases operative costs and identify patients with different levels of resource Srirup Chatterjee, Sushan Mukherjee, Satyajit Bose, Bishnu Kr Deka, consumption. Tanmoy Das, Saikat Sengupta, Simran Gupta Suraksha Hospital, Salt Lake City, Kolkata Background: Total arterial revascularization (TAR) using bilateral internal mammary arteries in a "Y" manner is an accepted mode of Starting of an independent career – With Off pump CABG – Experience of 1st 102 Cases conduit strategy in terms of long term freedom from repeated 49 Ajeet Bana, Vikram Goyal procedures. On the other hand, performing the procedure off pump Department of Cardiac Surgery, Santokba Durlabhji Memorial (OPCABG), does away with all the deleterious effects of Hospital, Jaipur cardiopulmonary bypass.Total arterial bypass on a beating heart encompassess the advantages of both. Background: Myocardial revascualrization on the beating heart Methods: We compared clinical outcomes in the last 200 patients is becoming increasingly popular. Off pump coronary artery bypass having TAR performed off pump, with data retrieved from a similar was performed primarily by senior surgeons who were instrumental subset of patients done on cardiopulmonary bypass (ONCAB), in a in popularizing beating heart surgery. Young surgeons experience was retrospective manner. Post operative clinical parameters (ventilation limited because of evolving technique. Nevertheless now many young time, number of transfusions, inotropic requirements, metabolic surgeons have started doing OPCAB with good results. acidosis) and outcome data (total ITU) and Hospital stay, peri Methods: After my basic training in conventional CABG, I started operative MI, atrial fibrillation, stroke, re entry for bleeding and doing OPCAB. Initial 50 cases I did under super vision and later on mortality) were analysed. started doing independently. I left my teaching unit and joined another Results: Comparing with similar group undergoing ONCAB, it cardiac center to start my independent career. became very apparent that there was marked improvement in both Since March 2002 to October 2002 we did total 102 CABG and all clinical parameters and outcome data. Average ventilation time was were OPCAB. Mean age was 58.7 years (range 37-81) with 84 male 2.4 hrs (5.8 hrs in ONCAB), avarage transfusion per pt was 1.2(3.9/ and 18 female. 36 patients were having unstable angina and two patient in ONCAB), significant inotropic requirement was patients were in cardiogenic shock. Majority of patients were having comparatively lower (18% compared to 31%). Mean total ITU and triple vessel disease (84) and isolated or associated left main disease hospital stay was 1.6 and 5.6 days respectively (compared to 2.8 days was present in 24 patients. Severe LV dysfunction (EF <35%) was and 8.8 days in ONCAB). There were less number of re explorations present in 18 patients. Associated co mortality like COPD 8, CRF 4 (3 compared to 7). Peri operative MI occurred in 2 patients in OPCAB and PDV 2 was also present in some patients. All patient were operated (3 in ONCAB). There were no significant difference in the incidence by mid line sternotomy with octopus III tissue stabilizer & starr fish. of Atrial Fibrillation, Mortality. There was lesser incidence of Intra coronary shunt was used in all patients but sling were not used neurological deterioration (0.4% compared to 3.5% in ONCAB). at all.

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Average number of grafts per patient was 3.14 (range 1 to 5). All artery and to compare the morphometry of the distal and proximal patients received at least one arterial graft. Total arterial radial arteries. revascularization was done in 46 patients. Sequential anastomosis was Material and Methods: 190 radial artery specimens (both proximal used in 48 patients. LIMA RIMA or LIMA Radial Y grafts were used and distal radial artery segments left after use) from patients in 11 patients. undergoing CABG at our centre were subjected to histopathological Results: These was one in hospital mortality. Average ventilation and morphometric analysis. The severity of the disease was evaluated time was 3.4 hour and ICU stay was less than 2 days. Blood product by the percentage of luminal narrowing and the intimal thickness usage was 1.75 units per patients. Two patients developed superficial index. Risk factors were determined by stepwise linear and logistic wound infection & one patient had surgical emphysemas. regression. One hundred paired specimens of distal and proximal RA Conclusion: In the era of OPCAB training of conventional CABG were compared morphometrically. is lacking but young surgeons should not be disheartened about it. Results: The incidence of intimal hyperplasia, atherosclerosis and My experience has shown that we can also perform OPCAB with good medial calcification in the distal radial arteries was 76.3% (145/190),, results after initial experience of conventional CABG and performing 5.78% (11/190) and 6.3% (12/190) respectively. The majority of the at least 50 OPCAB under super vision of a trained surgeon. radial arteries (166/190) 87.8% had less than 30% luminal narrowing. Factors found to be significant predictors of intimal hyperplasia (p<0.05) in radial arteries were peripheral vascular disease, smoking, age and diabetes. Medial calcification was only predicted by age, Minimally assisted direct coronary artery bypass comparative morphometric analysis between distal and proximal grafting (MADCAB) in ischaemic ventricles – 50 segments (n=100) showed that proximal radial arteries had a A malabar experience significantly smaller intimal area and percentage of luminal narrowing CS Sheen Peeceeyen, TT Abdul Vahab, AV Kannan, Murali P Vettath than distal radial arteries (p<0.01), Wilcoxon signed rank test). Department of Cardiac Surgery, Malabar Institute of Medical Conclusions: We advocate caution in using RA as a conduit in Sciences, Calicut, Kerala coronary artery surgery, particularly in elderly patients, diabetics, smokers with peripheral vascular disease. The distal radial arteries Introduction: Cardioplegia does not avoid ischaemic damage in are more likely to have more severe intimal hyperplasia. Therefore, patients with reduced left ventricular function nor does OPCAB in cases of longer diseased radial arteries, the discarded segments guarantee uncompromised haemodynamics and damage free should be at the distal end. myocardium always. We assessed the need for pump assistance in patients with low ejection fraction who underwent CABG on beating heart. Material and Methods: 98 CABGs were performed since July 2002 in this new centre. 14 (14.2%) on warm blood Cardioplegia, 44 (44.8%) OPCAB and 40 (40.8%) MADCAB. Patients with LVEF <40% (56 no.s Endoscopic conduit harvesting – Initial experience – 57.1%) were grouped into 4 as Group I (20 to 25%) – 7 (7.1%), Group Sunil Kumar Swain, Akshya Kumar Bisoi, 52 Ganapathy Subramanian, Sandeep Chauhan, P Venugopal II (26 to 30%) – 11 (11.2%), Group III (31 to 35%) – 15 (15.3%) & Group All India Institute of Medical Sciences, New Delhi IV (36 to 40%) – 23 (23.4%). All Gr I patients, those with ischaemic ventricles, and buried diffusely diseased coronaries were primarily Introduction: Coronary Artery Bypass Grafting is commonest selected for MADCAB (20 cases- 20.4%). All others were planned for cardiac surgery performed all over the world. Wound related OPCAB, 20 (20.4%) of which had to be converted to MADCAB. We complications particularly in elderly, diabetic, obese and female studied factors like time for anastomosis, postoperative bleeding, patients add to the morbidity and cost. enzyme levels, multi-organ function, postoperative ventilation time, Recently we at All India Institute of Medical Sciences started need for inotropes/IABP, onset of mobilization, ICU stay, and hospital endoscopic (30° endoscope, Ultracission Endoloop) harvesting of stays. great saphenous vein and radial artery. Out of 20 patients, 10 were Results: No operative mortality or stroke. None required IABP males and 10 females. 18 patients were diabetic and 14 patients had support. Anastomosis time, CPKMB rise & need for inotropes were moderate to severe obesity (body weight more by 20% expected). relatively less on MADCAB compared to OPCAB. Bleeding, Full length radial artery was harvested in 9 cases. 2 length vein in postoperative ventilation, time for mobilization and ICU stay were 16 cases and 3 length in 4 cases. Average time for great saphenous comparable. Temporary renal impairment occurred in 3 patients on vein was 45 min – 60 min and for radial artery 30–45 min. There was OPCAB compared to 1 on MADCAB. No difference in the hospital no damage to the conduits. None of the patients had any wound stay. related complications. Conclusion: In reduced LVEF, MADCAB is an alternative to ward Though the study group is small, the results are quite off the effects of global ischemia in cardioplegia and ischaemic damage encouraging and in the long run with practise the harvest time is inducible during OPCAB. bound to decrease.

Histopathology and morphometry of the radial Post-infarction mitral regurgitation: Early and late artery : A conduit for CABG 51 outcome following surgical intervention 53 Pankaj K Mishra, U Chouwdhury, B Airan, AK Bisoi, A Smartin, SK Choudhary, A Bhan, B Airan, UK Chowdhury, Anil Bhan, SK Choudhary, A Sampath Kumar, R Ray, P Venugopal A Sampath Kumar, AK Bishoi, S Kale, P Venugopal All India Institute of Medical Sciences, New Delhi All India Institute of Medical Sciences, New Delhi Introduction: Radial artery and internal mammary artery are Background: Ischemic mitral regurgitation is an important frequently used conduits for CABG. The purpose of this study was to determinant of survival in patients with coronary artery disease. A determine the histopathology, morphometry and risk factors for retrospective analysis was performed to evaluate the overall outcome development of intimal hyperplasia and atheroselerosis in the radial and its determinants.

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Patients and Methods: Between January 1988 and September 2002, OPCAB - Experience 96 patients underwent operations for mitral regurgitation of ischemic Pawan Kumar, SK Pranav, D Kulkarni, C Raghvendra, 55 origin. Age ranged from 32 to 71 years (mean 52.4±12.6 years) and 84 Uday Jadhav, AG Tendolkar (87.5%) were male. Fifteen patients (15.6%) had acute and 81 patients LTMMC & LTMGH, Sion, Mumbai (84.4%) had chronic ischemic mitral regurgitation. Thirty-five patients were in New York Heart Association class II, 39 in class III and 22 in Introduction: Off pump CABG continues to enjoy popularity as class IV. Moderate left ventricular dysfunction (EF <40%) was present CPB is avoided. We present our experience with OPCAB from October in 46 patients (48%) and severe dysfunction (EF <30%) in 16 patients 1999 till June 2002. (16.7%). All patients were operated using standard cardiopulmonary Material and Methods: 330 patients underwent CABG with a bypass technique. Mitral valve was replaced in 42 patients had primary intention of performe OPCAB. Male/Female 280/50 repaired in 54 patients. Repair included a combination of techniques: Age 28-70 years, Average 44 years Unstable angina 132 (40%), H/ chordal transposition (n=5), chordal shortening (n=21), papillary o MI 120 (36.4%) Hypertension 250 (75.8%), Diabetes 180 (54.5%), muscle shortening (n=3), leaflet resection (n=4), posterior Teflon collar COPD 50 (15%) EF 25%-62% (47%). annuloplasty (n=46), annuloplasty with Duran’s ring (n=6), and Technique: All the surgeries were performed using the Octopus commissural plication (n=10). 2+ or 3. Extensive opening of the right pleura was performed, along Results: Operative mortality was 10.5% (14/96). Low cardiac with vertical splitting of the pericardium, for the OM’s & high output was the cause of death in the majority (n=11). Low ejection diagonals. Extensive hitching of the pericardium was done. fraction and acute presentation were the independent predictors of Intracardiac shunts were used for all coronaries. In case of persistent operative mortality. Follow-up ranged from 2 to 160 months (mean haemodynamic alteration the patient would be shifted to CPB & the 76±28.4 months); late mortality was 39.1 (32/52). The commonest surgery would be performed, while on CPB, on a beating heart, cause being congestive failure (n=18). Acturial survival in operative without cross clamp and using the octopus stabilizer & intracoronary survivors was 42.6±10.4%. shunts. Conclusion: Ischemic mitral regurgitation with poor left Results: Number of grafts/patient 2.9 LAD 95%, Ramus 32%, OM ventricular function carries high early and late mortality. Though early 75%, RCA 70%, PDA 16% Intraoperative arrhythmias, Atrial fibrillation mortality has been reduced, late mortality continues to be high. 13%, ventricular fibrillation 1.8% (all cardioverted) Hypotension (<80 mmHg) seen during positioning 80 (24.3%) Conversion to CPB 20 (6.1%) ST elevation 50 (15.1%) Operative time 180±70 mins Mortality 10 (3%), 8 were conversion to CPB. Fresh MI 13 (3.9%) Ionotropes Radial artery in CABG : Midterm angiographic required to post operative period 20 (6%) Return to work 72±35 days. results 54 Conclusion: OPCAB is a procedure which has reduced the J Dhareshwar, AK Bisoi, A Bhan, B Airan, SK Choudhary, mortality & morbidity associated with a coronary artery bypass UK Chowdhury, A Sampath Kumar, P Venugopal grafting. All India Institute of Medical Sciences, New Delhi Objective: The aim is to share our mid-term angiographic follow- up results in 70 patients with radial graft for CABG. Patients and Methods: Between February 1996 to January 2001, 988 patients were operated for coronary artery bypass surgery using radial artery as one of the conduits. Seventy (70) of these patients Offpump coronary artery bypass in left main were randomly selected for angiographic study after an interval of coronary artery stenosis 56 PK Rath, R Mehrotra, U Patil, SV Vanzara, NC Garach, atleast 12 months when they presented for follow-up between January R Panda 2001 and August 2002. The angiography was done after an interval of Breach Candy Hospital, Lilavati Hospital, Nanavati Hospital, 12–70 months (mean 42±7.2 months). Mumbai Results: Of the 70 patients, 65.7% (46/70) were in NYHA class 128.5% (20/70) in class 2 and 5.7% (4/70) in class 3. None of the patients Background: To determine if off pump Coronary Artery Bypass had a perioperative MI or late cardiac event. 35.7% (25/70) were Grafting (CABG), can be done safely in patients with significant left diabetic and 65.7% (46/70) were hypertensive at the time of main (LM) stem stenosis. presentation. All the patients had received a free radial artery graft Methods: A total of 184 patients with significant LM stem lesion as one of the conduits, with the proximal anastomosis being done to (>50% luminal stenosis), were operated upon during the period from the aorta. The favoured target vessel was the obtuse marginal (92.8%; January 2000 to November 2002. 154 (83.7%) were male and 30 (16.3%) 65/70). The left internal mammary was used in 64 patients of this female. Age range was 43-85 (mean 61.2 years). 162 (88%) patients group, target vessel always being the left anterior descending were in NYHA class III and 12% (6.5%) were in class IV. 56 (30.4%) artery. had unstable angina. 33 (17.5%) had recent MI. 31 (16.8%) had EF<35%. On angiography, all the grafts were patent in 51 patients (72.8%). 11 (5.9%) were for reoperation coronary artery bypass grafting. The chief culprit usually being one or more of the vein grafts. The Majority had triple vessel disease. Octopus stabilizer was used in all radial artery grafts were found to be patent in 94.28% patients (66/ cases. 70). There was no evidence of any radial artery spasm or disease Results: A total of 3.96 distal anastomoses (3.8 being arterial) per within the conduit. All the 4 blocked radial artery grafts were patient were performed, using LIMA in 170 (82.4%), RIMA in 43 probably due to poor distal runoff consequent to progression of (23.7%), and radial artery in 167 (90.7%). Total arterial revascularisation disease in the native vessel. There was no evidence of any anastomotic was achieved in 150 (85.8%) cases. There was no mortality. Morbidity narrowing in the patent grafts. The patency of the pedicled left internal included CVA in 1 (0.5%) patient, reexploration in 1 (0.5%) renal failure mammary grafts of LAD was 96.8% (62/64). In 26 of the 51 patients not needing dialysis in 2 (1%) patients, perioperative MI in 1 (0.5%), where grafts were flowing well, there was significant progression of acute pancreatitis in 1 (0.5%), diaphragmatic palsy 1 (0.5%), pleural disease in the ungrafted vessels. effusion in 14 (7.6%) and atrial fibrillation 3 (1.6%) patients. Conclusion: The radial artery compares favourably with the left Conclusions: OPCAB can be performed safely and satisfactorily internal mammary artery. in patients with significant LM stenosis.

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Offpump reoperative coronary artery bypass Complications of suction stabilizing devices grafting in high risk patients 57 during Off pump coronary artery surgery 59 R Mehrotra, PK Rath, U Patil, SV Vanzara, Nitu Mandke, Ajay Chaugule, AR Shrirish Borkar, NC Garach, R Panda Zubin Nalladaru, Alaka Mandke Breach Canday Hospital, Lilavati Hospital, Nanavati Hospital, Breach Canday Hospital, Lilavati Hospital & Research Centre, Mumbai Mumbai Background: High risk cases benefit most when cardiopulmonary Aim: To understand the hazardous effects of suction pads on the bypass (CPB), aortic cross clamping and cardioplegic arrest are epicardium and myocardium and to take preventive actions. avoided. Satisfying results of off pump CABG (OPCAB) have Material & Methods: Cardiac stabilizers with suction pads became encouraged us to perform redo CABG without CPB. available to us by January 2002. The use of this stabilizer allowed the Methods: 45 patients comprising 40 males and 5 females with age exponential growth in the number of off pump surgeries all over the range of 50-79 years (mean 69.9 years) underwent redo OPCAB during world, as the coronary arteries on the back of the heart became the period from January 2000 to November 2002. Majority of the cases accessible for grafting. From 1st January 2000 till 30th June 2002, 1377 were high risk including 39 (86.7%) patients with ischemic patients underwent off pump coronary artery surgeries. Two of these cardiomyopathy, and 11 (24.4%) patients with significant left main 1377 patients developed complication directly related to the suction trunk stenosis (>50% luminal stenosis) along with significantly device. Epicardium got separated from the myocardium avulsing the diseased or completely blocked grafts. 40 (88.9%) were in NYHA Class intramyocardial blood vessel underneath the imprint of suction pads III and 5 (11.1%) in NYHA Class IV. 16 (35.5%) patients had recent MI. producing haematoma, which progressed undermining epicardium Redo sternotomy was performed. Octopus stabilizer was used in all over a large portion of heart and produced burrowing of haematoma cases. into the myocardium. It gave the appearance of ruptured heart with Results: An average of 3.8 distal anastomoses (3.3 being arterial) torrential bleeding. Both these patients were treated by going on per patient were performed using LIMA in 26 (57.8%), RIMA in 19 CPBypass by evacuating haematoma and obliterating the cavity with (42.2%) and radial artery in 38 (84.4%) patients. Total arterial biological glue. revascularisation was achieved in 21 (46.7%) patients. Morbidity Results: One patient died 2 hrs postoperatively due to uncontrolled included perioperative MI in 1 (2.2%), atrial fibrillation in 3 (6.6%), bleeding. The next patient survived the operation and was discharged pleural effusion in 1 (2.2%). There were 2 deaths within 30 days of home on 12th P.O. Day. operation. Conclusion: Any expansion of suction pad mark should be Conclusion: Redo OPCAB is feasible in high risk patients with immediately treated and it should not be allowed to progress and low morbidity and mortality. expand and burrow within the myocardium. This complication can occur at low or normal level of suction pressure and may be attributed to the weakness between the epicardium and myocardial fibrills.

Minimally invasive coronary artery surgery - Art Does mild ischemic mitral regurgitation impact and technology at its best 58 outcome after coronary artery bypass grafting? 60 Nitu Mandke, Ajay Chaugule, AR Shrirish Borkar, SK Sinha, Harpreet Singh Surya Mishra, Deepak, Sanjula Ashok Swarup, Alaka Mandke Department of Cardio Thoracic & Vascular Surgery, Batra Hospital, Breach Canday Hospital, Lilavati Hospital & Research Centre, New Delhi Mumbai Objectives: It is unknown whether mild ischemic mitral Aim: This study is done to evaluate the data and emphasize the regurgitation (MR) impact outcome after CABG. feasibility of doing more than 90% of coronary bypass surgeries off Methods: Results of all CABG patients with ischemic MR grade pump with excellent results. 2/4 operated during 1996-2002 (n=89) were compared with all CABG Material & Methods: We started coronary artery surgery in 1995. patents without MR (n=2209) during the same period. To further Between 1st January 1996 till 30th June 2002, 2209 patients underwent characterize patients with ischemic MR grade 2, a case-control study off pump coronary artery surgery. Cardiac stabilizers became available focusing on functional status was performed. Control patients without to us from January 2000. We analyzed our data from 1st January 2000 MR (n=89) were matched for age, gender and LVEF. All patients were till 30th June 2002. Total number of CABGs performed were 1474 out interviewed regarding angina symptoms and function. of which 1377 (95.43%) were done off pump. Ninety seven patients Results: Acturial survival at one and three years were lower in those who were done on CPBypass, 63 of those were intended to be the MR group compared to all CABG patients (91 vs. 96% and 84 vs. done off pump but had to be converted to CPBypass due to 92%, respectively (p<0.01). However, MR patients were older (65±0.9 haemodynamic instability. One hundred and sixty three patients were years, p<0.01). However, MR patients were older (65±0.1 vs. 68±0.9 not suitable for off pump surgery were still done off pump. Four years, p<0.01) and had lower LVEF (42±2 vs. 58±0.2%, p=0). In the hundred and ninty three out of 1377 patients had composit “Y” grafts case control study, preoperatively only NYHA class differed between using various conduits. In 1377 patients, 4699 anastomoses were the MR group and controls (3.2±0.2 vs. 2.2±0.2, p<0.05). Neither 30- performed (3.41 grafts/patient). day mortality (2.5% in both groups) nor acturial survival at one (91 Results: Two patients developed CVA, 5 patients were explored vs. 93%) and three years (83 vs. 87%) differed. NYHA class and angina for bleeding and 14 patients died (1.01%). One Hundred & sixty seven class improved similarly in both group. Postoperatively, 62% of the patients underwent graft angiography before discharge. All arterial patients in the MR group had reduced, 36% unchanged and 2% grafts were patent either individual or composite (100% patency rate). increased MR. One individual Saphenous vein out of 18 got blocked (94.4% patency Conclusion: CABG on patients with mild ischemic MR reduces rate). angina pectoris and improves functional status to the same extent as Conclusions: This data over last 30 months, suggests that large in CABG patients without MR. Postoperative mortality is comperable, number of patients can be done off pump with good results. Immediate Grade of MR is reduced or unchanged in CABG patients with mild graft patency rates are excellent. ischemic MR after CABG.

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Surgery in acute coronary syndrome and from 20-30%. Mean ejection fraction 25%. Stress thallium study was their sequelae 61 done to assess myocardial viability in 15 patients. All the patients D Ganguly, V Ravishankar, G Ganguly, SS Sidhu were in CHF and were aggressively treated with medications for Department of Cardiothoracic Surgery Army Hospital periods ranging from 10-14 days before being taken up for surgery. (Research & Referral) Delhi Cantt Pre-operative insertion of IABP was necessary in 4 patients and in 10 Background: Acute coronary syndromes are commonly classified patients it was inserted postoperatively. as unstable angina, Non Q wave MI and Q wave MI. All of these have Results: All patietns were operated using the conventional method common pathophysiology of atherosclerotic plaque rupture and of cardiopulmonary bypass and intermittent cross clamping of aorta. coronary thrombosis. This paper discusses the Army Hospital (R&R) LV was vented via the right superior pulmonary vein. IABP was used experience of surgery in cases of unstable angina and in cass of life in 14 patients. In one of these IABP was inserted via a conduit into the threatening complication of acute MI i.e. post infarction VSD and LV ascending aorta, as there was peripheral vascular disease involving wall rupture. both common iliac arteries. Methods: From January 2001 to September 2002 there were 24 Postoperative recovery of all patients was good. There was an cases of unstable angina out of 190 cases of CABG opted (12.6%). 15 improvement in the ejection fraction to 35-40%. Three patients required cases could be stabilized on medical management with Heparin and prolonged inotropec support [ranging from 3-5 days]. There were no NTG and were taken up for surgery electively during the same postoperative infections. There were two deaths, one on the 14th day hospitalization. However 9 cases did not respond to treatment and and the other on the 28th day after surgery due to respiratory infections were taken up for emergency CABG. [due to poor respiratory effort]. Results: 2 patients needed on line haemofiltration due to pre Conclusion: Thus coronary artery bypass surgery remains an existing renal impairment. 7 out of 24 patients needed IABP support. important method of treatment for patients with Ischemic 8 patients required 4-12 hrs of post op ventilation. There was one Cardimyopathy with congesive heart failure. Coronary artery bypass mortality in this series. This 70 yrs old lady died of septicaemia and surgery has acceptably low morbidity and mortality in this subset of renal failure on 6th post op day. All patients have been under follow- patients. up. One patient was readmitted with LVF after 15 days of discharge but improved with optimization of medical management. Complication following acute MI is usually life threatening and Left ventricular free wall rupture – A case report needs urgent surgical management. In this series there were 6 such CS Sheen Peeceeyen, TT Abdul Vahab, AV Kannan, 63 cases apart from 24 cases of unstable angina discussed above. They Murali P Vettath were as follows :- Department of Cardiac Surgery, Malabar Institute of Medical Post infarct VSD :-2 cases, they underwent VSD closure and CABG, Sciences, Calicut, Kerala Post MI ischaemic MR:- 2 cases they underwent MVR and CABG, Introduction: Left Ventricular free wall ruptures occur more Post infarct LV Pseudoaneurysm (LV wall rupture). They underwent frequently than ventricular septal ruptures after Myocardial Infarction. repair of the LV wall defect. Acute ruptures are usually fatal. Subacute and chronic ruptures All the these cases underwent emergency surgery. There was one present with cardiac tamponade or pseudo aneurysm. Surgical repair mortality. This 76 years old lady a case of post infarct VSD who already is inevitable for survival. had a cardiac arrest before operation and was on ventilation and IABP. Case Report: A 70-year old man was referred as a case of She remained in low c.o. after operation and died 6 hrs post op. Congestive cardiac failure. He was admitted in shock, with features of cardiac tamponade. Eacho revealed pericardial effusion with multiple strands in the pericardium. Emergency surgical decompression of tamponade was performed through a subxiphoid Coronary artery bypass surgery in ischemic incision under local anesthesia. Patient stabilized haemodynamically cardiomyopathy 62 and discharged after a week. Postoperative echo revealed Murali Babu, PSS Srinivas, V Sujatha, K Gopala Krishna, pseudoaneurysm of LV. He had no history or evidence of coronary T Rajendra Prasad artery disease or myocardial infarction. Seven Hills Hospital, Visakhapatnam Coronary angiography after 8 weeks revealed solitary lesion in Objective: In the current scenario Ischemic Cardiomyopathy Marginal circumflex and LV angio showed a faint filling of the cavity represents the commonest cause of congestive heart failure, with through a narrow outlet from the LV free wall. Surgical repair of the figures ranging from 40-70%. pseudoaneurysm was done by closing the narrow fibrotic opening Ischemic Cardiomyopathy represents the cumulative effects of with interrupted pledgetted mattress suture. The patient had an myocardial ischemia [stunning and hibernation] and infarction, uneventful stay in the hospital and was discharged on the 8th followed subsequently by ventricular remodeling. Postoperative day. In patients with ICM, all these states coexist and have tremendous This case is being presented for the uniqueness of its clinical importance in the prediction of prognosis after CABG. presentation, especially with no history or clinical features suggestive The aim of this presentation was to analyze the factors that are of preceding myocardial infarction. responsible for morbidity and mortality of patients with ICM and the effect of surgical revascularisation in improving the quality of life and survival in such patients. Methods: In our institution 242 patients underwent CABG since Re-do CABG where LAD was not grafted during first CABG May 2001. Of these patients 29 preented with Ischemic 64 Rajesh Desai, Sukumar Mehta, Utpal Shah, Sandeep Agarwal, Cardiomyopathy. Twenty-one of them were males and eight females. CRN Rao, Bipin Shah, Savrin Shah Average age of the group was 65 years. [The oldest patient operated Krishna Heart Institute, Ghuma, Ahmedabad was 79 years of age]. Sixteen patients were diabetics, 20 were hypertensive and eight had associated COPD. Objective: Review of Re-do CABG where LAD was not grafted in All had severe triple vessel disease with ejection fraction ranging the first operation.

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Method: 5 cases of re-do CABG were reviewed in last two years CABG at our institution. 745 (66.28%) were done off pump while 379 where LAD was not grafted in the first operation. All except one had were done on CPB. At 3 months patients were assessed for symptoms CABG done in India. All where operated after they had undergone (angina). Treadmill test was done using modified Bruce protocol. repeat angiography after they reported with severe symptoms. Their There average number of grafts was 3.1 in off pump and 3.3 in on latest angio were reviewed with the previous angiograms and their pump. LIMA was used in 98.4% in off pump and 98% in on pump. operation notes of the first surgery were also reviewed in details. Results: In both groups all the patients who were revascularised Results: n All patients had arterial grafts on their LAD. completely, remained asymptomatic and treadmill negative. Among n All were operated on Beating Heart. the incompletely revascularised patients, 1 in off pump group (0.1%) n No postoperative complication. and 3 in on pump group (0.7%) had angina in NYHA class II (p>0.05). n Patients were followed up with TMT and Echo. TMT was positive (mild to moderate) in 5(0.5%) and 7(0.8%) patients n One patient underwent a repeat angio which showed respectively in off pump and on pump groups. None of the patients functioning LIMA to LAD. reviewed had required readmission. Conclusion: LAD not grafted at the first operation should not be Off pump CABG gives comparable functional results at 3 months taken as non graftable. LAD grafted with LIMA will definitely improve follow-up. the quality and duration of surgery.

Radial artery as a conduit-lessons learnt Surgical treatment for infarct-related ventricular M Prasanna Simha, HCF Shanmukh, Ravishankar Shetty, 67 septal defect 65 Anil D Prabhu, PSS Bhat, AN Prabhudeva G Usha Rani, K Ch Venkateshwara Rao, Sri Jayadeva Institute of Cardiology, Bannerughatta Road, G Rama Subrahmanyam, NVN Varma, V Ravi Shankar Bangalore Care Hospital, The Institute of Medical Sciences, Nampally, Objective: Hyderabad The radial artery has been used as a conduit on and off in our institute since 1995. The routine use was tempered at times by Method: Twelve patients underwent surgical repair of post the presence of radial artery spasm. We have used a protocol in the infarction ventricular septal defect in our institution between 1995- last 104 cases which has proved to be reliable and has permitted 2002. Infarction was : anterior in 6 patients, inferior in 4 and combined minimally invasive harvest as well. anterior and inferior in 2 patients. Dacron patch was used to close the Changes in the methodology involved ventricular septal defect in 7 patients. Pericardial patch was used in 4 1. Initiation of a Milrinone infusion as soon as induction was patients and 1 patient had device closure of ventricular septal defect started. on cardiopulmonary bypass. 2. Infant feeding tube to loop and artery and rigorous Results: The overall mortality was 41% in this group. After implementation of a policy of keeping the tube curved institution of improved perioperative protocols like early insertion of throughout dissection to avoid traction. IABP, early operation, intraoperative ultrafiltration. Modified 3. Wide predicle while harvesting. ultrafiltration, delayed sternal closure, post operative continuous renal 4. Perfusion of the radial artery with warm blood+ replacement therapy in renal dysfunction patients, the mortality and Nitroglycerine+Milrinone+Papaverine mixture. morbidity has come down considerably. 5. Immediate anastomosis of the radial artery to the ascending Factors that were found to influence early death are: 1. The aorta to allow pulsatlle perfusion till the LIMA to LAD percentage of infarcted area, 2. The presence of cardiogenic shock, 3. anastomosis is completed. The presence of multiogran dysfunction, 4. Residual ventricular septal 6. Postoperative low dose IV Milrinone and oral Diltiazem once defects after repair. oral feeding is permitted. Late follow up was 90% and acturial survival is 85.7% at 5 yrs. Results: We had 2 postoperative deaths (1.9%) due to low output Survivors had mild to moderate LV dysfunction (mean EF=42%). and one perioperative infaction (0.9%) Conclusion: Device closure of post infarction ventricular septal Conclusion: The radial artery can be used regularly as a conduit defect along with assosciated procedures like Coronary Artery Bypass provided due care is exercised. Grafting Surgery, in appropriate cases offers an alternative method of management in this high risk group patients, by reducing the pump time. Our experience suggests that an aggressive approach should be taken in recommending early surgical intervention for post infarction ventricular septal defect before hemodynamic deterioration ensues Facile minimally invasive radial artery harvesting and severely compromises chances of survival. with a regular OT equipment (Laryngoscope) 68 M Prasanna Simha, HCF Shanmukh, Ravishankar Shetty, Anil D Prabhudev, PSS Bhat, AN Prabhudeva Sri Jayadeva Institute of Cardiology, Bannerughatta Road, Bangalore Functional results of Off pump vs On pump Background: 15 consecutive patients undergoing CABG with one CABG- 3 months follow up 66 radial artery as a possible conduit were slected for the study. John EV, Bakhtawar Murali, AR Raghuram, LF Sridhar, An infusion of 0.35 µg/Kg/min of Milrinone was started from MR Girinath induction. Initial dissection of the radial artery was done by a cut Apollo Hospital, Chennai down at the wrist and a conventional Laryngoscope was introduced Background: With more and CABG being done off pump, it is and progressive dissection was performed using a Mixter, only necessary that we look at the results critically. This study aims at electrocautery ligaclips. Additional new incisions were made as functional assessment at 3 months follow-up. required. The artrery was perfused with warm blood+Papaverine+ Methods: From June 2001 to June 2002, 1124 patients underwent Milrinone+Nitroglycerine mixrure and was anastomosed to the aorta

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and allowed to distend by aortic pressure till the LIMA to LAD revascularization for a wider territory, myocardial revascularization anastomosis was performed. (Grafting was done on pump for all the with "T" and "Y" graft was introduced in the 1990's using radial artery 15 cases). Graft flow was assessed by releasing the bull dog prior to and RIMA. In the absence of adequate angiographic follow-up - safety, anastomosis. Postoperative monitoring was done by online ECG/ST efficacy and reproductability of this procedure remain doubtful. In monitoring, cardiac enzymes and echocardiography. this prospective study we did total arterial revascularization on Results: 2 cases requiring partial open conversion for a slipped beating heart in 1012 cases using octopus suction device and clip and damage to a part of the distal radial artery. There was no angiographic results of 240 patients is presented. radial spasm perioperatively. A Typical harvest required 2-3 incisions Method: Total arterial coronary revascularization was performed typically 3 cms long and a small stab to apply the terminal clip Patients on the beating heart in 1012 cases (Age range 32--86 years) without were satisfied with the result and did not report any paresthesia or any selection bias. Single vessel disease was present in 97 (8.91%) cases, limb dysfunction. The harvesting time progressively decreased from double vessel disease in 246 (25.43%) and triple vessel disease in 766 30 minutes to 18 minutes. (65.66%) cases. Ejection fraction of less than 30 was present in 157 Conclusion: Facile minimally invasive radial artery harvesting is (15.1%) cases and preoperatively IABP was present in 18 (1.99%) cases. possible by using routine equipment available in a conventional Most of the patients were operated through midsternotomy and 27 cardiac operating room. cases through ThoraCAB. Postoperative angiogram before discharge was done in 250 (24.26%) cases. Various graft included LIMA (n=998), RIMA (n=190), radial & free RIMA (n=850 and 28 respectively) to make 'Y' with LIMA. A total of Coronary artery bypass surgery in patients above 3401 graft were put (range 1 to 6 grafts, average 3.36 grafts per 70 years of age 69 patients). Operative mortality was 0.5%. There was no incidence of Authors Names ????? stroke. The incidence of renal impairment was very less, even in Krishna Heart Institute, Ghuma, Ahmedabad patients with chronic renal failure. Blood transfusion was not required in 702 (69.99%) patients and 204 (20.42%) patients required one unit Objective: To review results of CABG in patients above 70 years of blood. Mean hospital stay was 5.6 days. Overall angiographic and to analyse the advantages of beating heart surgery in this age patency was 98.62%. Follow up ranged from 1 to 20 months. Eight of group. our patients died (3 had sudden death and 5 Patients died due to Method: Retrospective review of 159 patients who underwent non-cardiac causes) during follow up. Rests of the patients are doing CABG at our institute. CABG was performed on beating and non- well with improvement in functional status. beating heart. In the first year large number of patients underwent Total arterial revascularization on beating heart is a safe, effective conventional CABG. However in the second year 80% underwent and reproducible means of revascularization in almost all the patients CABG on beating heart. with excellent short-term patency rates and minimal morbidity. Results: 159 patients above 70 years underwent CABG from 1-5- 2000 to 30-9-2002. Six patients who underwent additional valve procedure and VSD closure were excluded from this study. Ninety patients underwent routine CABG and sixty-three underwent CABG on beating heart. Total 430 grafts (2.8 per patient) were put, out of which 254 were arterial grafts (approx. 60%) Mortality and morbidity Long-term results of mitral valve repair for were comparable in both groups. However there was a distinct non-rheumatic mitral regurgitation 71 advantage in beating heart group when operation time, ICU stay, need Roy S, Choudhary SK, Sampath Kumar A for BT, postoperative investigations, drugs, antibiotics and overall All India Institute of Medical Sciences, New Delhi hospital stay was concerned. Conclusion: n CABG in patients above 70 is as safe as in young Objective: This retrospective study analyses the long-term results patients. of mitral valve repair in patients with severe mitral regurgitation (MR) n Possible to put arterial grafts in most of these of non-rheumatic etiology. patients. Materials and Methods: Between Jan 1998 and April 2002, 116 (59 n Beating heart in this age group is more safe and males) patients with severe MR of non-rheumatic etiology underwent comfortable from all angles compared to mitral valve repair using a variety of techniques. The mean age of the conventional surgery. patients was 26.4 years (range 2-67 years). The causes of MR included n 90% of patients above 70 years are operated at congenital in 56, myxomatous in 44, infective in 7 and ischemic in 9. our institute on beating heart surgery. Ninety of these were in preoperative New York Heart Association class III and 26 were in class IV. Reparative procedures included: Posterior Teflon Felt Collar Annuloplasty (Modified Cooley's) in 80; Chordal Shortening in 37; Cusp excision in 34; Cusp thinning in 30; Cleft closure in 8; Chordal transfer in 6; Neochordae in 3. Total arterial revascularization on beating heart Results: The early mortality rate was 3.4% (4 patients). Follow-up (Our experience in 1012 cases) 70 ranged from 1-167 months (mean 47 months) and was 95% complete. Surya Mishra, Harpreet Singh, Deepak, Sanjula, SK Sinha There were 2 late deaths (1.7%). Six patients (5.2%) underwent Deptt. of Cardio Thoracic & Vascular Surgery, Batra Hospital, reoperation for severe MR post-repair. Ninety of the remaining 104 New Delhi patients (86.5%) have none or trivial MR at last follow-up. Actuarial, Introduction: In an attempt to avoid the deleterious effect of reoperation-free, and event-free survival in operative survivors at 130 cardiopulmonary bypass, off pump coronary artery bypass grafting months was 93±6%, 89.9±6% and 69.7±13.7%, respectively. Ninety has been rediscovered and refined, particularly with the advent of two of the 104 (88.5%) patients are in NYHA class I at last follow-up. better stabilizing devices (Octopus: Medtronic, Minneapolis, MN). Conclusion: Mitral valve repair in non-rheumatic group of patients Internal mammary artery is widely recognized as the ideal conduct gives extremely satisfactory results with current surgical techniques for coronary artery bypass procedures. To achieve total arterial and represents the preferred option in this subset of patients.

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Is aortic root in indians small? Conclusion: The antibiotic preserved or cryopreserved SK Choudhary, A Sampath Kumar, B Airan, A Bhan, 72 homografts are morphologically nonviable. The collagen network is UK Chowdhury, AK Bishoi, P Venugopal mostly preserved and provides the basis for homografts function. All India Institute of Medical Sciences, New Delhi Background: It is generally believed that aortic roots are small in Indian patients and are not suitable for insertion of # 25 or larger prosthesis. We undertook a clinical and a cadaveric study to assess Bicuspid aortic valve and ross procedure: this. Clinical and pathologic correlation 74 Methods: The preoperative profile and the surgical outcome of SK Choudhary, R Roy, V Devgourou, A Sampath Kumar patients undergoing isolated aortic valve (n=1133) between January All India Institute of Medical Sciences, New Delhi 1993 and December 2001 were analyzed. Either a Bjork-Shiley valve Objectives: The present study was performed to assess the (n=152) or an St Jude valve (n=1081) was used. Besides this, 509 degenerative changes in the pulmonary artery of patients with cadaver hearts were also studied for the size of aortic valve. bicuspid aortic valve (BAV) and its implications following the Ross Results: A total of 591 patients (52.2%) received a prosthesis # 25 procedure. or larger. The etiology (rheumatic vs non-rheumatic) and the Methods: Degenerative changes were assessed in samples of predominant lesion (AS or AR) did not affect the use of a large valve. ascending aorta and pulmonary artery walls obtained from patients However, the operating surgeon was the most important determinant with BAV (Group A, mean age 32.5±15.1 years), or tricuspid aortic of the use of a large valve (OR 2.1, 95% CI 1.7-2.7, p<0.01). Use of valve (TAV) (Group B, mean age 37.4±16.6 years), and from cadaveric larger valve did not affect the operative mortality or introperative/ donors (Group C, mean age 37.4±11.6 years). Survivors of Ross postoperative hemorrhage. Follow up ranged from 6 to 108 months. procedure (n=127), operated on between October 1993 and July 2001, The incidence of valve thrombosis was 0.15 ppy and 0.25 ppy in were also followed up for autograft insufficiency or dilatation. patients who received a prosthesis size > 25, or size <25, respectively. Results: Prevalence of degenerative changes in both the aorta and The incidence of paravalular leak was slightly higher (7 or 3) in patients the pulmonary artery were similar in all the 3 groups. However, the who received a smaller valve (<25%). The resting peak gradients across changes were more severe and occurred at an earlier age in pateints the aortic valve ranged from 21 to 46mmHg (26.8±8.4mmHg)/(m2) with BAV. Smooth muscle disorientation and elastic fragmentation for # 19 valve, whereas it was 0-4mmHg for # 31 valve. Cadaveric were characteristically seen in younger patients with BAV. The study: 509 hearts were studied. The mean aortic diameter in adult prevalence and severity of degenerative changes increased with age males (age 16 to 60 years) was 23.1±1.8mm; in adult female (aged 16 (p <0.01) in all 3 groups. Presence of degenerative changes in aorta to 47 years) it was 21.1±2.3mm. These correspond to valve area of significantly predicated for similar changes in the pulmonary artery 4.1cm2 (range 3.5-4.9 cm2) and 3.4 cm2 (range 2.7-4.3 cm2), respectively. (p=0.00). After the Ross procedure, mean follow up for patients with Conclusion: Irrespective of the etiology and lesion more than 50% BAV (n=50) was 46.0±14.8 months and only 2 patients had mild of our patients could accommodate a large valve (>25). Hence, autograft regurgitation. There was no autograft dilatation. Patients smallness of aortic root in Indians appears to be a myth. The mean with proven degenerative changes in their pulmonary arteries and aortic diameter (23.1±1.8mm) of Indian adult males corresponds to who underwent Ross procedure (n=4) did not show any autograft an St Jude Medical valve of 25 to 31 mm. For complete, gradient-free, insufficiency or dilatation (follow-up 2 to 24 months). physiological correction, a larger prosthesis should be chosen. Conclusion: Degenerative changes in the aorta and the pulmonary artery were equally prevalent in the subjects with BAV or TAV and appeared to be age related. However, changes were more severe in patients with bicuspid aortic valve. The surgical outcome following Pathology of explanted homografts Ross procedure remained unaffected by these changes. SK Choudhary, R Roy, SKM John, A Sampath Kumar 73 All India Institute of Medical Sciences, New Delhi Objective: The present study was undertaken to find out the morphology, cellular viability, and integrity of extracellular matrix in explanted antibiotic preserved or cryopreserved homografts. Follow-up of aortic valve replacement in patients with severe left ventricular dysfunction Methods: A total of 16 explanted homografts (8 mitral, 5 75 SK Swain, AK Bisoi, A Sampath Kumar, B Airan, A Bhan, pulmonary, and 3 aortic) were studied. Seven of these were antibiotic SK Choudhary, UK Chowdhury, S Chauhan, KK Talwar, P Venugopal preserved, whereas 9 were cryopreserved. Eight of these were All India Institute of Medical Sciences, New Delhi homograft mitral valve replacement (recipients age at implantation 15 to 45 years), 6 were aortic valve or root replacement (recipient's Objective: Aortic valve replacement (AVR) for aortic valve stenosis age 11 to 55 years), and 2 were right ventricle to pulmonary artery (AS and regurgitation (AR) in patients with severe LV-dysfunction conduit. Homografts were explanted after 8 weeks to 84 months of carries an increased perioperative mortality and morbidity. The aim insertion primarily due to valve failure, infection, or growth-related is to highlight on the outcome of such patients. conduit stenosis. Methods: 140 consecutive patients with severe LV-dysfunction, Results: The homograft cusps showed servere loss of normal undergoing AVR for either AS (n=60) or AR (n=80) were investigated. structure and cellular components. The leaflets showed loss of In the AS group the preoperative characteristics were: EF 21±6%: mean nucleated cells and appeared as anucleated structures. The endocardial gradient 40±9%, valve area 0.5±0.25 cm2. The characteristics for AR lining was lost in all the cases. Cuspal structure was typified by group were EF 19±4%. All the patients were in NYHA Class-IV. 50 hyalinized collagenous sheet. The normal layered appearance of the patients (35.7%) were on inotropic support before surgery. Six patients valve was not discernible in any of the cases. there was no evidence had CABG alongwith AVR. Follow up examination including chest of inflammation. Some of the cusps showed focal calcification. The X-ray, echocardiography and exercise testing were performed. papillary muscles in subvalvular apparatus of mitral homografts also Results: Six-in-hospital death (As group -4, AR group- 2) occured. underwent coagulative necrosis and lacked significant inflammatory Survival rates for AS were 1-year 91%, 2 year 87%, 5 years 76%: for infiltrate. AR: 1 year 86%, 2 year 80%, 5 year 74%. All patients had significant

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NYHA class improvement. The LVEDD decreased in AR patients from Left ventricular mass regression after aortic 76±12 mm to 54±9mm over 1 year. The EF improved to 41±11% during valve replacement: RTIICS experience 78 follow up. a short term study Conclusion: Despite severe left ventricular dysfunction and K Padhy, P Alam, A Saha, S Behra, K Sarkar, A Raghuvanshi increased 1 year mortality, Aortic Valve replacement was associated Rabindranath Tagore International Institution of Cardiac with improved functional status and LV function. Sciences, Kolkata Background: Left ventricular hypertrophy occurs secondary to pressure and volume overload or both in chronic aortic valve disease left ventricular hypertrophy has been shown to be a risk factor for Irrigated radiofrequency modified maze stroke, myocardial infarction and death and adversely affect LV precedure in treatment of atrial fibrillation 76 function and late outcome after aortic valve replacement. Thus its G Usha Rani, NVN Varma, M Gandhi, D Prasada Rao regression is an important marker of surgical benefit after Aortic Valve CARE Hospital, The Institute of Medical Sciences, Nampally, Replacement. Hyderabad Methods: From October 2000 to October 2002 and total of 104 cases of Isolated aortic valve replacement done at RTIICS. The valves Background: The Maze procedure is the only surgical treatment implanted ranged in size from 17 to 29 mm size. Patients were studied that can alleviate the three physiologic sequelae of atrial fibrillation by echocardiography pre operatively, at discharge, at 1 month, at 6 i.e. tachycardia, thromboembolic events and hemodynamic and 12 months. LV diameter and thickness were measured using 2-D compromise. In an effort to reduce the number of incisions required echocardiography and M-Mode echocardiography. LV mass was for the Maze procedure on irrigated radiofrequency device can be calculated. used to create the majority of the required lesions. Results: LV end- systolic diameter, end- diastolic diameter, septal In this study we used an irrigated radiofrequency device to create thickness and wall thickness decreased significantly after surgery blocks in lines of conditions in both atria during cardiac surgery. Nine (p<0.001). LV mass index reduced after surgery significantly. High patients with atrial fibrillation for at least 1 year and structural heart blood pressure, EF <35%, NYHA class III or more, AF are risk factors disease underwent open heart operation and an irrigated and adversely affect the outcome and influencing the regression. No radiofrequency modified maze procedure. correlation has been observed between size of valve and mass All 9 patients underwent Mitral valve replacement. 3 patients regression. underwent tricuspid valve repair and 1 patient underwent Aortic valve replacement as concomitant procedures. The additional cross clamp time required for the left atrial part of irrigated radiofrequency modified maze procedure was 15+3 minutes. The additional pump time to perform both left & right atrial maze procedure was Ischemic mitral regurgitation – Management with 28 mts.+5 mts. mitral valve replacement and coronary artery 79 Results: The hospital mortality rate was nil in this group of bypass grafting – Out comes patients. Freedom from atrial flutter or atrial fibrillation was 88.8% in G Ramasubramanyam, G Usha Rani, K Ch Venkateshwar Rao, G Nagasaina Rao, KV Ramana Raju, NVN Varma, M Gandhi, B Pavan this group of patients. Right atrial and left atrial transport function Kumar, D Prasada Rao was studied by electro cardiography, Doppler Echo cardiography post Care Hospital, Hyderabad operatively. Conclusion: We conclude that irrigated radiofrequency modified Background: Although several authors have favoured mitral repair maze procedure as an adjunctive procedure is safe, time sparing and in ischemic mitral regurgitation, mitral valve replacement is a valuable effective in eliminating atrial fibrillation & restoring atrial transport option and most often a necessity for patients with structural ischemic function. mitral regurgitation. Objective: To review the institutional experience with valve replacement for patients with acute and chronic ischemic mitral regurgitation sustained after myocardial infarction. Materials and Methods: Thirty-five patients operated between Starr Edward valve at mitral position June’99 to June’02 were analyzed retrospectively. There were about P Alam, A Saha, K Padhy, S Behra, K Sarkar, A Raghuvanshi 77 28 (80%) male and 7 (20%) female patients with mean age of 58.21±7.97 Rabindranath Tagore International Institution of Cardiac (range 41 to 75). Preoperatively, 6 (17.1%) patients were New York Sciences, Kolkata Heart Association (NYHA) class IV, 14 (40%) patients were in class III, and 10 (28.5%) patients in class II. The mean EF was 49.5±9.75. All Background: A Retrospective study was done to evaluate the patients had severe mitral regurgitation by Trans Esophageal haemodynamic profile and result of Starr Edward valve at mitral Echocardiography (TEE) prior to operation. Out of 35 patients, 26 position from October 2000 to September 2002. (74%) were elective and 9 (26%) were operated on emergency/urgent Methods: One hundred and Thirty seven patient underwent mitral basis. valve replacement with Starr Edward valve at our insitution. 97 patient Results: All 35 patients underwent Coronary Artery Bypass have isolated mitral valve pathology and 40 have both mitral and Grafting (2.64±1.03 grafts) and mitral valve replacement; 34 (97.14%) aortic valve pathology. 89 patients have regurgitation lesion and 48 with mechanical prosthesis and 1 (2.8%) with biology prosthesis. The have mitral stenosis. In 8 tricuspid annuloplasty was done, 3 received CPB time was 154.04±41.29 minutes. Of thirty-five, seven were with prosthetic ring. acute structural disease, of which 4 (11.4%) were chordal rupture with Results: Post op echo showed mean gradient of 7.2 mmHg. Three Leaflet Prolapse and 5 (14.2%) were Posterior Papillary Muscle rupture was no major thromboembolic complication and stuck valve. One with Leaflet Prolapse. The over all mortality (odds ratio 0.78) was patient died in early post op period. 17%, constituting 3 patients (8.5%) in 30-day mortality and 3 (8.5%) Conclusion: Starr Edward Prosthetic valve in mitral position has late deaths at mean follow-up of 20 months. The mortality was high good haemodynamic profile and no major post operative problem. when operated on emergency basis (i.e., 4 out of 9 patients, 44.4%)

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compared to (2 out of 26 patients, 7.6%) elective cases. Patient Medtronic valve was used in 60 cases and carbomedics valve in 37 morbidity includes episodes of CHF (11%), TIA (5%), Renal and cases. 94 patients had no mitral valve preservation done, while 3 Hepatic dysfunction (8.5%). The major risk factors were Hypertension patients had total mitral valve preservation. (85.7%), Diabetes Mellitus (60.7%), Smoking (21.4%) and Family Results: Out of 97 cases there was an overall mortality of 11 cases. history (7.1%). 12 patients (34%) required Intra Aortic Balloon Pump. Early mortality due to massive haemorrhage was seen in 2 cases, Conclusions: Mitral valve replacement combined with myocardial irreversible myocardial failure was seen in 4 cases (all 4 cases had revascularization in non-emergency cases has better outcomes than thromboembolic episode in form of hemiparesis and pre-op inotrope in acute situation. Preoperative risk factors for early mortality are, support) while 5 cases died of sepsis with multiorgan failure. 1 patient emergency operation and reduced left ventricular function, where as had postop cerebrovascular accident while none of them had incidence renal and hepatic dysfunction are factors for late mortality. The of Stuck valve. survival of the patients in the acute structural mitral disease subgroup Conclusions: This study reflects incidence, Management and was significant worse. prognostic value of Rheumatic MS with LA Clots.

Anticoagulation clinic in a super speciality Anticoagulation dose to maintain higher INR cardiac center 80 for high risk patients with mitral valve 82 Hannah Satish, Sunitha C Srinivas, Muralidhar, replacement helps in reducing thromboembolic Prem Anand Nagaraja, Shyamala Bhaskaran complications – A preliminary report Narayana Hrudayalaya Institute of Medical Sciences, Drug K Madhan Kumar, Irineu, Chiran Babu, Anil Kumar, J Balachander, Information Centre, Karnataka State Pharmacy Council, Al-Ameen M Nachiappan, KSVK Subba Rao College of Pharmacy, Bangalore JIPMER, Pondicherry Introduction: Inadequate anticoagulation represents an important Background: The patients undergoing MVR for complicated and frequently encountered problem in Warfarin therapy. Having mitral valve disease have higher risk of thrombo-embolic initiated a anticoagulation clinic in our institute, we investigated phenomenon. This study evaluates the role of higher dose of awareness among heart-valve recipients on Warfarin. anticoagulation in these patients. Methods: A process was initiated for preparing and standardizing Materials and Methods: Total number of patients in each group the counseling material to be handed over to the patients who was 24. Study group (INR=3 to 3.5) was evaluated prospectively underwent heart valve replacement and needed Warfarin for life. 42 from September 2001 to August 2002 with a follow-up ranging from Valve recipients along with one family member each attended an 2-14 months. Control group (INR=2 to 2.5) was evaluated Awareness Workshop. Participants answaered four questionnaires retrospectively from September 2000 to August 2002 with follow- during the course of the workshop. up ranging from 14-26 months. The risk factors being large LA, Results & Discussion: Participants reported high awarness with H/o CVA, AF, LA clot, restenosis and LV dysfunction. regards to the importance of Warfarin therapy (100%), the need for Observation: In study group, M:F 17:7 with age range of 16-47 standardized labs (100%) and the need to inform dentists before any years. Large LA was found in 12, H/o CVA in 2, AF in 17, LA clot procedures (100%). Awareness of Vit-K and its influence on PT/INR in 8, restenosis in 4 and LV dysfunction in 4 patients. Valve used was low (50%) and only 24% reported stocking extra Warfarin at home. were TTK Chitra (17), Bileaflet (1) and Ball & Cage (6). Mortality 62% of valve recipients were aware of other drugs that may interfere was three, two due to arrhythmia and one due to low cardiac output with Warfarin. Awareness of all aspects of Warfarin therapy had state. significantly increased after the session, as evidenced by the post-test In control group, M:F 15:9, with age range of 14-26 years. Large results. LA was found in 17, H/o CVA in 1, AF in 15, LA clot in 5, restenosis Valve recipients continue to contact the Anti coagulation clinic on in 4 and LV dysfunction in 5 patients. Valve used were TTK Chitra a regular basis for adjustment of the Warfarin dose after getting their (10), Bileaflet (1) and Ball & Cage (13). Mortality was three, two INR results. had thrombotic occlusion of the prosthetic valve and one had CVA Participants reported high adherence to their medication and drug with renal failure. regime. Few participants were aware of dietary practices affecting Conclusions: Higher dose of anticoagulation helps in reducing Wafarin therapy. Awareness & compliance have important roles in thromboembolic complication in MVR patients without increasing achieving stable and adequate anticoagulation in heart valve the incidence of dose related hemorrhagic complication. However recipients. this is an early report and further follow-up is needed.

Mitral valve replacement in rheumatic MS Prosthetic valve endocarditis – JIPMER experience with LA clots - A study of 97 cases 81 N Sabanayagam, Chiran Babu, Sai Chandran, Anil Kumar 83 Sanjeev Devgarha, Vikas Ahlawat, Ramgopal Yadav, J Balachander, M Nachiappan, KSVK Subba Rao Vinay Naithani, Anil Sharma, CP Srivastava JIPMER, Pondicherry Department of CTVS, SMS Medical College, Jaipur Methods: From January 1986 to September 2002, 447 patients Introduction: Patients with Rheumatic MS often have LA clots. underwent valve replacement operation in JIPMER 9 (2%) of them These are usually seen inpatients with large LA, in patients with AF developed prosthetic valve endocarditis. 6 (66%) of them underwent & in patients with history of thromboembolic episode. valve replacement in their third decade. 7 (77%) are males and 2 (23%) Methods: Since January 2001 to August 2002, 97 such cases of are females. Prosthetic valve endocarditis (PVE) occurred in aortic Rheumatic MS with LA clots were operated and reviewed position in 6 (66%) and in mitral position in 3 (33%). Early prosthetic retrospectively. In all 97 cases Mitral valve replacement was done. valve endocarditis occurred in 8 (88%) and late in 1 (12%). In 8 cases

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(88%) tilting monodisc valve was used and in 1 case (12%) ball and standard transseptal incision – The T incision and its benefits over cage valve was used. Complications during the course of illness conventional transseptal and left atrial approach. occured in the form of aortic root abscess (1), CVA (2), stuck valve (2), Materials and Methods: Between Jan 2001-June 2002 total 100 peripheral emboism (1) and splenic abscess (1). patients were operated in our institute for mitral valve replacement. Results: Surgery was done in 3 patients (33%) of whom 1 survived. Fifty patients had modified transseptal approach (Group I) In this a T 6 patients were managed medically of whom 3 survived. Overall shaped incision was made in the septum. Fifty patients had mortality was 55%. conventional left atrial approach (Group II) for mitral valve Conclusion: We conclude that PVE occurs more commonly in replacement. Preoperative demongraphic variables, ECG findings, and aortic position and with monodisc valves. PVE carries a high mortality echocardiographic findings were compared. Intraoperative variables and prevention is better than cure. like CPB time, cross clamp time, and exposure of mitral valve were compared. Postoperative, blood loss, rhythm disturbances, echocardiographic changes and mortality were compared between two groups. Modified ross procedure: The aortic valve Results: procedure for the young There was no significant difference between two group 84 in preoperative variables. Mean CPB time (118.33±37.17 vs Srirup Chatterjee, Satyajit Bose, Sushan Mukherjee, Bishnu Kumar Deka, Tanmoy Das, Simran Gupta, Saikat Sengupta 104.84±39.3) mean Cross clamp time (78.92±30.97 vs 72.65±32.85) were Suraksha Hospital, Salt Lake City, Kolkata not statistically significant between two groups. Excellent exposure of mitral valve was obtained in all patients (50 out of 50) in group I Background: The Ross procedure holds credence as the best and 25% patients in group II. There was no significant difference possible method to provide a valve substitute which is next only to between two groups in the blood loss. No statistically significant the normally functioning native aortic valve in terms of growth difference in the rhythm noticed in modified transseptal group potential, flow dynamics and gradient. compared to left atrial group. There were two deaths, one in each Methods: There has been many modifications since, and we report group. None of them were related to any arrythmias. our results in the 47 cases of the Modified Ross Operation since June Conclusion: Modified transseptal approach gives much better 1997. The Male to Female ratio was 33:14, age ranging from 4 months exposure for mitral valve replacement especially when there is small to 35 yrs. There were 40 cases of rheumatic pathology, 4 cases had left atrium without any complications during or after surgery. Congenital AR and 3 patients had AR due Endocarditis. The hemodynamic lesions were AR in 35, predominantly AS in 12. There was associated MR in 5 and one of them had GR IV TR, and 3 patients had associated VSDs. 37 cases were of the Autograft proceduree alone, Comparison of modified transseptal and standard transseptal approaches for mitral valve 86 5 patients had associated Mitral Valve Procedures, 3 repairs and 2 replacement replacements, and one patient had Tricuspid Valve repair, The RVOT RS Dhaliwal, U Rama Krishna, Saji was reconstructed with Gore-Tex tube Graft in the initial 6 cases, Gore- Chandigarh Tex tube with implanted Autologous Pericardial Valve in 11 cases, Gore-Tex tube with re-implanted patients's own Aortic Valve cusps Introduction: Satisfactory surgical management of acquired mitral in 14 patients, and BIOCOR RVOT Conduit Valves in 16 patients. valve disease requires optimal operative exposure without impairment The bypass techniques were standard using bicaval cannulae and of atrial physiology, namely SA node and AV node function. For good tepid blood cardioplegia, both antegrade and retorgrad. Aprotin in exposure of mitral valve various techniques have been described. Here was used with pump priming. The average bypass time has been 167 we described a modification in standard transeptal approach and mins and the average cross clamp times have been 133 mins. compared the result of this with standard transseptal approach for Results: There were two cases of re-entry secondary to post MVR. operative bleeding and one young man required a graft to the LAD Methods: Between Jan 2001 to June 2002 eighty two (82) patients due to difficulty in coming off bypass after a doubted injury to the who underwent MVR either by modified transseptal (Group II) or by LAD near the first septal branch. standard transseptal (group II) approaches were studied. Preoperative There was one early mortality (a four month old infant with demographic variables. ECG findings, echocardiographic findings endocarditis). There was an minimum improvement of one NYHA were noted. Intraoperative variables like CPB time, cross clamp time, class postoperatively. Post op echocardiography showed no AR in 33 exposure, and postoperative blood loss, rhythm disturbances and patients, Grade I in 11 patients and Grade II in 3 patients. All the echocardiographic changes were compared. biocor RVOT conduits have been working well. Results: There was no statistically significant difference in the Conclusion: We conclude that the Modified Ross procedure is an preoperative variables between two groups including cardiac rhythm, useful alternative for Aortic Valve replacement of the young and Fifty (50) patients had modified transseptal approach and 32 patients should be the procedure of choice whenever feasible. had standard transseptal approach for MVR. CPB time in group I was 104.84±39.30 and in group II was 101.62±32.85 (P>0.1 NS). ACC time in group I was 72.65±32.85 and in group II 71.82±24.85 (P>0.1 NS). Excellent exposure was obtained in 50 out of 50 in group I, 23 Comparison between modified transseptal patients our of 32 in gorup II. and left atrial approaches for mitral 85 There was no statistically significant difference in preoperative valve replacement and postoperative cardiac rhythms between two groups. Trasient RS Dhaliwal, U Ramakrishna, Davinder cardiac arrythmias were noted in few patients in the immediate Chandigarh postoperative period and most of them were reverted to normal preoperative rhythm once the underlying causes like hypokalemia Introduction: Various surgical modifications have been described were corrected. Persistent changes observed in 3% of patients in group to have an excellent exposure of the mitral valve during mitral valve I and 2% of patients in group II after 5 days (P>0.1 NS). There were surgery. But, many of them are associated with intraoperative or two deaths, one in each group, None of them were related to any postoperative complications. Here we described a modification in the arrythmias.

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Conclusion: Modified transseptal approach is an useful technical acitrom, warfarin and dindevan. 11 patients were changed to parentral modification of standard technique for an excellent exposure of the anticoagulants 48 hours before delivery. Oral anticoagulants were mitral valve. It is safe and carries no risk of cardiac arrythmias. continued in 15 patients who were admitted in advanced labour. 21 patients had normal vaginal deliveries and 5 had caesarean sections. None of the babies had embryopathy and the overall outcome of pregnancy was favourable. One mother went through 2 unplanned Closed mitral valvotomy - Still relevant in the pregnancies with no adverse effects. indian context 87 Conclusion: 1. Warfarin embryopathy may not occur as frequently Vikas Ahlawat, Sanjeev Devgarha, Ramgopal Yadav, as is quoted in literature. 2. In many circumstances continuation of Vinay Naithani, Anil Sharma, CP Shrivastava oral anticoagulants throughout pregnancy upto the time of delivery Department of CTVS, SMS Medical College, Jaipur can be done with no deleterious effect. 3. Deliveries must conducted in an adequately equipped unit with facilities for monitoring Introduction: Mitral Stenosis is the most common sequelae of coagulation parameters. Rheumatic Heart Disease seen in the Indian population. Patients commonly present in second and third decade of life with dyspnoea on exertion, palpitation, haemoptysis, orthopnoea. Treatment options are Closed Mitral Valvotomy, Balloon Mitral Valvotomy, Open Mitral Double valve replacement - Early results Valvotomy & Mitral Valve Replacement. Praveen Varma, Amit Misra, KS Neelakandhan 89 Methods: This study was carried out in the Deptt. of CTVS, SMS Department Cardiovascular & Thoracic Surgery, Medical College, Jaipur from January 1999 to September 2002. In our SCTIMST, TVM study of 449 patients, 427 cases had severe mitral stenosis with no calcification and no LA/LAA clot pre operatively while 22 patients Objectives: Double valve replacement carry significant mortality had associated mild MR. Age range was from 8 years to 52 years with and morbidity. Early mortality ranges from 10 to 15% in various average of 20±7 years. Out of 449 cases, 201 were males while 248 studies. Double valve replacements done in our institution from April were females (11 pregnant ladies who were operated in second 2001 to September done in our institution from April 2002 to September trimester). Surgical approach was left anteriolateral thoracotomy 2002 (18 months) were retrospectively analysed for outcome. via4th/5th ICS. Methods: 72 Double Valve Replacement surgeries were done in Results: Out of 449 patients who underwent CMV, 198 patients 71 patients. 50% of patients wre in NYHA Class III and 19.4% were in were dilated upto 3.25 cm2 while 194 patients were dilated upto 3.5 NYHA Class IV. 9.9% were in congestive failure. Predominant lesion cm2. Inspite of using2D-Echocardiography and Trans Esophageal was Mitral Stenosis with Aortic Stenosis. 11 cases had undergone- Echocardiography as routine preoperative investigations, there was closed Mitral Valvotomy. Associated Tricuspid lesion was seen in accidental finding of LA clot in 8 patients and calcified valve in 40 20.8%. 3 patients with re-stenosis died per-operatively, 2 of myocardial patients per operatively. 16 patients developed mild MR and 2 faillure and one of AV groove disruption. developed severe MR. There was an overall mortality of 14 cases (2 Results: Post operative complications included re-explorations for were pregnant females). Hospital stay was 6±2 days. Average bleeding (14%), cerebro-vascular accidents (2.7%), infective expenditure was 2000±500 Rupees. endocarditis (2.7%), prosthetic valve dysfunction (1.35%), and Conclusion: This study reflects that Closed Mitral Valvotomy is complete heart block requiring permanent pacemaker implantation an excellent operation in patients of Indian subcontinent as it is cheap, (1.37%). has good results with low mortality and gives patients symptom free Conclusion: Double valve replacements can be undertaken with palliation with native valve for 10±3 years acceptable mortality and morbidity.

Radio frequency ablation: A treatment modality Outcome of pregnancy in patients on oral for chronic - Atrial fibrillation: Aims experience 90 anticoagulants for prosthetic heart valves - 88 R Mahadevan, P Manoj, AP Chandrasekharan, Shiv K Nair, Some new insights Prakash Kamath, V Satya Prasad SK Varma, Jitendra Rathod, Srinivasan Muralidharan Department Cardiovascular & Thoracic Surgery, Amrita Institute of Department of Cardiothoracic & Vascular Surgery, G Kuppuswamy Medical Sciences and Research Center, Cochin Naidu Memorial Hospital, Coimbatore Patients & Methods: Three patients with Mitral valve disease (2 Background: This study was undertaken to analyse the outcome patient withsevere MS and 1 with MR) underwent Mitral valve of pregnancy in patients on oral anticoagulants for previously replacement with modified maze procedure using radio frequency implanted prosthetic valves whose oral anticoagulants could not be ablation. RA appendage was amputated and a T cut made changed to parenteral forms due to practical difficulties in monitoring perpendicular to the appendage. RA opened & RF ablation done from of anticoagulation. SVC to IVC, RA appendages to tricuspid valve across the interatrial Materials and Methods: We studied the records of 26 patients septum & then from Tricuspid valve to IVC. LA opened and RF with prosthetic heart valves who had deliveries between 1992-2002. ablation done around pulmonary veins connecting the two & from 15 patients had MVRs, 7 had AVRs and 4 had DVRs. The prostheses these to the Mitral Valve. Left atrial appendage was amputated and implanted included Starr Edwards, Maachi, St. Vincents and TTK closed from outside and from inside. Chitra valves. The course of pregnancy, change in anticoagulation if Results: All 3 patients reverted to NSR on the table and were any, detalis ofdelivery and overall outcome of pregnancy were maintaining NSR at discharge. analysed. They were on a small dose of B Blockers on discharge. Results: All the pregnancies were unplanned and all patients were Conclusion: RF Ablation not only helps in attaining NSR but on oral anticoagulants for more than 60 days after their first missed improves cardiac output, LA transport function and improved period when pregnancy was confirmed. Anticoagulants included prosthetic valve function.

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A multivariate analysis of incremental risk Methods: Between September 2001 and October 2002, nine patients factors for operative mortality and functional suffering from active prosthetic aortic valve endocarditis underwent results after mitral valve replacement for chronic homograft aortic valve replacement. Age ranged from 24 to 61 years mitral regurgitation - A preliminary report 91 (mean =42). On blod culture, 7 patients had Staph. aureus and 2 had AG Ahangar, Shah Shabir, MA Bhat, AM Dar, GN Lone, Streptococcus species. Ishtyak Ahmed Mir Results: There was no hospital mortality. Blood cultures prior to Department CTVS, SK Institute of Medical Sciences, Srinagar discharge from hospital were negative in all cases. Doppler Objective: The object this study is to establish the preoperative echocardiography done at the time of discharge showed tivial aortic parameters namely NYHA functional class, cardiothoracic ratio (CTR), regurgitation in 7 patients and mild aortic regurgitation in 2 patients. left ventricular end systolic diameter (LVESD) and ejection fraction At follow up ranging from 2 to 12 months (mena =4 months) none of (EF), which might effect singly or in combination, the operative risk the patients showed recurrence of endocarditis. in isolated chronic mitral regurgitation (MR). Conclusion: We believe that a homograft aortic valve replacement Methods: We reviewed the records of all patients operated upon is a good surgical option in the treatment of prosthetic valve in our department from Jan. 1995 to June 2002. Patients, with associated endocarditis and aortic root abscess. This procedure can be done with cardiac diseases and previous surgery were excluded, leaving 49 a low risk and good outcome even in this seriously ill subset of patients for the study. Medtronic Hall mechanical prosthesis were patients. exclusively used for valve replacement. Follow-up period ranged from 6 months to 48 months (Median 42.1 months). The method of analysis was designed as follow: a) Each patient was allocated a positive (+) Off-pump valve repair using the Coapsys device: or a negative (-) variable for each parameter b) Five patient groups A feasability study in patients with functional 94 were formed on the basis of the free association of parameter variables. mitral regurgitation c) Single variables and their association with early and late mortality Y Mishra, S Mittal, N Trehan 2 and functional results were compared by statistical analysis (x , t-test). Escorts Heart Institute and Research Center, New Delhi Results: The results of the study showed a) early mortality was significantly influenced by ejection fraction (EF) (P<0.05 b) Late Introduction: Functional mitral regurgitation (MR) results form mortality was significant influenced by NYHA class, EF and LVESD dilatation of the mitral valve annulus and/or lateral papillary muscle (p<0.05) c Each parameter variables (+or–) and/or their association displacement in dysfunctional left ventricles. This study evaluated significantly conditioned functional results. the ability of the Myocor® Coapsys_device to restore leaflet apposition and valve competency of pump withut atriotomy in patients with functional MR undergoing concomitant coronary artery bypass Electrocautery maze in giant LA grafting. M Prasanna Simha, HC Shanmukh, Ravishankar Shetty, Methods: The Coapsys device was surgically implanted in 8(6 male) patients with functional MR of grade 2 or larger. The mean age Anil D Prabhu, PSS Bhat, AN Prabhundeva 92 Sri Jayadeva Institute of Cardiology, Bannerughatta Road, of the patients was 63±6.4 years with a mean ejection fraction of Bangalore 38.9±3.9 percent. The coapsys consists of anterior and posterior epicardial pads connected by a sub-valvular chord. The posterior pad Introduction: Large left atrial are considered relative was postitioned at the annular level and centered relative to the contraindication by some for the maze procedure for atrial fibrillation. posterior leaflet. The sub-valvular chord bisected the valve We have previously described an electrocautery maze using a perpendicular to the coaptation line. The Coapsys was sized by monopolar conventional cautery with a 96% conversion rate when reducing the device dimension, drawing the posterior leaflet and done bi-atrially. annulus toward the anterior leaflet. During sizing, MR grade was Methods: We defined a giant left atrium as one with an LA size assesed real time using color flow doppler echocardiography. Final greater than 6.0 cms on M Mode echocardiography and LA occupying device size was selected when MR was eliminated or minimized. at least 50% of the right hemi thorax. Results: In all patients, MR was reduced to ± 1 following Out of 164 consecutive mitral valve disease were a biatrial electro- implantation. Mean MR grade was reduced from 2.9±0.5 pre cautery mazes was required, 54 cases (32.9%) met the above criteria implantation to 0.8±0.5 post implantation (p<0.001). All implants were for giant Left atria. (Range=6-9.2 cms). All cases were subjected to the performed off pump without atriotomy. No device related adverse standard biatrial electrocautery maze. events were noted. Results: Sinus rhythm was obtained in 51 cases (94.4%) with 48 Conclusions: The Coapsys_consistently and significantly reduced cases (88.89%) achieving atrial E wave velocity >40 cms/sec on the or eliminated functional MR acutely. Follow-up is currently underway 10th postoperative day. The results were stable at 3 months follow to assess the chronic stability of the repair. up. Conclusion: Biatrial electrocautery maze can be offered to even giant left atria with a 94% sinus rhythm conversion and 88.9% effective atrial function. Ross procedure - Initial experience Julius Punnen, C Binoy, Sandeep Attawar, T Mathew, 95 CKK Kuldeep, Colin John, Rajnish Garg, Devi Prasad Shetty Homograft replacement for aortic root abscess Narayana Hrudayalaya Institute of Medical Sciences, Bangalore and prosthetic valve endocarditis 93 Method: During the period from August 1999 to July 2002 (3 years) Gulam Ali, Avery Matthew, C Binoy, PV Rao, Pravin Kumar, Keshavamurthy, Devi Prasad Shetty we performed 32 Ross procedures. The early experience being at Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Manipal Heart Foundation and the later one year at Narayana Hrudayalaya. The pulmonary autograft was used as a root Introduction: Prosthetic valve endocarditis though uncommon is replacement in all these patients. devastating despite intensive medical and surgical therapy. Results: There was no operative mortality. 2 patients were re-

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explored for bleeding and two others had delayed chest closure on ventricular function (4) Type of lesion (5) Type of prosthesis used first post-op day. The mean ICU stay was 3.02 days (range 1-6 days) (6) Redo procedures. and hospital stay ranged from 8 - 15 days. Postoperative echo showed One Hundred Twenty patients operated for double valve at our trivial AR in 15 patients and mild PR in 8 patients and improved LV centre from April, 1994 to August, 2002 were taken for the study. function in all except one patient. In a follow up ranging from 3 months Six parameters were taken into account. Patients were divided in to 6 months, there were no mortalities and no valve related advarse Three age groups of less than 20 years, 20 to 40 years and more events or explants. than 40 years. Duration of illness was divided into less than 5 years, Conclusion: Though Ross procedure has been available as an 5 to 10 years and more than 10 years. Pre operative left ventricular alternative to aortic valve replacement for over thirty years, it did not function was divided into normal >50% ejection fraction, mild (49- gain popularity in our country. Although our experience is small, the 35%), moderate (34-20%) and severe

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Management of aortic regurgitation (AR) hours and 2 (12%) patients are in the junctional rhythm.3 patients associated with subarterial ventricular septal 99 (18%) remained persistently in AF. All the patients who have not defect (VSD) in young patients: Valve repair or responded, kept on oral amiodarone on discharge and all of them are replacement in controlled ventricular rate of 70-80/mt. The postoperative LA size Kaushalendra S Rathore, Arvind V Singh, Prabhat K Singh, Aditya was 46 mm (39-64 mm) with LA volume of 176 ml (126-307 ml). Kapoor, Nirmal K Gupta Conclusion: Elecrocautery Maze with LA reduction is safe and Department of CVTS, Department of Anaesthesia and Department effective in restoring the electro-mechanical function of left atrium in of Cardiology Sanjay Gandhi PGIMS, Lucknow cases of Mitral valve disease with chronic AF with large LA. Objective: To assess the outcome of patients requiring aortic valve replacement and their comparision in which valve repaired. Methods: 36 out of 300 patients operated for VSD over a 10 years period had associated aortic regurgitation. Experience with the Chitra valve Results: The incidence of Aortic Regurgitation was 12%. Age Pawan Kumar, Pranav SK, D Kulkarni, Raghvendra C, 101 Sredhar Reddy, Uday Jadhav, AG Tendolkar ranged from 5 to 32 years (17.72±6.84 years). 29 patients underwent LTMMC & LTMGH, Sion, Mumbai 400 022 aortic valve replacement (80.56%) while valve repair was done in remaining. There was no peri-operative mortality. The follow up was Background: The only Indian valve is being used for last 4 years of 6 months to 10 years (6.20±4.97 years). There were two late deaths. at our institute and we present our results with the same (Feb 1999 to AV repair done in patients age ranging from 5 yrs to 15 yrs (11.2±2.67 Aug 2002) yrs). In patients with valve repair, one developed mild AR immediately Material & Methods: No. of Chitra valves used = 654 No. after surgery while two more patients developd mild AR after the of patients = 547 Male/Female = 310=237 five years. After one year, 77% were in NYHA class I, 23% in class II. MVR = 348 AVR = 92 DVR = 107 After 5 years out of 31 patients, 18 were in NYHA class I (58.06%), 12 Associated procedures performed were in class II (38.70%) & 1 in class III. After 8 years out of 21 patients, 12 OMC = 31, CABG = 04, TV repair = 45, TV replacement =11, in NYHA class I (63.15%), 5 in class II (26.31%) & 2 patients in class III ASD closure = 21 (10.52%), two lost to follow up. Six patients, completed their 10 year An INR between 2.0 to 3.5 was maintained for all patients. Aspirin follow up, 3 are in class I (50%), 1 in class II (16.66%) & 2 in class III was added as per recommendations of AHA. (33.33%). Results: Mortality (30 days) = 12 (2.2%) Conclusion: Although aortic valve repair is preferred, increasing MVR = 9 (2.6%), AVR = 3(3.3%), DVR = 0(0%) age makes aortic valve replacement an alternate modality of treatment. Re exloraton for bleeding=15(2.8%), Sup. Inf.=10(1.8%), Heart Two predictors of postoperative functional status are the age of the block=02(0.4%) patients at the time of surgery & preoperative left ventricular Average FU = 30 days to 3 years Mean FU=450 patients (82.3%) dysfunction. Late postoperative functional status can be predicted at Incidence of TEE=14(2.6%) the follow up of one year. Incidence of IE=01(0.2%) Average peak gradient across AV: 21 mm=9±4 mm Hg, 23 mm=8±3 mm Hg Conclusion: The TTK Chitra heart valve is a safe valve. The Electro-mechanical function of left atrium incidence of thromboembolism is higher. followingleft atrial electrocautery maze with 100 left atrial reduction and modified mitral valve replacement Amrendra Singh, Nirmal K Gupta, Aditya Kapoor, CMC-Recommendations Prabhat K Singh Pawan Kumar, D Kulkarni, Raghvedra C, SK Pranav, 102 Departments of CVTS, Cardiology and Department of Anaesthesia, Uday Jadhav, AG Tendolkar SGPGIMS, Lucknow LTMMC & LTMGH, Sion, Mumbai Background: Atrial Fibrillation (AF) and large left atrium (LA, Background: CMC has remained the gold standard procedure, ≥ LA size 50 mm LA volume >180 ml) in the mitral valve disease till recently, in patients of mitral stenosis, with a pliant valve. We implies loss of atrial function as well poses risk of forming thrombus. continue to perform this procedure routinely at our center & present This study was done to see if mechanical function could be restored our experience below. in this subset of patients with mitral valve disease with chronic atrial Material & Methods: No. of patients (between Jan 2000 to June fibrillation and large LA. 2002)=194 Male/female=63/131 Methods: 16 patients of mitral valve replacement along with LA Age=25 yr 3 months, range=8-45 years reduction and Left atrial electrocautery maze were included from April Pre operative Wilkins score=Average=7.5 2002 to Oct. 2002. Preoperative mean LA size was 60 mm (50-95 mm) Pre op MV area=1.22 sq. cm and mean LA volume was 330 ml (210-534 ml). Surgical procedure All the procedure were performd by a standard anterolateral include isolation of pulmonary veins plus a lateral lesion to the level thoracotomy and using the Tubbs transventricular dilator. In adult of mitral valve annulus along with left atrial appendectomy with patients the valve was dilated to 32 mm to 38 mm. However, the electrocautery after reduction of aneurysmally enlarged LA along with palpating finger determined the final extent of dilation. mitral valve replacement. Perioperative ECG and 2D ECHO were Results: Mortality=2/194-1% performed to evaluate atrial functions. Complications requiring emergency CPB=2/194-1% Results: The age ranged from 20 to 50 years (26.7±5.3). There were Incidence of MR requiring surgery=2/194-1% two postoperative deaths, one due to low cardiac output and another Average FU No.=75% Duration=2 mnths to 2 years due to bleeding. Mean duration of follow-up is 16 weeks (4-22 weeks). Re surgery for mitral Restenosis within FU=1/194-0.5% 9 patients (56%) recovered from CPB in sinus rhythm and 6 remained Conclusion: The entire procedure to be performed strictly under in sinus rhythm in follow up. 3 patients reverted back to AF after 24 vision. Finger is the best vision.

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Comparison of various prosthetic valve types in Results: There was only one death due to intractable venricular patients undergoing mitral valve replacement 103 fibrillation/ There was no incidence of structural valve failure. There (MVR) were no valve related morbidity or mortality. All the values are Jagdish Prasad, Ajay Saraswat, Sanjeev Kalra, Milind Umre, expressed as mean±S.D. The mean LA-LV gradient (mm Hg) in HC Sachdeva, RP Singh, Meenakshi, Kishan Kumar, Vikas Kapoor Group I across the various sizes of CHV was: 23(5.75±2.62), Deptt. of Cardio Thoracic & Vascular Surgery, Vardhman Mahavir 25(4.85±1.95), 27(3.89±1.31) and 29(3.27±0.71). In Group II LV-AO Medical College & Safdarjang Hospital, New Delhi gradient (mmHg) across the prosthesis was 21(17.11±4.4), Objective: To study the various mechanical prosthetic valves like 23(14.0±4.99) and 25(9.5±2.89). Monoleaflet, Bileaflet and Ball and Cage type of valves in relation to Conclusion: Study concludes that CHV provides excellent the postoperative hemolysis, valve gradients, LV dynamics, NYHA haemodynamic relief comparable to other available prosthetic Class, Thromboembolic phenomenon of the patients. valves. Material & Methods: We retrospectively studied 310 patients who underwent MVR at our center from April, 1995 to August, 2002 and were coming for regular follow up. We divided the patients in three main groups depending on the type of prosthesis used – Monoleaflet Aortic valve replacement in patient with previous (Group I), Bileaflet (Group II) and Ball and Cage type (Group III). cardiac surgery 105 There were 108 (34,83%) in Group I, 170 (54.83%) in Group II and 32 VR Machiraju (10.32%) in Group III. Post operative valve induced hemolysis was 5200 Centre Avenue # 216 Pittsburgh PA 15232 USA studied by macro and microscopic examination of urine. We studied the post operative gradient across the prosthetic valve and LV Introduction: Aortic valve replacement in patients with previous dynamics (LV ejection fraction (LVEF), fractional shortening (FS) and cardiac surgery occurs for several reasons. Patients who had coronary LV volume (LVV) with echo cardiography done on the 5th post artery bypass surgery develop age related calcific aortic stenosis. operative day and six months after the surgery. Data was collected in Failure of previous aortic prosthesis because of degeneration or tissue the follow up of the patients regarding their present NYHA Class in – growth of mechanical valves causing impedance to the flow and any episode of Transient Ischemic Attacks (TIA), neurological creating obstruction. Prosthetic valve endocarditis in both tissue and deficits or deterioration and loss of valve clinks. mechanical valves requiring redo aortic surgery and also patients who Results: In the 310 patients studied postoperative hemolysis was had valve repairs for congenital abnormalities of the aortic valve later found in 5 patients in GroupI, 2 patients in Group II and one in Group developed calcific aortic stenosis. Similarly patients who had III. In Group I the valve gradient varied from 2 mm to 11 mm Hg, in rheumatic mitral valve abnormality and requiring redo surgery. Group II of the gradient varied from no grat in most of the caseswhile Methods: One of the challenges in redo aortic surgery is to do a the LVV decreased in most of the patients in all groups. All patients statisfactory aortotomy to expose the aortic valve. The presence of in all groups has class by six months. Overall their were 5 patients proximal anastomosis of coronary artery bypass grafts certainly creates had documented Thromboembolic phenomenon out of which 3 were a difficult problem. The choice of the various valve substitutes in group I and 2 in Group II. depending upon the patients's condition and anatomy are considered. Conclusion: Out study shows that there is no major difference in The risk of calcific cerebral emboli that can occure from calcific post operative hemolysis, valve gradient, LV dynamics, NYHA Class ascending aorta also from calcific aortic stenosis would cause increased and incidence of thromboembolism in the three groups. morbidity and mortality. In a period of five years 150 patients from age 30-89 underwent redo cardiac surgery and aortic valve replacement. Results: The total mortality in these patients is 10%; however, the cerebral embolic complications were about 7.3% and 80% of these patients who had cerebral embolic comlications ended in mortality. Safe and hemodynamically good results with the Re-operative bleeding ocurred in 10% of the patients. Multi-system Chitra heart valve: An initial experience 104 failure and mortality occurred in the re-operative bleeding patients. SP Manoj Kumar, B Dubey, HS Anand, SR Mohanty, S Basavaraj, PK Dash, S Rao So the two main complications that can increase surgical mortality Dept. of CTVS & Cardiology, Sri Sathya Sai Institute of Higher are cerebral vascular accident and post-operative bleeding. Medical Sciences, EPIP Area, Whitefied, Bangalore Cerebrovascular accidents occurred in patients above 80 years. Conclusion: While redo aortic valve replacement in patients with Background: Rheumatic valvular heart disease is common in India. previous cardiac surgery can be successfully done, patients with above Many patients still require prosthetic heart valve replacements even 80 years of age should be carefully examined with CT scans and though other procedure are available. Chitra Heart valve is an echocardiography to rule out calcification of the ascending aorta. indigenously created low cost prosthesis available in our country. We present our experience with this valve, especially in reference to its haemodynamic profile. Patients and Methods: Hundred Chitra Heart Valves (CHV) were implanted from July 2001 to July 2002. Sixty-two valves were Comparative mid-term echocariographic analysis implanted in mitral position (Group I) and 38 were imlanted in aortic of various mechanical prosthetic heart valve at 106 mitral position position (Group II). In Group I, 16 patients were in NYHA Class II, 44 Rakesh Chittora, RM Mathur, KK Kushwaha patients in Class and rest in Class IV, whereas in Group II, 19 patients Departments of Cardiothoracic and Vascular Surgery, SMS were in Class III. Eight patients had undergone previous Closed Mitral Hospital, Jaipur Valvotomy (CMV) and 5 patients were operated for severe mitral regurgitation after balloon valvotomy In Group I, 34 patients were Introduction: The aim of the study to compare the mid-term operated for mitral stenosis, 19 for regurgitant lesion and rest had echocardiographic hemodynamics of carbomedics (Bileaflet), mixed lesions. In Group II, regurgitant lesion continuted 17 in Medtronic-hall (Tilting disc) & Starr-Edwards (6120) mechanical valve number and stenotic lesion was present in 16 patients. at mitral position.

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Methods: The study of 62 isolated mitral valve replacement done double-switch operation. One patient had a Senning procedure for by various size mechanical heart valve between Jan. 2002 to Sept. 2002 isolated ventricular inversion. is included. Out of these 30 had carbomedics. 24 had Medtronic-hall Associated defects included left ventricular outflow obstruction 8 had Starr-Edward-6120. The echo-cardiographic assessment was in one patients, ventricular septal defect (VSD) in two, atrial septal done at 2 weeks interval post-operatively. The valves were assessed defects (ASD) in six and patent ductus arteriosus (PDA) in 6, for mitral valve area by planimetry pressure half time. Gradient across Cardiopulmonary bypass time ranged from 99 to 300 minutes the valve was assessed by modified Bernoulli equation, Valvular or (mean=126 min) and aortic cross clamp time was between 56 and 132 para-valvular leak was observed by transthoracic study. minutes (mean=78 min). One patient needed total circulatory arrest Results: Among mitral valve prosthesises, effective orifice area for 40 minutes. offered by Medtronic-hall valve (tilting disc) ranged from 1.90 cm2 Hospital stay ranged from 9 to 98 days (median = 24 days). There (size 23) to 2.84 cm2 (size 27), for carbomedics (bileaflet) ranged form was one early death in hospital (mortality rate -= 4.1%). 2.3cm2 (size 23) to 3.41 cm1 (size 29) & by Starr-Edwards (cage & ball) Conclusion: The Senning procedure still has a role in conditions 1.33 cm2 (size 3M), it is 2.87 mmHg and 2.4 cm2 (size 3M), Mean where anatomical repair requires an atrial switch and is also a gradient for Medtronic ranged from 4.13 to 4.83 mmHg, for satisfactory alternative for patients with d-TGA who are unsuitable carbomedics it is 2.97 mm. for an arterial switch operation due to delayed presentation or Conclusion: Among various used mechanical valve at mitral unfavorable coronary anatomy. position, carbomdic prosthesis offered relatively less resistance to forward flow & larger effective orifice area than other valves.

Intracardiac repair of 100 consecutive cases of tetralogy of fallot-analysis of hospital outcome 109 Can sildenafil citrate be used for pulmonary NG Narendra, S Sivasubramanian, Rahul Shetty, hypertension in CHD patients undergoing 107 Sanjay Dhaded, Colin John, Rajesh Sharma, Neeti Chandra, corrective surgeries Devi Prasad Shetty Nityanand Thakur, Mahadev Dixit, Mohan Gan, Naresh Kumar, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Suresh Kumar, Anand Vagrali, Vithalrao Dhulkhed, P.R. Balaji Objective: We analysed an unselected series of 100 consecutive KLES Heart Foundation, KLES Hospital & MRC, Belgaum cases of Tetralogy of Fallot undergoing intra-cardiac repair. Background: Pulmonary hypertension remains a problem in Patients and Methods: Between October 2001 and August 2002, patients of CHD with PH undergoing corrective surgery. 100 patients underwent surgical repair for Tetralogy of Fallot in our Methods: 6 patients - with diagnosis of TAPVC (Intra cardiac type) institution. This included patients with more complex associated were taken for surgical correction. The average pulmonary artery conditions like absent left pulmonary artery, anomalous coronary pressure was 96 mmHg systolic (near systemic). Patients underwent arteries, absent pulmonary valve, borderline small left ventricles and all routine investigations and cardiac catheterization for ascertaining small pulmonary artery branches. We have not excluded any patients the PVR. All this patients received sildenafil citrate per oral 25 mg 8 on considerations of age and weight alone. hrly, from the time of coming off CPB. The mean age at repair was 6.9 years (range 0.8 to 38 years) and Results and Conclusion: We found that the over time period of mean weight was 11.3 kg (range 6.5 to 52 kg). Pulmonary artery size 12 hrs, supported by mandatory ventilation; Nitroglycerin drip. The was assessed to be suitable for repair in 82 patients on pre-operative pulmonary artery pressure reduced to 30% of systemic. Sildenafil echocardiography and cardiac angiography (57 had good sized and citrate available in tablet form could be easily administered and was 25 fair sized pulmonary arteries). Pre-operative haematocrit ranged cost effective. Although the patient sample is small and adverse and between 36% and 65% (mean 48%). All patients underwent side effects of drug are not assessed it can become a very good option intracardiac repair under cardiopulmonary bypass at 20 to 26 C and for management of pulmonary hypertension. with myocardial protection by intermittent administration of sanguineous cardioplegia using St. Thomas cardioplegic solution. Results: Trans-atrial repair was possible in 34 patients. 56 patients required a trans-annular patch and 5 had right ventricle outflow patch repairs. 5 patients had severe outflow tract obstruction and required Indications and early results of senning operation homografts to establish right ventricle to pulmonary artery continuity. S Sivasubramanian, NG Narendra, Julius Punnen, Colin John, 108 The post-repair RV/LV pressure ratio ranged from 0.5 to 1.0. Early Rajesh Sharma, Keshavamurthy, Devi Prasad Shetty mortality was 8%; all deaths were due to low cardiac output following Narayana Hrudayalaya Institute of Medical Sciences, Bangalore repair. Objective: To present our experience with the Senning operation Conclusion: Intra-cardiac repair of Tetralogy of Fallot is a safe highlighting the indications and short-term outcome. operation with good early outcome across all age groups even for an Patientes and Methods: Between May 2001 and September 2002, unselected patient group with complex variants of morphology. twenty-four patients underwent a Senning procedure at our institution. The patients ranged from 12 days to 14 years in age (median 182 days) and weighed between 3.25 and 28 kg. (median 6 kg) Results: 22 patients had a Senning procedure for D-Transposition One and half ventricular repair for treatment of of the Great Arteries (d-TGA), two of which palliative. In most of complex congenital heart disease 110 CKK Kuldeep, Julius Punnen, Colin John, Rajesh Sharma, these cases a Senning procedure was made necessary because of older K Muralidhar, Devi Prasad Shetty patient age due to delayed presentation. In the 120-day-old patient, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore an intramural course of the left coronary artery made an arterial switch procedure impractical. Two patients had corrected transposition of Introduction: One and half ventricular repair is defined as the great arteries and underwent Senning procedures as a part of a complete intra-ventricular repair combined with a Bi-directional Glenn

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shunt (BDG) to off-load the insufficient right ventricle (RV). Seven Coronary translocation - The preferred method of patients assessed to be less suitable for bi-ventricular repair but more repair for ALCAPA 112 than a candidate for single ventricular repair electively underwent Vaghela Vipul, Koshy GS Sajan, Sunil, R Krishnakumar, this procedure. K Shivaprakasha, Rao Suresh Method: 4 patients with Ebstein's anomaly and diminutive RV, Division of Paediatric Cardiac Surgery and Cardiology, Department two patients with multiple Ventricular Septal Defects (VSD), severe of CVTS and Cardiology, Amrita Institute of Medical Sciences, pulmonary stenosis (PS), hypoplastic RV and tricuspid valve, and one Cochin patient with UhI's anomaly underwent this procedure. These patients Background: Varios techniques for ALCAPA repair have been were assessed for mean hospital stay, inotrope requirement, oxygen reported. With increasing experience of coronary transfer in all forms saturation, central venous pressure (CVP), diuretic requirement and of coronary anatomy in arterial switch operations, direct coronary functional class at follow-up. translocation has emerged as the preferred method of repair of Results: There was one hospital death. Two needed permanent ALCAPA. pacemaker implantation for complete heart block and none had Objective: To review our experience of the result of coronary evidence of right heart failure at a mean follow up of two months. translocation in ALCAPA. Conclusion: One and half ventricular repair allows utilization of Material and Methods: During the period from November 1998 a hypoplastic RV in the pulmonary circulation and may provide result to August 2002, 17 patients had surgical repair for ALCAPA at AIMS. superior to Bidirectional Glenn shunts or Fontan repairs in a selected Those who had surgical correction, form the subject of this study. Two population. patients who had Takeuchi repair, and two adults who had interruption of ALCAPA and CABG, were excluded. The remainder thirteen patients had coronary translocation. The age ranged from 38 days to 7 years. There was severe LV dysfunction (n=8), moderate in 2, and mild in 1 patient. 2 others had normal LV function. One patient had associated TOF, for which a Rastelli operation with coronary translocation was done. The thirteen patients who underwent coronary translocation had direct translocation, neo-LMCA creation by pulmonary/aortic artery flaps, pericardial augmentation of the anastamosis or a pericardial tube conduit in 1 case. A retrospective study of the modified blalock taussig shunts - A six-year review 1996-2001 111 Results: Two died in the immediate post operative period. 1 was Anand Agarwal, RV Kumar, RC Mishra, Hari Krishna Babu, a neonate with grade 4 MR, while the other was an infant with grade KV Ramana, DV Ramana, P Rajagopal 4 MR and severe LV dysfunction. 11 patients, who survived, had mean Department of Cardiothoracic Surgery, Nizam's Institute of Medical CPB time of 261 min, and mean ACC time of 93 min. TCA was required Sciences, Hyderabad in 2. Mean ICU stay was 18 days and mean hospital stay was 30 days. At mean follow up period of 6 months, improvement of LV function Introduction: Despite the advent of Primary one stage repair of (mean EF 47±8%, range 35 to 56%) and reduction in MR were noted Tetrology of Fallot, the palliative procedures, the modified B-T shunt in all patients. being the most frequently used, still has a role in circumstances such Conclusion: All varieties of coronary anatomy in ALCAPA can be as anomalous coronary artery crossing the RVOT, in patients with translocated to the aorta. Significant improvement in LV function and extremely small pulmonary arteries, in patients who have been having reduction in MR were noted. severe unrelenting cyanotic spells or in patients with significant and severe associated lesions that may preclude total repair. This retrospective study was done to evaluate the spectrum of disease pattern for which modified B-T shunt was done, the size of the shunts Minimally invasive cardiac surgery - A new used in differing age groups, the outcome in terms of immediate incision 113 survival and symptomatic improvement in terms of absence of A Chiran Babu, Irineu Pereira, N Sabanayagam, cyanotic spells. K Madhan Kumar, M Nachiappan, KSVK Subbarao JIPMER, Pondicherry Methods: 72 patients who had modified B-T shunt between January 1996 and December 2001 were included in the study. The pre Background: Minimally invasive surgical techniques in cardiac and postoperative data was recorded from the hospital records. All surgery have evolved throughout the last 10 years. The advantages shunts were constructed through a posterolateral thoracotomy with of minimally invasive procedure include minimization of surgical the interposition made between subclavian and pulmonary artery with trauma, superior postoperative outcome and a cosmetically accepted PTFE graft. scar. So in order to establish the safety of minimally invasive The age ranged between 3 months to 17 years, the mean age being techniques, a new incision combined with manubrium sparing 4.95 years. The most common indication was TOF, the others being sternotomy has been described. The incision starts in the midline at DORV-VSD-PS, TOF-pulmonary atresia etc. 37 were left sided shunts the fourth intercostals space level, extending for 2 cm on either sides and 34 were right sided and 15 patients underwent emergency along the submammary crease. The skin flap elevated. Manubrium operation. sparing sternotomy done, with extension onto the 2nd intercostal Results: There was improvement in mean systemic saturation from space on the right side. 70±5 to 85±4.62 patients had freedom from cyanotic spells in the Materials and Methods: Over a period of 3 years from October immediate postoperative period. Excessive pulmonary blood flow, 1999 to September 2002, 19 patients in the age group of 4 to 27 years chylothorax and Horner's syndrome were some of the complications underwent surgical correction of simple congenital cardiac postoperatively. 5 of 72 patients died postoperatively. Thirty patients malformation through an inverted U incision fashioned along langer's had definitive repair in the follow up period. lines of skin tension combined with manubrium-sparing sternotomy. Conclusions: The modified B-T shunt remains an important These included 15 cases of ostium secundum ASD's, 1 case of sinus palliative procedure in a selected group of patients with cyanotic venosus type ASD with PAPVC, 1 case of ASD with HAPVC and congenital heart disease as a step in the staged repair. unroofed coronary sinus and 2 cases of inlet VSD's.

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Results: The postoperative recovery was generally uneventful. The coronary sinus and a vertical vein drained the left lung to innominate operative, ACC and CPB times were comparable to conventional mid- vein, but there was no common chamber. The PFO was restrictive sternotomy approach. There were no cases of femoral cannulation or and there was a large PDA. conversion to conventional mid-sternotomy approach. There were 2 Method: Through sternotomy under CPB, it was technically cases of excessive post-op bleeding which were re-explored through difficult to connect the vertical vein to left atrium and hence only the the same incision. There were 2 cases of flap necrosis managed right lung was corrected. After initial smooth recovery, baby needed conservatively. All the postoperative scars were cosmetically two reintubations due to severe hypoxia following right lower and acceptable and the scar shrinks and reduces in time. All surgeries upper lobe collapses. A left lung correction attempted as a closed were performed using routine standard instruments. technique was not tolerated, but after establishing CPB through Conclusion: In selected cases of new incision with manubrium resternotomy, vertical vein to left atrium anastomosis could be done sparing sternotomy fashioned along Langer's line of skin tension through Thoracotomy successfully. allows healing with a cosmetic scar and reduced morbidity at no extra Result: The baby tolerated the second procedure well, but cost without jeopardizing the safety of patient. developed severe pneumonic consolidation of left lung probably due to manipulation while attempting closed correction. This lead to prolonged ventilation and the baby succumbed to multiorgan failure Muscle-sparing axillary thoracotomy for after one week. persistent ductus arteriosus closure - 114 Conclusion: We feel that a total correction in the first stage itself JIPMER experience by combined sternotomy and thoracotomy would have allowed a A Chiranbabu, Irineu A Pereira, Sudhir Bhat, M Nachiappan, better outcome and should be the preferred mode of correction in KSVK Subba Rao similar cases. Circumferential draping of the patient will allow careful JIPMER, Pondicherry rotation for both approaches on bypass. Background: Minimally invasive surgery is making its way into the cardiac surgery, as it has in the other branches of surgery. The essence of minimally invasive surgery is less surgical trauma, speedy Experience with repair of sinus of post operative recovery, less postoperative pain, without valsalva aneurysms 116 compromising patient's safety. Here we have used the muscle sparing Trushar Gajjar, LN Achar, D Abhijeet, Saibal Neogee, axillary thoracotomy for persistent ductus closure. The incision placed Nimisha, Rekha Matta, Neelam Desai in the 4th intercostal space, between anterior and posterior axillary Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, folds, the latissimus retracted and the serratus anterior split along Anantapur the direction of its fibres. Intercostals cut near their inferior attachment Aim: To evaluate morphology & results of surgical repair of SOVA. to ribs and two ribspreaders are used to facilitate exposure. Methods: From November 1991 to October 2002, 73 patients aged Materials and Methods: Over a period of four years from August 10 to 45 years underwent surgical correction of Sinus of Valsalva 1998 to September 2002, 29 patients in the age group between 3 months aneurysm. Aneurysm orginated in Right (n=62), & Non coronary to 15 years underwent surgical interruption of persistent ductus (n=11) sinuses & entered the RVOT (n=56), RA (n=13), RV inlet (n=1) through a muscle sparing axillary thoracotomy - through 4th & was unruptered (n=3). Coexisting cardiac lesions included VSD intercostals space. The ductus was doubly ligated and transfixed. The (n=38) in which juxta arterial type was seen in (n=18), & juxta aortic male: female = 1:4.8. Three patients (10%) were less than one year; 13 in (n=20) pts. Variable degree of aortic insuffiency was seen in (n=27) (45%) between 1 to 5 years; 9 (31%) between 6 to 10 years and 4 (14%) pts. There was 3-hospital mortality. In all patients except (n=5) between 11 to 15 years. chambers of entry & exit were opened for repair of the aneurysm. Results: Post operative period uneventful in all patients. The post- Single patch closure was used when VSD & RSOV co-existed with operative recovery and requirements of analgesics was considerably resuspension of aortic annulus from the patch. 9 patients needed aortic less compared to conventional posterlateral thoracotomy. 3 patients valve replacement for significant AR & 2 patients underwent aortic less than one year were in congestive failure, abated with surgery. valve repair. One case had superficial wound infection, managed conservatively. Results: Over all survival was 96%. One pt underwent reoperation There were no conversation to standard approach in any of the cases. for leak in NCC to RA fistula. Out of 14 patients with mild AR at Conclusions: Muscle sparing axillary thoracotomy for surgical primary operation none developed progressive AR, even the moderate interruption of ductus is an useful alternative to conventional AR which was left during primary surgery on follow-up found to be posterolateral thoracotomy, with less surgical trauma, less postoppain, same. All were in NSR. speedy recovery and a cosmetic scar without compromising patient's Conclusions: Early survival after SOVA repair is excellent. Risk safety and without ueed for any special instrument. for recurrent fistula or VSD is minimal. Late AR is still a risk, in RCS- RV fistula with asso juxta arterial or aortic VSD. Repair of SOVA by opening entry & exit site permits complete repair. Need of reoperation Obstructed bilateral HAPVC : Learning from a increase with type of repair (direct vs. patch). challenging experience - A case reporf 115 Manoranjan Misra, SR Krishna Manohar, Thomas Titus, PR Suneel, KS Neelakandhan Surgical correction of TAPVC-Experience in Department of CVTS, Sree Chitra Tirunal Institute for Medical 101 cases Sciences & Technology, Trivandrum 117 Trushar Gajjar, D Abhijeet, LN Achar, Saibal Neogee, Aim: Anomalous venous connection of one lung has to be corrected Nimisha, Rekha Matta, Neelam Desai since any problem in the opposite normally draining lung will lead to Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, fatal hypoxia. We report a rare case where relaxation of this principle Anantapur lead to morbidity and mortality. Aim: To study the spectrum of clinical presentation, morphological Case: Patient was a 6 month old baby who presented with features, surgical techniques & outcome of TAPVC in various age obstructed mixed TAPVC and severe PAH. The right lung drained to groups.

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Methods: From July 1992 to October 2002, 101 patients were Overlooked bowel atresia in obstructed TAPVC in operated for TAPVC. Aged ranged from 5 months to 39 years. The neonates - Chitra experience 119 type of TAPVC was supracardiac (n=53), Cardiac (n=33), and Mixed SR Krishna Manohar, Thomas Titus, KS Neelakandhan (n=15). Diagnosis was established by echocardiogram and cardiac Sree Chitra Tirunal Institute for Medical Sciences and Technology, catheterization in all cases. Supracardiac type was repaired by Trivandrum, Kerala Schumacker-King technique whiel those of Cardiac type had either Background: Out of three babies operated last year for obstructed Deroofing of coronary Sinus or Baffle with redirection of pulmonary infra cardiac total anomalous pulmonary venous connection (TAPVC), venous return. In Mixed variety where the left pulmonary veins were we lost two neonates due to extra cardiac anomalies which were opening into left innominate vein, Mullers technique was used. detected in the post operative period by paediatric surgeons. Associated anomalies encountered were VSD (n=2), PS (n=1), MS Methods: Three babies aged, 4, 22 and 44 days presented with (n=1), PDA (n=2), Left atrial isomerism (n=1), LSVC (n=1). obstructed infracardiac TAPVC's. The two younger ones were severely Postoperative Echo was done on all patients prior to discharge to malnourished and the other was on ventilator. Shumacker & King document absence of pulmonary venous obstruction, Residual shunt repair was done as emergency in all under total circulatory arrest, & pulmonary arterial hypertension. leaving the descending vein open. All came off bypass with stiff Results: Early Mortality was in 3/101 patients. Later mortality inotropic supports. was 0%. One patient had pulmonary hypertensive crisis, one patient Results: The 44 day old baby had uneventful recovery. The had left Pulmonary vein obstruction. All patients were in NYHA class younger ones needed prolonged inotropic supports and peritoneal I or II. There was no residual shunt in any patient. Postoperative dialysis. Both developed abdominal distension and regurgitated the arrhythmias were found in (n=4) patients. nasogastric feeds. On referral, paediatric surgeons diagnosed Conclusion: Overall long-term survival & final recovery is good. duodenal atresia in the younger one and small bowel atresia is the Pulmonary hypertensive crisis & Pulmonary vein obstruction were other. Due to poor hemodynamics and peritoneal dialysis surgical the cause of morbidity. Cause of mortality was multi-organ failure in correction could not be done and we lost both due to multi organ two patients & one patient was not weaned off cardiopulmonary failure. bypass. Conclusion: As neonates with infracardiac TAPVC present early with obstruction and the cardiac lesion gets priority, associated major extra cardiac anomalies may be overlooked as in our cases. A high degree of clinical suspicion and paediatric surgical consultation can result in simultaneous correction of both anomalies and better survival.

Predictors of outcome following the arterial Branch pulmonary artery plasty: Surgical switch operation 118 techniques and early results 120 S Sivasubramanian, Avery Matthew, Rahul Shetty, A Govil, B Airan, A Bhan, SK Choudhary, UK Choudhary, Colin John, Rajesh Sharma, Keshavamurthy, Devi Prasad Shetty AK Bishoi, A Saxena, SS Kothari, P Venugopal Narayana Hrudayalaya Institute of Medical Sciences, Bangalore All India Institute of Medical Sciences, New Delhi Objective: To analyse results of our arterial switch operations and Background: Branch pulmonary artery stenosis frequently identify risk factors for outcome. accompanies other intracardiac lesions. We evaluate the outcome Patients and Methods: Between May 2001 and September 2002, following surgical repair of this not so uncommon condition. 36 patients underwent the arterial switch operation (ASO) at our Patients and Methods: Between April 1998 and March 2001, institution. 12-had ASO for d-Transposition of the Great Arteries (d- branch pulmonary artery plasty was done in 23 patients at our centre. TGA) with intact ventricular septum (IVS) (Group-A). 24 had ASO The preoperative coexisting intracardiac anomalies were tetralogy of for either d-TGA with Ventricular Septal Defect (VSD) or Double Fallot (n=12), single ventricle with pulmonary artery stenosis or atresia Outlet Right Ventricle (DORV) with VSD (Taussig-Bing anomaly) (n=7), double outlet right ventricle (n=1), truncus arteriosus (n=1), (Group-B). The mean age of patients in Group A was 17.3 days (range tricuspid atresia (n=1) and 1-transposition of great arteries (n=1). Of 3 to 45 days) and mean weight was 3.17 kg (range 2.6 to 4.1 kg). Ing these, 2 patients already had total correction for tetralogy of Fallot Group B, the mean age was significantly higher at 122.1 days (range 3 and 4 had modified Blalock taussig shunt. The location of branch to 540 days) and mean weight was 3.7 kg (range 2.1 to 8.0 kg). All pulmonary stenosis was most commonly left pulmonary artery origin. cases were done on cardiopulmomary bypass at 18 to 20°C without Branch pulmonary artery plasty was performed along with total circulatory arrest. correction (n=9), bi-directional Glenn shunt (n=6), right ventricle to Mean bypass time was 225.5 min (range min). Post-operatively pulmonary artery homograft conduit repair (n=5), isolated left patients needed ventilatory support for a mean of 8.4 days (range 3 to pulmonary artery/high pulmonary artery plasty (n=2) and fenestrated 20 days) and mean duration of stay in the intensive support for a total cavopulmonary connection (n=1). mean of 8.4 days (range 5 to 21 days). Results: In immediate postoperative period, 3 patients had p RV/ Results: Overall these were 8 early deaths (22.2%), all of which LV >0.8 and significant residual right ventricular outflow tract A. were in Group B (33.3%). Mortality was related to delayed gradients were detected (>20 mmHg). The repair was revised on presentation, cardiac morphology (severe from of DORV with remote cardioplegic arrest. Subsequently the gradients disappeared. VSD), coronary artery anomalies, and associated coarctation of the Immediate post operative echocardiography in the intensive care unit aorta. One patient developed complete heart block requiring showed no residual shunts, significant RVOT gradients or RV implantation of a permanent pacemaker. dysfunction. Follow up was 3 to 26 months. There was no late Conclusion: Poor outcome following the arterial switch operation mortality. 20 patients were in NYHA class I or II. Of these 20, 15 were was predicated by delayed presentation, coronary artery anomalies, more than one year post operative and off all medication. DORV with remote VSD and associated coarctation of the aorta. Echocardiography during follow up showed no residual shunts, right

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ventricular dysfunction or right ventricular outflow gradients (n=20). Follow-up ranged from 1 to 15 years. Thee was one late death due Three patients had significant gradients. At cardiac catheterisation to non-cardiac cause. One patient required reoperation for failed aortic performed after 3 to 26 months, the peak right ventricular pressures valve repair. ranged from 18 to 76. Cineangiography revealed stenosis at the site Conclusion: We recommend surgical repair of this condition to of reconstruction in 3 out of 23 patients. deal with aortic regurgitation and to avoid the potential risk of Conclusion: We conclude that satisfactory mid-term results could thromboembolism, and infective endocarditis. However, surgical be obtained with surgical correction of branch pulmonary artery repair offers no guarantee against arrhythmias and conduction stenosis. However, these patients require close follow up for longer abnormalities. duration as the development of restenosis remains a distinct possibility.

Optimal blooc GAS strategy for brain Total cavopulmonary connection using protection in pediatric cardiac surgery 123 interartrial septum: Technique and results 121 Saket Agarwal, Anil Bhan, Rajesh Sharma, Pravin Saxena, M Hote, B Airan, SK Choudhary, UK Chowdhury, Rajeev Gupta, Panangipalli Venugopal SS Kothari, A Saxena, P Venugopal All India institute of Medical Sciences, New Delhi All India Institute of Medical Sciences, New Delhi Background: Hypothermic cardiopulmonary bypass poses a risk Background: The Fontan procedure has undergone several to the viability of brain. The data available on neurological recovery modifications to avoid atrial arrhythmias and thrombus formation. after use of Ph-Stat and alpha-state modes is quite variable. We used interatrial flap to create intra-atrial tunnel. A decade long Occassional devastating brain complication prompted us to switch experience is being presented. over to PH stat strategy in Pediatric cardiac surgery. Patients and Methods: Between June 90, and September 2002, 31 Methods: The study was a retrospective data analysis of patients (age 1-17 years), underwent modified total cavopulmonary consecutively performed reparative cardiac procedures in pediatric anastomosis using interatrial septal flap to create the lateral tunnel. age group (less than 14 years) using the alpha-stat modality (n=280) In 18 patients the septum remained non-fenestrated, whereas in 13 and compared with prospectively performed corrective cardiac patients the septal flap was fenestrated with a 4 mm punch. procedures in similar patients with the PH-stat modality (n=213). All Results: There was one early death due to low cardiac output. In the clinical variables (CPB time, cross clamp time, lowest temperature another patient Fontan procedure was taken down because of poor reached, perfusion pressures), anaesthetic protocol and perfusion hemodynamics. Five patients developed significant pleural effusion. protocol in the two groups were similar. However, in the Alpha-stat

One patient had transient supraventricular arrhythmias. Follow-up group no CO2 was flushed into the circuit while in the PH-Stat group

ranged from 1 month to 10 years. There was one late date due to non- Co2 was flushed into the circuit to maintain normal PH and PCO2 at cardiac cause. All patients are in sinus rhythm and there was no the desired temperature. All the patients were operated at moderate episode of thrombus formation. 24 hour-Holter monitoring performed or deep hypothermia. None of the patients had circulatory arrest. in 10 patients showed no supraventricular arrhythmias. Results: There were 7 early deaths (2.5%) associated with Echocardiography revealed absence of obstruction or leak. neurological complications in the Alpha-Stat group. The computer Conclusion: Total cavopulmonary anastomosis using autogenous tomographic picture was uniformly the same in these patients. Grey- atrial septum is a useful modification for classical cavopulmonary white matter differentitation was lost, supra-tentorial compartment anastomosis and provides good early and late results with no risk of looked more hypodense compared with posterior fossa and corpus thromboembolism and no need for anticoagulants. striatum definition was lost. There was no neurological damage of any magnitude in the PH-Stat group. Conclusion: pH-Stat strategy seems to be the superior strategy in terms of brain protection for management of hypothermic (moderate Aneurysm of sinus of valsalva dissecting into or deep) cardiopulmonary bypass in pediatric cardiac surgery. interventricular septum 122 SK Choudhary, A Bhan, B Airan, UK Chowdhury, AK Bishoi, A Sampath Kumar, P Malhotra, P Venugopal All India Institute of Medical Sciences, New Delhi Background: Dissection of interventricular septum (IVS) by Adult TOF- surgical experience follow-up MUGA aneurysm of the sinus of Valsalva (ASV) is extremely rare. We present scan and assessment of quality of life 124 M John, Santosh Kumar, AK Bisoi, B Airan, A Bhan, our experience with the management of 16 patients with this condition. SK Choudhary, UK Chowdhury, A Sampath Kumar, R Juneja, Patients and Methods: Sixteen patients with ASV dissecting into U Kiran, Rakesh Sharma, P Venugopal the IVS were managed (14 operated) between May 1987 and All India Institute of Medical Sciences, New Delhi September 2002. Age ranged from 11 years to 60 years. Nine patients had complete heart block preoperatively, and 12 patients had moderate Background: Tetralogy of Fallot is the commonest congenital or severe aortic regurgitation. One patient presented with CVA. Two cyanotic Heart disease in adults. With improved surgical techniques patients refused operation and only permanent pacemaker and easy accessibility often they undergo total correction. implantation was done. Objectives: The study was designed to see the immediate and In the remaining 14 patients, the aneurysm opening was closed long term outcome and quality of life following total correction. either directly or with a patch. In addition, AVR was required in 7 Patients and Methods: Between January 1991 and December 2001 patients and aortic valve repair was done in 3 patients. a total of 284 patients age ranging from 14 years to 50 years (mean Results: All patients survived the operation. Three more patients 19.4±1.5 years) underwent Total Correction at our Institution. There required PPI and one patient developed recurrent ventricular were 195 (69%) males and 89 (31%) female patients. 45 (16%) patients tachycardia. Thus all patients, except two, had conduction block or had previous palliative shunts. 31 (11%) patients underwent rhythm disturbances in the course. preoperative coil embolization for major aortopulmonary collaterals.

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Total of 50 patients were randomly subjected to MUGA scan for annular pericardial patch. The VSD was closed with a Dacron patch assessement of ventricular function. They also filled the standard through the RA in all the cases. WHO quality of life questionnaire. Results: On table Prv/Plv ratio ranged from 0.3—0.8 (mean Results: 61 (21%) patients had major inhospital nonfatal 0.5±0.1). RVOT gradient on table (post CPB) ranged from 4 to 62 complications. The hospital mortality was 9.56% (28 pts). The follow mmHg (mean 20±12.4 mmHg). There were 19 early deaths, 63% of up ranged from 1 month to 10 years (mean 4.6±2.3 yrs). They were 7 these (12/19) were due to myocardial dysfunction. 6 patients had to late deaths and 12 patients were lost to follow up. Reoperations were be reoperated (0.6%) for a residual VSD. The incidence of complete performed on 13 (5%) patients. 94% of patients were NYHA class I. heart block requiring pacemaker was 2.17% (22/1012). The follow up MUGA scan showed good ventricular function in 86% of patients ranged from 1 month to 12 years (mean 52.4±18.4 months). There were scanned, 88% of respondants have perceived improved quality of life. 2 late deaths. 3 patients were reoperated (2 for a residual VSD and 1 Conclusion: With the improvement in surgical technique, for AVR). RVOT gradient at a mean follow up of 3 years ranged from mycardial preservation and intensive care Total correction in this 0–36 mmHg (mean 16.3±5.9 mmHg). 120 patients underwent a 24- subset of high risk patients offers best option for long term symptom hour holter monitoring for postoperative arrythmias. Of these 6 free survival. patients had significant ventricular and 7 had supraventricular arrythmias. 93.5% of survivors were in NYHA class 1. Conclusion: The transatrial approach gives statifying results in total correction of TOF. Right ventricular outflow tract after non-conduit repair of tetralogy of fallot with coronary anomaly 125 A Smartin, B Airan, SK Choudhary, A Bhan, UK Chowdhury, A Bishoi, R Juneja, N Makheeja, A Sampath Kumar, P Venugopal Aneurysms of the sinus of valsalva: Morphology All India Institute of Medical Sciences, New Delhi and long-term surgical results 127 Background: Anomalous coronary artery across the RVOT M Hote, SK Choudhary, B Airan, A Bhan, AK Bishoi, frequently poses problem in surgical correction of TOF. We evaluate UK Chowdhury, S Kale, A Sampath Kumar, P Venugopal the early and long-term outcome in patients after non-conduit repair All India institute of Medical Sciences, New Delhi in such patients. Objective: One hundred and seventy patients with aneurysms of Patients and Method: A total of 72 patients with TOF and an sinus of Valsalva underwent surgery between January 1977 and important coronary artery crossing the RVOT underwent complete September 2002. The morphological features and the surgical outcome repair without use of an extracardiac conduit between January 1990 in these patients are analyzed. and September 2002. Age of these patients ranged from 9 months to Patients and Methods: The age ranged from 4 to 62 years (median 14 years (mean 3.5±2.7 years) Fourteen of the patients had already 26 years) and all were congenital in etiology. The aneurysm originated received a systemic to pulmonary artery shunt. Repair was exclusively from the right coronary sinus in 130 (76.5%), from the non-coronary done by the transatrial (n=20) or transatrial-transpulmonary (n=52) sinus in 32 (18.8%), from the left coronary sinus in 2 (1.2%) and from approach. more than one sinus in 6 (3.5%) patients. In 17 patients (10%) the ASV Results: There were two operative deaths (CVA in one and remained unruptured. It ruptured into the right ventricle in 100 (58%), intrabronchial hemorrhage in the other). The remaining patients were into the right atrium in 46 (27%), and into the left ventricle in 3 patients. followed up for 1 to 132 months (mean 52.6±16.8 months). Early In 14 instances, the ASV dissectred into the interventricular septum. postoperative gradients ranged from 4 to 56 mmHg (mean 18.6±13.8 A ventricular septal defect was present in 69 (40.6%) patients, and in mmHg) and 10 patients had gradients more than 30 mmHg. On follow the majority (n=63), it was subarterial. Moderate to severe AR was up echocardiography after 1 to 84 months (mean 36.6±16.4 months) present in 48 patients. Surgical correction was through a bicameral gradients fell to 4 to 56 mmHg (mean 12.6±80.7 mmHg) and only 4 approach (n=125), or through the aorta (n=32), or the chamber of patients had gradients more than 30 mmHg. Only one patient, rupture (n=13). operated recently (follow up 1 month) had prohibiting high gradient. Results: There were 3 operative deaths and 6 late deaths over a Conclusion: Acceptable results are achievable following repair of follow up of a month to 25 years. Two patients required reoperation TOF in the presence of anomalous coronary artery across the RVOT for failed aortic valve repair. Actuarial and event free survival at 23 using the transatrial or transatrial transpulmonary approach. years were 94.0±3.0% and 82.0±6.0%, respectively. Presence of Gradients across the RVOT either decrease or remain stationary on significant AR was associated with reduced event for survival. A subsequent follow-up. comparison of the Indian patients with patients collected from the literature revealed that the Indian patients represent a separate subset of patients and can be placed in middle of the spectrum between the Oriental and the Western patients. Conclusion: Indian patients represent a different set of problems. Transatrial approach for total correction of Adequate surgery yields gratifying early and late results. tetralogy of fallot 126 J Dhareshwar, B Airan, SK Choudhary, A Bhan, UK Chowdhury, AK Bisoi, R Juneja, A Sampath Kumar, P Venugopal All India Institute of Medical Sciences, New Delhi Patients and Methods: The transatrial approach was used in 1012 Trans atrial approach for total correction of patients with suitable anatomy between June 1987 and August 2002. tetralogy of fallot– No patch technique 128 J Dhareshwar, M Hote, SK Choudhary, UK Chowdhury, The ranged from 6 months to 46 years (median 6.0 years) and weight B Airan, SS Kothari, P Saxena, P Venugopal ranged from 3 to 68 kgs (median 14 kg). 156 patients had undergone All India Institute of Medical Sciences, New Delhi a previous shunt procedure. 67% patients (678/1012) had a trans RA- PA approach with 273 patients (27%) having only right atrial approach. Aim: To analyze our results and describe our no patch technique 33% patients (334/1012) had a minimal ventriculotomy with a trans of transatrial total correction of Fallot's tetralogy.

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Patients and Methods: Between January 2000 and August 2002, Material & Methods: Retrospectively 62 patients, 73 procedures 79 patients of Tetralogy of Fallot were operated using only a transatrial performed on them, between January 1996 and September 2002 were approach. The Dacron patch VSD closure, infundibular resection and analysed. The age ranged from 3 days to 37 years (mean 4.2±1.2 SD). pulmonary valvotomy were done through the right atrium. There was There were 46 males (74%) and 16 females (26%). The various no pulmonary arteriotomy, ventriculotomy or outflow patch. The age operations that were undertaken were Total Cavopulmonary ranged from 6 months to 35 years (median 5 years) and weight ranged connection (19) BT Shunt (7), Bidirectional Glenn (11), PA banding from 3 to 52 kg (median 12 kg). (4), Double Switch Operation (12), Rastelli Procedure (5), VSD closure Results: There was no hospital mortality. Early postoperative with pulmonary valvotomy (1), Systemic atrioventricular valve repair echocardiography revealed mild residual VSD flow requiring no (4), Replacement (8) and Aortic Valve Replacement (2). 7 of 11 BD intervention in 2 cases. Nodal rhythm requiring temporary pacing Glenn patients had previously undergone BT shunt 2 of the 19 Fontan was seen in 6 patients (7.6%). There were no cases of complete heart patients had previous followed BT shunt followed by Glenn block requiring permanent pacemaker. The followup ranged from 2 procedures. Two patients who underwent PA Band previously to 34 months (mean 10.5 : t 2.4 months). Mean RVOT gradient at 3 subsequently had Fontan Procedure and Double Switch Operations months follow up was 12 : t 2.9 mmHg (range 8 to 31 mmHg). 88.6% respectively. One patient had undergone conduitplasty 6 years (70/79) patients are NYHA class I and off all medications and 9 following Rastelli procedure. All the patients were post-operatively patients (11.3%) are in Class II with mild RV dysfunction, well followed with echocardiography studies. controlled on medications. Results: The mean follow up period ranged from 1 month to 7 Conclusion: The no patch technique of transatrial approach has years (mean 36±3 months). In-hospital deaths in 7 patients (2 PA band, excellent results in selected cases of Tetralogy of Fallot. 1 BD Glenn, 2 DSO, 1 TCPC and 1 atrioventricular valve repair) and nonfatal complications in another 15 patients. 5 patients were lost to follow up. There were 3 late deaths (BD Glenn - 1, DSO -1 & Rastelli procedure-1). Conclusion: In our opinion though the options are many in repairing the congenitally corrected transposition the Double switch operation or Univentricular repair remains the operations of choice. Subaortic membrane excision: Long term results M Hote, B Airan, AK Bishoi, A Bhan, SK Choudhary, 129 UK Chowdhury, A Sampath Kumar, P Venugopal All India Institute of Medical Sciences, New Delhi Objective: To analyze the long-term outcome following surgical correction of isolated discrete subaortic membrane (SAM). Patients and Methods: A total of 73 patients (age 1-41 years, median 9 years) were operated on for SAM between January 1987 and September 2002. Preoperative gradients across the left ventricular Management for systemic atrioventricular valve regurgitation in corrected transposition of 131 outflow tract ranged from 50 to 154 mmHg (mean 84.7±32.3 mmHg). great arteries Eighteen patients had trivial aortic regurgitation (AR), thirteen had AK Bisoi, S Swain, B Airan, A Bhan, R Sharma, A Saxena, mild and six had moderate to severe AR. Left ventricular ejection S Chauhan, P Venugopal fraction (LVEF) ranged from 20 to 68% (mean 45±16%). Thirteen All India Institute of Medical Sciences, New Delhi patients had significant left ventricular dysfunction (LVEF less than 40%). Transaortic resection of SAM was performed in all patients along Introduction: Congenitally corrected transposition of great arteries with excision of a wedge shaped segment of septal muscle underlying is a rare clinical entity. Most of them were associated with some degree the membrance. Four patients required AVR, and aortic valve repair of systemic Atrioventricular valve regurgitation. The aim of the study was performed in one. is to highlight the outcome of various procedures in dealing in this Results: There were no early or late post-operative deaths. On regurgitaion. follow up of upto 160 months, only four patients had gradients more Material and Methods: Between Aug 1993 and July 2002, 22 than 30 mmHg (one patient required reoperation). In one patient, AR patients were retrospectively analysed who had corrected progressed and required reoperation. In other patients, AR either transposition with left AV valve regurgitaion. The mean age ranged reduced or did not progress further. LVEF improved to 45 to 70% from 6 months to 18 years. There were 15 males and 7 females. 10 (mean 57±7.3%). patients had grade I/II and 12 had Grade III/IV regurgitaion. Those Conclusion: Resection of SAM carries long-term benefits. Routine with Grade I/II regurgitation, underwent double switch operation 8 septal myectomy appears to be associated with a low risk of patients and Rastelli's procedure 2 patients. Patients with grade III/ recurrence. IV regurgitation needed either repair (4) or replacement (8). Results: The patients who underwent double switch, on subsequent follow up were found to have disappearance of regurgitation within 6 months of surgery. In the replacement group 1 patient had severe ventricular dysfunction for which ventricular assist device was put and subsequently weaned off successfully. One patient Corrected transposition – Our experience had complete heart block for which permanent pace maker SK Swain, AK Bisoi, B Airan, A Bhan, R Sharma, 130 implantation was done. Patients who underwent repair, had preserved SK Choudhary, UK Chowdhury, N Makhija, ventricular function in the immediate postoperative period. A Saxena, P Venugopal Subsequently regurgitation reappeared and progressed 1 year after All India Institute of Medical Sciences, New Delhi surgery. Background: Congenitally corrected trasposition of great arteries Conclusion: In our opinion, double switch operation is the is a rare clinical entity. Here we wish to share our experience in dealing treatment of choice whenever feasible and replacement gives durable with these patients. result with an acceptable risk of complete heart block.

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Combined sternotomy and thoracotomy surgery. One patient with mild AR and coronary anomaly, who approach for single stage correction of ventricular 132 underwent trans-AR ICR, developed progressive AR four years after septal defect with complex coarctation of aorta surgery and is awiting valve replacement. One patent (1.5%) R Murugu Sundara Pandiyan, SR Krishna Manohar, developed complete heart block, requiring PPI. Sixteen had Thomas Titus, KS Neelakandhan incomplete RBBB. Except the patients with RV dysfunction and AR, SCTIMST, Trivendrum all others returned to NYHA I. Introduction: Though interrupted aortic arch and coarctation of Conclusions: DCRV confers good long term results, if operated aorta can be repaired through sternotomy during repair of associated early in life, which prevents late complications like RBBB, RV failure lesions, repair of complex coarctation is extremely difficult from etc. anterior approach. Patients: One five year old child and two infant's presented with large subaortic VSD, severe pulmonary artery hypertension and severe coarctation. The first child had recurrent coarctation with a large false Giant right atrial diverticulum with ASD aneurysm. The second one had preductal coarctation with ductus A Anto Sahayaraj, N Nagarajan, A Sukumar, Rajan Santosham 134 supplying the lower body. The third child had juxtaductal coarctation Government General Hospital & Madras Medical College, with severe long segment isthmus hypoplasia. Chennai Methods: The chest and abdomen were circumferentially draped Background: Right atrial diverticulum is an extremely rare entity, so that the child could be easily rotated to lateral position and back to with only two other case reports in the literature till date. The patients supine position without disconnecting monitoring lines and bypass may present with embolic events and tachyarrhythmias. tubings. After sternotomy CPB was instituted and the child was Case Report: A 17-year-old male presented with palpitations, and carefully turned to lateral position. Repair of coarctation was done class II dyspnoea. The plain chest X-Ray showed cardiomegaly. ECG through thoracotomy. The child was shifted back to supine position revealed WPW syndrome. Echocardiography showed a gaint right for VSD closure, sternotomy and thoracotomy were closed after atrial diverticulum about 10×8×5 cms lateral to the tricuspid valve achieving hemostasis. The third child had undergone delayed closure. and overlying the right ventricle and an atrial septal defect (OS type) Results: The child with false aneurysm had a smooth recovery about 2×1 cms. Cardiac catheterization revealed a large right atrial and restudy showed a good result. Both the infants had severe diverticulum. The patient underwent partial resection and plication pulmonary artery hypertension with crises and right ventricular of the right atrial diverticulum and pericardial patch closure of the dysfunction. They deteriorated inspite of pro-longed ventilation and ASD, to prevent paradoxical embolism due to thrombus formation in succumbed to multisystem organ failure. the diverticulum and to reduce the risk of tachyarrhythmias. The wall Conclusions: Though this technique needs rotation of the patient of the diverticulum and trabeculated like the muscular portion of the under bypass, the exposure for repair of complex, coarctation was atrial wall and microscopically was similar to normal atrial wall. excellent without the lung coming in the way. This can be used for Results: Postoperative recovery was uneventful. similar situations where a single approach can not result in total Conclusions: Right atrial diverticulum is an extremely rare correction of the hemodynamic abnormality that is essential for the condition and surgical resection of the diverticulum is curative. post operative recovery.

Left atrial appendage aneurysm – A rare Follow-up study of sixty-six cases of intracardiac congenital cardiac discorder 135 repair for double chambered right venticle 133 Senthil Kumar Subbian, A Sukumar, N Nagarajan, Manoranjan Misra, R Sankar Kumar, KG Shyamkrishnan, Rajan Santosham SR Krishna Manohar Thomas Titus, KS Neelakandhan Madras Medical College and Govt. General Hospital, Chennai Department of CVTS, Sree Chitra Tirunal Institute for Medical Science & Technology, Thiruvananthapuram Background: Left Atrial appendage aneurysm is a very rare congenital heart disease. Search for published material on this Introduction: Double chambered right ventricle is a rare congenital condition yields only about 65 case reports that have been reported. cardiac disease, characterized by anomalous muscle bundles causing They usually come to light when investigated for the abnormal cardiac midcavity right ventricular obstruction. silhouetters they produce or when they cause embolic episodes. They Material and Method: Sixtysix patients of DCRV underwent have been managed surgically both under cardiopulmonary bypass intracardiac repair (ICR) from 1979 to 2002. Fourteen patients had and without CPB. isolated DCRV. Others had associated anomalies, the commonest Case Report: We present a case of a 12-year-old boy with this rare being VSD (fortytwo cases). There were fortysix adults and twenty disorder. He presented to us with mild breathlessness and frequent children. Trans-RA ICR was done in nineteen cases. Others required palpitation, which turned out to be episodes of SVT-a common RVOT patch. Out of five cases with AR, two required valve complication of this condition. He was thoroughly investigated with replacement and the other two valve repair. 2D echo, angiogram, CT scan and MRI. He was taken up for surgical Result: Early mortality was 4.5% (3 cases); two died due to repair after sternotomy. We could see a hugely dilated left atrial myocardial failure and one due to acute myocardial infarction. There appendage once the pericardium was opened. He was taken up on was no mortality on follow-up. Nine patients (13.6%) have tiny CPB and LA was opened. The opening to the aneurismal sac was residual VSD. Twelve patients (18%) have residual RVOT systolic narrow ad the aneurysm could be invaginated inside out through gradient, from 15 to 40 mm/Hg (mean 25mm/Hg). Important late this opening. The aneurysm was excluded by continuous sutures at complication occurred only in adults. A twenty six year old patient this opening and was excised. with VSD developed moderate RV diastolic dysfunction ten years Results: Postoperatively the patient had features of mild cardiac after surgery due to progressive RBBB. One patient with significant failure, which recovered promptly with antifailure therapy. residual VSD and PS underwent re-operation two years after first Conclusions: Surgical correction using CPB is safe and curative.

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The ross procedure in the young with aortic Repair of multiple muscular VSDs in infancy valve disease 136 R Kaushik, VK Sharma, M Luthra 138 Nelson Alphonso, Maxs Baghai, Ranjit Deshpande, Military Hospital (CTC) Pune Rajeev Godbole, Robert Tulloh, Conal Austin, David Anderson Department of Congenital Heart Disease, Guy’s Hospital, St Background: Repair of trabecular muscular ventricular septal Thomas Street, London SE1 9RT defects in infancy are a surgical challenge. They are often multiple and may require repair through the right ventricle sometimes using Background: The increased understanding of the advantages of an external buttress technique without a patch, or a patch closure the pulmonary autograft, the lack of durable bioprosthetic valves and through the apex of the left ventricle. PA banding in very sick infants the inherent risks associated with anticoagulation for mechanical with multiple VSDs in intractable failure may be indicated. valves, has led to the increasing use of the Ross procedure for aortic Method: Over the last 3 year period, 10 infants (wt 2.5 - 6 kg) with valve replacement, especially in children and young adults. We have multiple muscular VSDs with elevated pulmonary vascular resistance, retrospectively reviewed our mid-term results in both paediatric and have required repair because of CCF and failure to thrive inspite of adult groups. medical management. In all patients the repair was possible through Method: Over a 11 year period from August 1991 to August 2002, an RA incision. 4 of these children required a double patch repair. In 60 patients underwent the Ross procedure for aortic stenosis (50%), the last 6 infants bovine pericardium has been used for the patch aortic insufficiency (14%) and mixed aortic valve disease (36%). The material. median age was 15.1 years. 62% were males and 60% were younger The margins of the multiple muscular VSDs were not always than 20 years. The pulmonary autograft was implanted as an inclusion clearly discernable as happened in 5 patients. In them a bovine cylinder. pericardial patch was used to exclude the entire apical septum with Results and Conclusion: There have been no deaths in this series. plegetted interrupted sutures, dividing the posterior limb of the TSM Over a median follow-up period of 5 years (2 to 122 months), 4 patients to provide a clear area for suturing if required. required reoperation. Overalll freedom from reoperation (Kaplan- Results : Period of ventilation ranged from 48 hrs - 8 days. Control Meier) is 88% at 9 years. For patients younger than 20 years, freedom of ventilation, sedation, phenoxybenzamine and other vasodilators from reintervention is 97% at 7.5 years. were used to control pulmonary hypertension. One child with a Despite the increased technical complexity, the Ross procedure double patch repair developed a heart block and 2 patients died can be performed safely even in a paediatric population with because of sepsis and poor blood gases. Post operative satisfactory medium term results. echocardiography showed a residual VSD in 1 of the 5 patients in In many parts of the world the lack of homografts for whom the apical septum was patched with bovine pericardium. reconstruction of the right ventricular outflow tract limits the use of Conclusion: This method of using bovine pericardium to exclude the Ross operation. We also present an analysis of the alternative for the entire apical septum (also dividing part of the TSM) has not led to pulmonary valve replacement including xenografts, monocusps, increased morbidity of mortality and may be an appropriate method bovine valved conduits, stentless valves, Shelhigh and Contegra of repair form multiple apical muscular VSDs. conduits and percutaneous pulmonary valves.

Short term results of the rastelli repair R Kaushik, M Luthra, MK Unni, R Kaushish, 137 HS Bindra, SK Kaul Military Hospital (CTC) Pune Use of xenograft conduit in truncus arteriosus repair 139 Method: 14 children (age 8 months – 14 years) have undergone a R Kaushik, VK Sharma, M Luthra Rastellis repair over a 3 year period for TGA - VSD - PS 10 and DORV Military Hospital (CTC) Pune - PS 4. Moderate hypothermic CPB with cold potassium antegrade cardioplegia was used in all patients for repair. Methods: 3 children weighing less than 5 kg (age 6 weeks - 8 In the earlier 5 patients (TGA-VSD-PS 3, DORV-PS 2) RV-PA months) have been operated for Truncus arteriosus at this center in continuity was established using a Dacron conduit (with a pericardial the last 2 years. They all presented with cyanosis and cardiac failure monocusp in 4), while a valved xenograft conduit was used for RV- and were taken up as semi-emergency cases. PA reconstruction in the remaining 10 patients. Sizes of conduits used Opeation was done under cardiopulmonary bypass, with a period were between 16-22 mms diameter. 2-3 sizes larger than predicted by of circulatory arrest in 1 child. One had type 1 and two cases had wt/body surface area were used to allow for growth. Period of type II truncus (Collett Edwards classification). The pulmonary trunk ventilation varied from 24 hrs to 7 days, and was longer in the group button or the non-confluent pulmonary artery origin was dissected of pts in whom Dacron conduits were used. There was no mortality. off from the truncus and connected to the right ventricular outflow Results and Conclusions: Follow-up period of 1 mth - 3 years has tract by a size 14 mm Biocor xenograft valved conduit in all 3 children. shown grade 2-3 pulmonary regurgitation in 4 of the 5 pts with the I child also required of the truncal valve for significant regurgitation. unvalved dacron conduits though this was being well tolerated. There Results : 5-14 days post op period of ventilation was needed and was no significant PR in patients with the xenografts. RVOT gradients in all children the chest had to be kept open to prevent compression varied from 8 – 30 mmHg. of the conduit but could be closed within 24-72 hrs. 2 children required Valved xenograft conduit 2-3 size larger than predicted by weight/ peritoneal dialysis. 1 patient showed rapidly detiorating blood gases body surface area tables function well in the short term, when used the day after extubation and expired. for Rastelli repair. Dacron conduits with monocusps were associated Conclusion: Xenograft valved conduit of size 14 has proved to be with longer periods of post operative ventilation as well as need for an adequate conduit in the less than 5 kg wt child even though the post of medication. chest may required to be kept open till the child stabilizes.

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Mitral valve repair in atrioventricular Contegra xenograft as right ventricle to septal defects 140 pulmonary artery conduit 142 R Kaushik, VK Sharma, M Luthra Purohit Manoj, Bhat Akhlaque, Wijemanne Iresh, Pozzi Marco Military Hospital (CTC) Pune Paediatric Cardiac Surgery Unit, Alder hey Hospital, Royal Liverpool Children’s NHS Trust Methods: Over the past 5 years, a total of 21 children have been Liverpool, UK operated at this centre for atrioventricular septal defects (AVSD). 11 were boys and 10 girls, their ages ranged from 4 months to 14 years, Background: Pulmonary homograft is at present the conduit of and body weight was 3 to 31 kg. 14 children had partial AVSD and 7 choice for establishing continuity between the right ventricle (RV) had complete AVSD. Besides patch repair of the septal defects and and the pulmonary arteries (PA). Paucity of conduits and non- suture repair of the cleft mitral leaflet, 2 children with partial AVSD availability of small sizes has restricted its use. and all 7 with complete AVSD required some other form of repair of Methods: For the last three years we have used bovine jugular the mitral valve. vein valved conduit (Contegra, Venpro, Irivine, California) as RV to Mitral valve commisuroplasty was done in 8 and chordal PA conduit. In this study we evaluate the short-term results of this shortening in 2 patients. A teflon collar was used when the above conduit. From April 2000 to October 2002, Forty-six patients had methods were not effective in 4 children. The assesment of Contegra valved conduit (CVC) in our unit. Depending on the completeness of mitral repair was done by filling the LA through the indication for surgery patients were divided in three groups; group mitral valve and in case of doubt, on beating heart with coronary 'a' had CVC as a part of primary repair (25 patients): group 'b' had reperfusion while on normothermic CPB with an open LA. CVC as replacement conduits (6 patients) had group 'c' had CVC as Results : Inspite of attempted repair, presence of significant MR part of Ross procedure (15 patients). The mean age at surgery in group as assessed at operation in 1 patient of complete AVSD required a 'a' was 22.5 months (range 3 weeks to 3.6 years); group 'b' 8.5 years valve replacement. Subsequent post operative echocardiography (range 3.3 to 14.6 years) and Group 'c' 19.6 years (range 5.8 to 35.2 showed grade 2/3 MR in 1 of the remaining 6 complete AVSDs and years). required a valve replacement a year later. The rest had nil or minimal All patients were followed by Doppler echocardiography at one MR month, 3 months, six-month and at six monthly intervals thereafter, Conclusions: Use of a Teflon collar is an effective method of repair for a mean follow-up duration of 10.8 months (range 4 weeks to 30 when other methods are not successful and repair can be assessed on months). Mean flow velocities and degree of valve regurgitation was beating heart by coronary reperfusion with an open LA. studied to evaluate conduit function and these were plotted against time. Eight patients had cardiac catherisation, six in group 'a' and one each in group 'b' and 'c' for suspected conduit dysfunction. Results : No patient had deterioration of conduit function at echocardiography. The mean velocity at last follow-up in group 'a' was 2.24 m/sex, 2.1 m/sec in group 'b', and 2.01 m/sec in group 'c'. Six patients in group 'a' who had cardiac catherisation for progressive Systemic pulmonary artery shunts relevance in rise in velocities at ecocardiography had no conduit related pathology. the present era 141 One patient had infundibular stenosis, three had pulmonary BR Jagannath, P Srinivasa Reddy, B Kiran Kumar, confluence stenosis, one had peripheral pulmonary stenosis and in Pankaj Kumar Srivastsava one patients no pathology was detected. Mild pulmonary Southern Rly. Hqrs. Hospital, Ayanavaram, Chennai regurgitation (PR) was seen in three patients in group 'a' and in one patient in group 'b', and moderate PR was seen in one patient in group Introduction: Systemic pulmonary shunt is a palliative procedure 'b'. Cardiac catheterisation for group 'b' & 'c' patients was done for for congenital cyanotic heart diseases with decreased pulmonary non conduit related problems. blood flow. Indication of these shunts included – small PA, small LV, Conclusions: Contegra valved conduit is a good alternative to Coronary Artery crossing RVOT, infants not considered fit for going homografts for establishing RV to PA continuity. It has excellent short- on CPB. In present era most of these indications are not considered term hemodynamic results with additional benefits of case of good enough to preclude corrective surgery at first instance. availability in a wide range of sizes, improved technical handing and Our study is a retrospective study including shunts done in last excellent haemostatic properties. 15 years. Data is available for 128 patients operated during this period. Majority of them had modified BT shunt (15/128). 81 patients were male & 47 female with the age ranging from 7 days to 22 years. Observation: Majority of the patients were diagnosed to be having TOF 49.2 or DORV, VSD, PS (22.65%), others include Pulmonary Repair of total anomalous pulmonary venous Atresia, TGA with VSD PS, complete AV cannal defect with PS etc. connection in infancy: Factors influencing 143 Indication for shunt included – spells (42.96%), small pulmonary early outcome Lokeswara Rao Sajja, Gopichand Mannam, Sriramulu Sompalli arteries – 46.89% small LV (3.9%) & others. Care Hospital, The Institute of Medical Sciences, Banjara Hills, Results : In hospital mortality for shunt was 4.68% 6/128. 59 Hyderabad (46..45%) patients underwent post shunt catheterization out of which shunt was functioning in 74.57% patients, stenosed in 9 (15.25%) Background: Corrective surgery for total anomalous pulmonary patients & occluded 6 (10%) patients. 2nd shunt was performed in 16 venous connection carries high risk in terms of morbidity, mortality (12.59%) patients. Out of 16, one patients expired. 30 (30%) patients and prolonged hospital stay. The present study was carried out to underwent further corrective/palliative procedures. 24.6% patient had evaluate the factors determining the outcome in these infants. intra cardiac repair with 58.9% of those patients having trans annular Methods: Thirty four patients suffering from total anomalous patch. In hospital mortality was 31.57%. venous connection underwent repair between July 1995 through Conclusion: Current role of BT shunt is limited. Our data indicates October 2002. The median age was 6.2 months (ranged from 3 days that primary repair should be the first choice in all patients because to 11 months), 8 (23.5%) infants under the age of 3 months. The body of high drop out rate after BT shunt and its adverse effect on the ICR. weight of infants ranged from 3.2 Kg – 7 Kg (median weight 5.1 Kg).

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Fourteen (41.1%) of children were small for their ages (50th percentile). Effect of early post operative restrictive The different pattern of anomalous connection were supracardiac 14 physiology on late exercise capacity in patients 145 (41.1%) cardiac 17 (50%) draining to RA 6 patients, through coronary with tetralogy of fallot (TOF) sinus 11 patients, Infradiaphragmatic 1 patient (2.9%) and mixed type Kaushalendra S Rathore, Aditya Kapoor, Prabhat K Singh, 2 patients (5.8%). Twenty six patients had obstructive drainage with Prabhat Tiwari, Nirmal K Gupta severely elevated pulmonary arterial pressure and moderately Department of Cardiothoracic and Vascular Surgery, Cardiology elevated pressures were seen in 8 patients. A cardiac catheterization and Department of Anaesthesia, Sanjay Gandhi PGIMS, Lucknow, UP was done in only 3 patients and remaining 31 patients diagnosis was made only by transthoracic echocardiography. Most of the children Objective: Effect of early right ventricle restrictive physiology on underwent TAPVC repair using cardiopulmonary bypass and deep exercise capacity and arrthmogenesis has been studied in 60 hypothermia (25° C) and using hyperkalemic blood cardioplegic consecutive patients underwent total correction for TOF. arrest. Only one child underwent repair using total circulatory arrest. Methods: On follow-up 2D ECHO, Treadmill testing, Holter All patients with supra cardiac type and two patients of cardiac type monitoring and Pulse oxymetery performed. Two groups were made a posterior approach was used for anastamoses and transatrial based of the presence (group I) or absence (group II) of laminar approach was used in the rest of the patients. antegrade diastolic pulmonary artery flow through out the respiratory Results : There was no intra operative deaths, 4 four patients cycle, which was coincident with atrial systole. (11.7%) died in the hospital between 2nd and 26th post operative day. The mean age ranged 4 to 27 years (7.9±3.6 years). A wave was The cause of death in three patients were pulmonary arterial present in 44 patients. Maximum exercise time of group I (7.48 min, hypertensive crises and gram negative septicemia in one. Four patients range 6 min to 13 min) was not significant different from group II (8.1 needed peritoneal dialysis. 18 patients needed ventilation for more min, range 6.5 min to 13 min). than 48 hours. Results: Maximum heart rate achieved by group I (mean 65%, Conclusion: TAPVC repair in infancy can be accomplished with range 67% to 104%) and group II (mean 77%, range 72% to 106%) satisfactory out come. Lower age, lower body weight, severe PAH was stastically significant. METS (Metabolic equivalents) achieved and longer ICU stay seem to have adverse effect on outcome in our by both of the group were similar (mean 7.6, range 6 to 13). hands. Type of TAPVC did not have any influence on the out come. Chronotropic index was not significant different in two groups (48.66%, range 23% to 97% vs 49%, range 25% to 96%). Predicted Vo2 of both groups were same (mean 26 ml/kg/min, range 25 ml/kg/ min to 30 ml/kg/min vs 29 ml/kg/min, range 26 ml/kg/min to 32 ml/kg/min), p>0.5. Maximum patients of both the groups had fair exercise capacity (88% vs 90%). There were no deaths. No arrythmias were detected on holter monitoring in any patient. Spectrum of congenital cardiac anomalies and Conclusion: Presence of right ventricular restrictive physiology their management in clinically diagnosed 144 does not reduce the physical exercise capacity as compared to those congenital rubella syndrome: Single center do not have although the parameters are suboptimal than normal experience over 6 months children. K Padhy, P Alam, V Kohli, P Kohli, A Saha, A Raghuvanshi Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata Background: Congenital rubella syndrome has almost been eliminated in the developed world but continues to be seen in India. Assessment of RV diastolic dysfunction after total We describe a series of Congenital Rubella Syndrome patients with correction of tetralogy of fallot 146 special reference to their cardiac anomaly. Kaushalendra S Rathore, Aditya Kapoor, Prabhat K Singh, Methods: A clinical diagnosis of Congenital Rubella syndrome Prabhat Tiwari, Nirmal K Gupta was established using well described clinical criteria. 15 patients Department of Cardiothoracic and Vascular Surgery, Cardiology and Department of Anaesthesia, Sanjay Gandhi PGIMS, fulfilled the clinical criteria with male female ratio of 9:6 mean age of Lucknow, UP 22 months. Historically 5/15 (33.3%) were born preterm, 10/15 (66.6%) patient in whom birth weight was available were smalll for the Objective: Sixty-four consecutive patients of TOF undergone total gestational age history of rash with fever in first trimester was correction were studied to document the effect of right ventricular available in 9/15 (60%) 14/15 were under weight 13/15 had height diastolic dysfunction on immediate results. <5th percentile. Methods: 2D ECHO done on 7th post operative day and after 1,3 Results: PDA was present in 13/15 patients and 1/15 had & 6 months. pulmonary atresia with VSD. Associated VSD was present in 6. Age ranged from 1 year to 27 years and weight from 7 to 39 kg. Pulmonary valve stenosis was present in 4 patients. Brach PA stenosis Mean Nakata index was 242.2±85.3 (range 137 to 462) and the mean was present in two and aortic stenosis in 1 patients. Sensorineural Z value was 0.61±0.84 (range -1 to +2). Transannular pericardial patch deafness was present in 6 patients and cataract in 10/15. PDA was used in 72.58%. The follow-up ranged from 1 to 21 months. On transcatheter coil closure was performed in 2/13 and surgical ligation follow-up echocardiograms the patients were devided in two groups in 3/13. RPA stenting and BPV were done in one of the patients at the on the basis of presence (group I, n=45) or absence (group II, n=19) same time with coil closure. 1 patient with Pulmonary atresia and of, laminar ante grade diastolic pulmonary artery blood flow VSD underwent BT shunt. Trascatheter and surgical management is coincident with atrial systole (A wave). planned for the other patients. Results: In Group I, the Pulmonary artery "A wave velocity" Conclusions: In conclusion congenital rubella syndrome continues increased from 0.33±0.08 cm/sec in expiration to 0.46±0.13 cm/sec in to be seen in India and can present with varying congenital lesions. inspiration (p<0.05). The A wave duration increased rom130.08±12.7 Prevention of rubella during pregnancy needs to be reinforced to msec to 184.3±13.66 msec during inspiration. The group I patients prevent this condition. had lower “E wave (early diastolic wave) deceleraton” time, E velocity,

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E VTI (velocity time integral) and E/A ratio across the tricuspid valve Extracardiac Fontan – Outcomes & variables while higher A velocity (atrial systole wave) and VTI. The mean determining them 149 ventilation time, inotropic requirement and hospital stay, were Pawan Kumar, D Kulkarni, C Raghvendra, SK Pranav, significant higher in the group I (p<0.05). Three patients died in Group Uday Jadhav, AG Tendolkar I each due to sudden ventricular fibrillation, brain damage & right LTMMC & LTMGH, Sion, Mumbai ventricular diastolic dysfunction with septicemia. Background: ECFO has been performed in our center since the Conclusion: Right ventricle diastolic dysfunction exists in a last 3 years using the standardized technique described. significant number of patients of TOF and has significant effect on Material & Methods: No. of patients 10, Male/Female 7/3, peri-operative results like higher inotropic requirement, longer Average age 2-25 years, Average 5 years. Weight 10.5-52 Kg (21 Kg), ventilatory support time and longer hospital stay. Average Nakata 210 mm2/m2, range 160-290 mm2/m2, PAP 19 mmHg (12-35 mmHg) 0%=41-65% (52%), Size of conduit 20-24 mm (24 mm 7, 22 mm 1, 20 mm 2). Technique used is the same as described by the operating surgeon on a previous occasion. Results: Mortality 02 (Low CoP 1, Respiratory 1), Mortality in relation to Nakata = both had less than 180 mm2/m2, In relation to PAP=01 had more than 25 mmHg. Inotropes- nil= 05, dobutamine=03, Senning’s surgery – Experience adrenaline=02, Extubation time- 140 to 330 mins (190 mins), Post op Pawan Kumar, SK Pranav, D Kulkarni, C Raghvendra, 147 O%-74-100% (99%), Incidence of Pleural effusion (> 5 days)=3/8, Uday Jadhav, AG Tendolkar 37.5%, In relation to Nakata=no relation, PAP=higher with PAP >22 LTMMC & LTMGH, Sion, Mumbai mmHg (2/8), Incidence of Chylothorax=2/8, 25%. All the cases of pleural effusion & chylothorax were treated by drainage & diet. In Background: The atrial switch by Senning’s technique remains relationto Nakata=no relation, PAP=cannot be ascertained, TEE-nil, the most commonly performed surgery, for TGA, at our centre. Arrhythmia=01/08. Material & Methods: Duration of study “January 2000 – June 2002” Conclusion: Well known pre operative variables determine the No. of patients 06, Male/female 06/00 Average age 6 months 12 years, mortality & morbidity associated with an ECFO. The main average 2 years Weight 3.8 Kg – 24 Kg, Average 5.5 Kg, NYHA class, determinants in our experience are Nakata index <180 mm2/m2 & II-3, III-2, IV-1, 1 had undergone a BAS at birth. 1 had Lt. Juxtaposed PAP>22 mmHg. appendages. Standard technique described was used for all. Sternum The above indices can be calculated accurately on a reliable approximated in all. echocardiography examination. Higher incidence of pleural effusion Results: Mortality 03/06 (50%), Arrhythmias 01/06, Average is noted in patients with a lower Nakata (as mentioned above & an period of ventilation 2 days, Anti failure treatment was continued in elevated PAP. The similar reason may be implicated for chylothorax. all. Follow-up 6 months to 2 years, 100%. All in NYHA class I. Both of the above respond very well to tube drainage & conservative Conclusion: A Senning procedure is an excellent definitive repair treatment. for neonates & infants with TGA in our country (where the age of presentation is generally late).

BT Shunt – Size of conduits Pawan Kumar, D Kulkarni, C Raghvendra, SK Pranav, 150 Uday Jadhav, AG Tendolkar Adult TOF – results of ICR LTMMC & LTMGH, Sion, Mumbai Pawan Kumar, SK Pranav, D Kulkarni, C Raghvendra, 148 Background: BT shunt still remains a routine procedure, as the Uday Jadhav, AG Tendolkar LTMMC & LTMGH, Sion, Mumbai limitations of intracardiac repair exist. Studies exist to choose size of conduit. We present our technique for the same. Background: Adult TOF (>14 years age) is not an uncommon Material & Methods: Between January 2000 to June 2002, No. of feature in our country. We present our experience with the same subset patients 51, Male/Female 31/20, Lt. Side 35, Rt. Side 16, All on the of patients. same side as the arch. Average age 2 years 6 months, range 15 days to Material & Methods: All patients who underwent an intra cardiac 20 years. Average wt. 6.5 Kg, range 2.8 Kg to 43 Kg. Blood group repair (between Jan 2000 to June 2002) after the age of 14 years have O+ve-20, B+ve-17, A+ve-9, AB+ve-4, O-ve-1. been included in this study. No. of patients 27/68, Male/Female 18/ Size of shunt was primarily in accordance with age. <6 months=4 9, Blood group O+ve-10, B+ve-10, A+ve-5, AB+ve-1, A-ve-1, Age Ave- mm graft, 6 months - 2 years= 5 mm graft, 2-6 years= 6 mm graft, >6 19 years 3 months, range 14 to 30 years. Previous shunt 4/27, Average years= 8 mm graft. This technique could be followed in 39/51, ie, haematocrit 15.5 gms. All were by a ventriculotomy. Pericardial patch 76.5%. Only if the discrepancy with the branched PA was significant, widening done 26/27, 96.3%, Transannular Vs subannular 20 vs 6. the size chosen was different. Hence 8 patients for a 6 mm shunt Results: Higher return from the PA noted in all. Mortality Over received a 5 mm shunt and 3 patients for a 8 mm shunt received a 6 14 year mortality (4/27) -14.8% Vs under 14 year mortality=9.5%. All mm shunt. transannular patch. Ionotropic requirement for >2 days Over 14 year Results: Mortality=6/51=11%. 4 due to low CoP. Improvement in (8/27) 29.6% Vs under 14 years (5/41) 12.2%. RBBB complete with lt. O%=by 14%, Graft block=01/51=2%, CCF=nil. No difficulty during Axis deviation Over 14 year (5/27) 18.5% Vs under 14 year (5/41) takedown, during an intracardiac repair. 12.2%. Conclusion: A modified BTS remains an invaluable surgey for Conclusion: Adult TOF is definitely associated with a higher cyanotics of all ages, especially in our setup/s, where there are morbidity. Special attention & prolonged support is required in significant limitations for an intracardiac repair. Performing the shunt patients with previous BTS & pulmonary atresia. The operative on the same side of the arch is technically easier to perform & also to mortality is similar in all age groups. take down.

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Perioperative management and outcome of Group II needed the same (p<0.001). Multivariable and univariable TAPVC: Our experience 151 analysis of factors responsible for excessive volume and duration of Sathish Kumar Missula, Sri Ramulu Sompalli, drainage was also done. Preoperative packed cell volume was a risk Bala Raju Ravirala, Murali Mohan Kari, Gopi Chand Mannam factor for prolonged (p=0.019) and high output effusion (p=0.007). Care Hospital, The Institute of Medical Sciences, Banjara Hills, Longer ventilation was associated with more (p=0.019) and persistent Hyderabad drainage (p=0.019). Background: Operative correction of total anomalous pulmonary Conclusion: Younger patients with high preoperative haematocrit, venous connection (TAPVC) involves a greater risk in terms of udergoing Tetralogy of Fallot correction associated with long cardio mortality, morbidity and prolonged ICU stay. Although various factors pulmonary bypass time, use of trans annular pericardial patch, who determine the positve outcome, effective Perioperative management are more sick and require more inotropic support, longer ventilation is utmost important, in addition to the corrective surgical procedure and longer stay in ICU in the post operative phase develop persistent itself. The present study was aimed to analyze our management pleural effusion. protocols and the outcome. Patients & Methods: From July 1995 through October 2002 thirty- four patients with TAPVC taken up for surgical correction were included in the study. The median age was 6.2 months (3 days - 11 Adult tetralogy of fallot – Experience over months) and the median weight was 5.1 kgs (3.2-7 kgs). Severely a decade 153 elevated pulmonary (PA) pressures were observed in 26 patients (5 Trushar Gajjar, D Abhijeet, LN Achar, Saibal Neogee, Nimisha, patients needed preoperative ventilation) and moderately elevated Rekha Matta, Neelam Desai pressures in 8 patients due to obstructive drainage. All the patients Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, were induced with ketamine and intubated using vecuronium for Anantapur providing muscle relaxation. Anaesthesia was maintained by bolus Background: Adult TOF, which is soon becoming a rare entity, is doses of midazolam, fentanyl and vecuronium and isoflurane (0.4- still seen in 3rd world countries like ours. 1%). Haemodynamics were optimized using dobutamine (2.5 mcg/ Methods: In a span of 10 years we have come across 108 cases kg/mt), nitroglycerine and/or sodium nitroprusside. In addition, aged 18 to 36 years who underwent Intracardiac repair in our institute. fentanyl (5 mcg/kg/hr) was used as an infusion. Standard techniques 3 of them had Dextrocardia, 7 of them had palliative procedures 6 to were practiced for the institution, maintenance and weaning from 21 years earlier. Preop. 95 Patients were in NYHA Functional class II, cardio pulmonary bypass. Standard paediatric cardiac monitoring was 10 in class III, and 3 in class IV. Operative mortality was 0%. Blood adopted. Post operatively all the infants were ventilated electively loss in Postop. Period was curtailed by the use of FFP, Fresh blood & (Pco2<25 mmHg, PH>7.5) for 24-36 hours and weaned off after Aprotinin in very cyanotic patients. Re-exploration was done in only achieving satisfactory haemodynamic stability and acceptable blood 3 patients. 45 patients had a longer Postop. ICU stay needing Inotropic gasses. Dobutamine (7.5-12.5 mcg/kg/mt), NTG, SNP, fentanyl, Support for a minimum of 2-3 days & more fluid requirement. Majority midazolam, dexamethasone and captopril were the mainstay of recovered uneventfully with good results. Aortopulmonary collaterals pharmacological support. unless significant in size were left alone. Follow-up ranged from 3 Results: There was no intraoperative mortality, 4 patients (11.7%) months to 10 years. died in the hospital between 2nd and 26th postoperative days. 4 Results: Residual cardiac defects were observed in 8 patients. patients needed peritoneal dialysis and 18 patients needed ventilatory Postoperatively 90 were in NYHA class I, 10 in class II. Major support for more than 48 hours. ventricular arrhythmias were recorded in 2.7% of patients. 2D Echo Conclusions: Management of surgically corrected infants with revealed good LV/RV function in 95 patients. Higher postoperative TAPVC can be accomplished with acceptable mortality and morbidity RVOT gradient was found to be dynamic obstruction, which using standard institutional protocols. responded well to Beta-blockers. Conclusions: Total correction of TOF can be performed safely in adults with low mortality & good functional improvement. The incidence of residual cardiac defects is low. The long-term importance Prolonged serous pleural effusions after of ventricular function & arrhythmias remains to be ascertained. tetralogy of fallot correction – Is the cause 152 surgical? SP Manoj Kumar, SR Mohanty, B Dubey, HS Anand, S Basvaraj, S Rao Department of CTVS, SSSIHMS, EPIP Area, Whitefield, Bangalore Background: Tetralogy of Fallot is a common cyanotic congenital Non valvar congenital LVOT obstruction – heart disease. Many patients develop pleural effusion in the Our experience 154 PS Seetharama Bhat, Ashok Kumar, Kiran, postoperative phase; in some it is excessive and persists for longer Prasanna, Shanmukh, AN Prabhudeva duration. Sri Jayadeva Institute of Cardiology, Bangalore Methods: Two hundred and thirty patients of tetralogy of fallot were operated from April 2001 to September 2002, out of which 23 Introduction: Congenital left ventricular outflow obstruction may patients developed persistent pleural effusions, which constituted the be at subvalvar, valvar or supravalvar level. study (Group I). Other were randomized, who were the control group Methods: We operated on 5 cases of subvalvar obstruction and 3 (Group II). Multiple factors were analyzed. cases of supravalvar obstruction in the last 2 years. All but one of the Results: Among the preoperative variables studied, Group I subvalvar obstruction had discrete complete or partial fibromuscular patients were younger compared to Group II (p=0.02). ring in LVOT. One patient had accessory chordae attached to the Cardiopulmonary bypass time was significantly longer in Group I subaortic curtain which was diagnosed accurately pre-opratively by (p=0.01). Trans annular pericardial patch was used more often in echocardiogram. Group I (p<0.02). Eighty two percent of the patients in Group I Results: The supravalvar obstruction was at the site of sinotubular required Inj. Adrenaline also as inotropic support, whereas 21% of junction. One of them had additionally several plaques of athermoma

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in the sinus and sinotubular junction constributing significantly to experience, this contributed to faster recovery and earlier extubation the LVOTO. This patient had very high triglyceride levels with in these neonates. Moreover, whenever we encountered mediastinal subcutaneous fat deposits throughout the body. bleeding due to coagulopathy after a prolonged complex procedure There has no surgical mortality with insignificant gradients post requiring massive blood product transfusion, dialysis proved a safe operatively. One patient died six months later of arrhythmia. vent for easier management of blood component load. Conclusions: Rare causes of LVOT obstruction to be borne in mind Methods: Our technique of placement of Tenkhoff peritoneal while dealing with LVOTO. catheter is by supra hepatic approach, through the lower end of the sternotomy wound just beneath the xiphisternum. The catherter is tunneled and brought out through a separate stab incision in the sub- xiphoid area. We have used elective dialysis in 98 consecutive neonates Systemic – pulmonary arterial shunts in neonates after cardiac surgery in a period of six years. The range included VSD D Anil Kumar, RN Suresh Kumar, PN Rao, Sushil Chandran, 155 closure (n=10), transposition complexes (n=60), TAPVC (n=20), H Mahmoud, AK Dhir, DK Saxena, AS Pillay, primary interuption+VSD repair (n=4), and truncus arteriosus repair CG Venkitachalam, YA Nazer, MR Sedagathian, Tim Cartimill, IM Rao (n=4). Dialysis is performed electively on a half hourly/hourly basis Departments of Cardiology and Cardiac Surgery, Mafraq Hospital, depending up the clinical situation, using a low volume cycle Abu Dhabi, UAE technique (10 ml/kg/cycle), a low osmolarity dialyisis fluid and a Background: Neonates requiring systemic – pulmonary arterial short indwelling time. The catheter is removed before extubation. shunt (SPAS) belong to a diverse clinical spectrum. Results & Conclusions: We have not encountered any Methods: Retrospective analysis of the data regarding 48 complication due to the dialysis. There was no incidence of sepsis or consecutive neonates who underwent SPAS during the period May peritonitis. Moreover, with our supra hepatic approach technique, 1995 through October 2002 is presented. Mean age : 11.6 days (range the removal of the catheter is uneventful without any prolapse of 2-30 days); mean weight: 3.26 kg (range 2.0-4.0 kg). The babies were omentum. classified into four groups. Group I : Large VSD, well developed two ventricles in D or L loop, severe RVOT stenosis or atresia conforming to Tetrology of Fallot/Pulmonary artresia anatomy (n=18). Group II: Single ventricle with pulmonary atresia (n=19). Group III: Single Transcaval repair of sinus venosus syndrome ventricle/pulmonary atresia with isomerism and/or TAPVC (n=5). PN Rao, RN Suresh Kumar, Anil Kumar, Sushil Chandran, 157 Group IV: Pulmonary atresia with intact IVS (n=6) Diagnosis was H Mahmoud, AK Dhir, DK Saxena, AS Pillay, made on basis of 2D Echo. Indication for cardiac catheterization was CG Venkitachalam, YA Nazer, Tim Cartmill, IM Rao deliniation of PA anatomy/ductus laterality (n=4) or balloon atrial Departments of Cardiology and Cardiac Surgery, Mafraq Hospital, septostomy (n=4). Abu Dhabi, UAE Results & Conclusions: The surgical procedure was a modified Background: Surgical correction of sinus venosus syndrome has Blalock Taussing shunt on the situs. Three cases required a central been associated with sinus node dysfunction and venous obstruction shunt. In one case where a modified BT shunt was done along with post operatively. Various surgical techniques have been used to repair repair of obstructed supracardiac TAPVC in a univentricular heart this defect involving incisions across the cava-atrial junction, right with isomerism, the baby did not come off bypass. There was no atrial free wall muscle flaps and transction and relocation of the SVC mortality in the 47 neonates who had the arterial shunt as the only to the right atrial appendage. procedure. Four cases required revision of the shunt in the immediate Methods: We present the technical details and our experience with post operative period for shunt thrombosis; one of them required transcaval repair. Between November 1998 to September 2002, eight conversion to a central shunt. patients with sinus venosus syndrome underwent surgical repair. The The 47 patients were followed up for a mean period of 26.4 months mean age was 12.5 years (range 5-58 yrs). Two different incisions: a (range 1 month - 42 months). In Group I, 9 patients have undergone transverse superior vena caval incision (five patients) and a lateral total correction with or without a conduit (double switch in one), while transcaval incision (three patients) were used. A fresh autologous 3 had new arterial shunts for shunt/PA stenosis. In Group II, 8 cases pericardial patch was used to close the defect in all the patients. have undergone bi-directional glenn with atrial septectomy (n=2) and Results and Conclusions: There was no operative mortality. All PA plasty (n=3). In group III, 1 had a PA plasty with bi-directional the patients are in sinus rhythm. There was no evidence of residual glenn. In Group IV, 2 have undergone bi-directional glenn and 2 have SVC or pulmonary venous obstruction. had pulmonary valvotomy±RVOT widening. Transcaval repair is safe and provides direct access to the atrial septal defect and anomalous pulmonary veins. It is easy to perform and does not affect the sinus rhythm or compromise the systemic or pulmonary venous drainage. Safe approach to peritoneal dialysis in neonatal cardiac surgery – Mafraq hospital technique 156 D Anil Kumar, RN Suresh Kumar, PN Rao, Sushil Chandran, H Mahmoud, AK Dhir, DK Saxena, AS Pillay, CG Venkitachalam, Open pleurectomy for persistent chylothorax YA Nazer, MR Sedagathian, Tim Cartimill, IM Rao complicating surgery for congenital heart defects 158 Departments of Cardiology and Cardiac Surgery, Mafraq Hospital, in children Abu Dhabi, UAE Ramana Rao V Dhannapuneni, Kostas Kotidis, Christos Alexiou, Mark S Hickey Background: In the immediate post operative management of Department of Cardiothoracic Surgery, Glenfield Hospital, neonates undergoing complex cardiac surgery, we have found elective Leicester, UK peritoneal dialysis as a very useful tool. In these neonates, we feel that the major role of elective dialysis post operatively is control of Objective: Chylothorax following repair of congenital heart defects electrolyte imbalance and fluid removal; it allows the neonate to is unusual and is primarily treated wth tube thoracostomy and dietary recover from the effects of low cardiac output and oliguria. In our modification. We describe three paediatric cardiac patiens who

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developed postoperative chylothorax and were managed with open TOF with absent pulmonary valve syndrome with pleurectomy. absent LPA-A case report 160 Methods: Description of three cases. Jayesh Akbari, KG Shyam Krishnan, KS Neelakandan, Results: A prematurely born male with right cardiac isomerism Thomas Titus and congenital heart block, underwent ligation of PDA. Sree Chitra Thirunal Institute of Science and Technology, Postoperatively he developed perisistent radiological shadowing of Trivandrum, Kerala the left lung and could not be weaned fro the ventilator. Chest drain Introduction: Absent pulmonary valve syndrome is rate congenital insertion at four weeks of age and analysis of pleural aspirate, malformation, comprising 3%-5% of all cases of the tetralogy complex, confirmed the presence of chylothorax. Following left thoracotomy combination of absent LPA with this is not described in literature. and pleurectomy the chylous leak ceased. A male child with complex A 27 yrs male presented with DOE NYHA class II of 15 years congenital heart disease had undergone bilateral bi-directional Glenn duration. On examination having mild cyanosis and clubbing. p-80/ aged four months and had a completion Fontan procedure five years min, and BP-110/70 mmHg. Apex beat in Lt. 6th intercostal space later. He developed chylothorax, refractory to conservative just medial to anterior axillary line, systolic thrill LSB, left parasternal compromise. He underwent bilateral thoracotomy and complete haeve present S –normal, grade 4/6 ESM and grade 3/6 EDM at ULSB. pleurectomy 28 days postoperatively, which resolved the chylous leak. 1 S2–single, Trachea shifted to left. X-ray chest showed CTR-55%, A male child born with Transposition of the Great Arteries, a mediastinal shift to left, prominant pulmonary bay and oligemic lung restrctive VSD and a rudimentary left ventricle underwent a balloon field. ECG was suggestive of RAD, RVH with RV strain, & 2D echo atrial septostomy at 9 days of age and a bi-directional Glenn five showed large SAVSD, pulmonary annulus small, LPA absent, months later. Post-operatively he developed a chylothorax and this suspicious of single coronary of RCC origin, so cath done which was treated by tube thoracostomy first and by left thoracotomy and showed, mild systemic desaturation, single SAVSD, Dillated RA, pleurectomy 21 days postoperatively. The chylous drainage ceased Dilated MPA, absent LP. No definite pulmonary valve seen, severe after the pleurectomy. PR, normal coronaries. Conclusions: Open pleurectomy can be an effective therapeutic Procedure: Under moderate hypothermic CPB, intra cardia repair option for the management of persistent chylothorax complicating including trans RA VSD closure and trans annular patch closure done. surgery for congenital heart defects in children. Patient made smooth post operative recovery and post operative investigation showed no residual Defects. Conclusions: We are presenting this case since this is a very unusual associated with tetralogy complex.

Outcome of bidirectional glenn shunt-Chitra experience 159 R Marugu Sundara Pandiyan, R Sankarkumar, Double outlet right ventricle-Surgical experience KG Shyam Krishnan, SR Krishna Manohar, Thomas Titus, & follow-up 161 KS Neelakandhan KG Shyamkrishnan, SR Krishna Manohar, R Sankar Kumar, SCTIMST, Trivendrum KS Neelakandan, Thomas Titus Sree Chitra Tirunal Institute for Medical Science and Technology, Introduction: Bidirectional Glenn shunt is an established palliative Trivandrum, Kerala procedure in a variety of cyanotic heart diseases and is associated witha varied outcome. Background: Althugh DORV occurs in 0.09 per 1000 birth, its Patients and Methods: Ninety nine patients who had undergone surgical correction offers a challenge to the surgeon & so is its outcome. Bidirectional Glenn shunt between January 1991 and June 2002 in Our experience with 32 cases of DORV with or without RVOT our hospital for a variety of complex cyanotic congenital cardiac obstruction from Jan. 93 to Dec. 2002 is being discussed. Cases with conditions form the basis of this study. Of these 99 patients, 27 had demonstrable Aorto mitral discontinuity only were considered. tricuspid atresia with VSD and PS; 22 had DORV, VSD, PS; 20 single Method: There were 19 males & 13 females, age ranging from 14 ventricle morphology with PS: 16 had D-TGA, VSD, PS; 5 had complex months to 29 years. Group I comprises of 12 patients with DORV, tetrology of Fallot; 4 had pulmonary atresia; 4 had corrected TGA, SAVSD & noRVOTO, with PAH. Group II comprises of 20 patients VSD, PS and 1 had unbalanced atrioventricular septal defect with PS. with DORV SAVSD + RVOTO. Associated anomalies included ASD, Follow up period ranged from 3 months to 11 years (mean of 2.9 years). PDA, subaortic membrane. 3 in Gr. II had privious BT shunts. Results: Sixty five patients (65.7%) are doing well with good All of them were evaluated by CXR, EOCG, Echo & cath, They functioning shunt. Twenty three patients (23.23%) had undergone were operated under CPB, moderate hypothermia crystolloid or blood completion TCPC. Eleven patients (11.9%) died. Two patients could cardioplegia. Group I underwent intra cardiac tunneling using decron not be weaned off bypass. Six of them succumbed to low cardiac & group II in addition to tunneling RVOT reconstructed with TAP in output. Two aied of cerebral embolism. One patient had refractory 14 outflow patch in 5+ trans RA resection in 1 Associated defects & junctional tachyarrhythmia. The mean Hemglobin and hematocrit shunts were also dealt with. regressed from 19.56g/100m1 and 63.24% (preoperatively) to 13.39g/ Results: There were 3 deaths in Gr. I 2 due to severe PAH & 1 100m1 and 42.57% (postoperatively). Saturation improved from probably due to unrecognised LVOTO. There were 5 deaths in Gr. II 72.03% to 85.9%). all of them had due to severe low output state. There was 1 late death Conclusions: Inspite of good palliation offered by Bidirectional after 1 year in Gr. II due to severe LV & RV dysfunction with no Glenn shunt, 38 patients (38.38%) remained unfit for completion Residual defect. Follow-up has been ranging from 3 months to 52 TCPC. There was no significant effect on PA pressure or PA growth. months (22.5 m). All the 23 surviors are in FCI although 3 in group I Ligation of MPA did not influence outcome. The result was poor in have residual PAH, 2 in Gr. II have developed mild AR & 1 has emergency operations, age less than 6 months, unfavourable PA moderate residual RVOTO. anatomy and borderline PA pressures. All of them need life long follow-up.

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Study of two different variants of supracardiac Ebstein's anomaly – Tricuspid valve repair TAPVC 162 or replacement? 164 Rajarshi Basu, Goutam Sengupta, Subhankar Bhattacharya I Guha, BC Roy, A Mandal, S Dey, A Chakravarti, A Dey, IPGME & R, Kolkata R Vashisth, S Chakraborty Department of Th & CV Surgery, Medical College, 88 College Background: Operative correction of two variants of Supracardiac Street, Kolkata TAPVC is discussed. Case Summary: Two young men aged 22yrs. and 26 yrs. presented Introduction: Ebstein anomaly of the tricuspid valve is not too with cyanosis and pulmonary midsystolic murmur, wide fixed split common congenital anamoly. We have an experience of 7 cases of of second heart sound. Chest X-ray revealed typical "Snowman's sign" Ebstein's anomaly. M:F=4:3. in one patient, but in the other case the sign. was not prominent. Material and Methods: In our experience at Department of Echocardiaography revealed common pulmonary venous chamber Cardiovascular and Thoracic Surgery, Calcutta Medical College, over draining into right side of heart. Angiography revealed vertical venous a period of 5 years. After standard CP bypass with bicaval cannulation communication to left innominate vein in one patient and to superior RA was explored, anatomy defined. In suitable cases (5/7) Danielsen venacavae in the other. Both the patients were subjected to operative repair was performed. In patients with tethering of anterior leaflet correction under cardiopulmonary bypass. In one case vertical vein with RV wall (2/7) the valve was excised and replaced with a stented can be identified early before institution of CP Bypass. In the other tissue valve. patient vein connecting common chamber to SVC could not be Results: Of the 7 patients one died of unrelated complication. dissected out in its usual location. The outlet opening was identified One had severe wound infection. after opening common chamber and closed through it. Anastomosis Inference: Ebstein anomly of the triuspid valve can be successfully of common chamber to left atria was done followed by repair of A.S.D. repaired if the anatomy is favourable. Otherwise the valve should be The peri-operative period was uneventful and both patients recovered replaced. well. Conclusions: Definitive correction of difficult TAPVC can achieve good post-operative results. Right aortic arch, Rt. descending aorta with right sided PDA 165 V Arun, S Balachandran, S Visvakumar, M Varadarajan Cardio Thoracic Surgery Department, Govt General Hospital, Chennai Background: A right aortic arch is frequently associated with anomalies of the great vessels or congenital intracardiac abnormalities. Rarely a right sided patent ductus ateriosus is the only vascular lesion Transatrial transpulmonary repair of tetralogy with a right sided aortic arch. of fallot 163 Case Report: An 18 yr old girl presented with effort intolerance Bhagawan Koirala, Jyotindra Sharma MS, Uttam Shrestha, and recurrent respiratory tract infection. On clinical examination she Purna Raj Joshi, Siddhartha Pradhan, Rabindra Timala, Anju Shrestha, was acyanotic and had a continuous murmur in the rt. second Murari Upreti, Jeju Nath Pokharel, Govind P Shrama intercostal space. Department of Cardiac Surgery, Shahid Gangalal National Heart Echocardiogram revealed a PDA with Lt to Rt shunt.X-ray chest Center and Tribhuvan University Teaching Hospital, Kathmandu, showed a situs solitus, levocardia, rt. aortic arch with prominent Nepal pulmonary vascular markings. MRI and Cath studies were performed Background: Cardiac surgery is just being established in Nepal. for better delineation. Chromosomal study for ch 22q 11 deletion was This report summarizes the initial experience of a new cardiac surgical also done. program in Nepal. Rt. posterolateral thorocotomy was done. The aortic arch was rt. Methods: Of the 370 heart surgeries performed by a single team sided with the azygos vein across it. The ductus arose from the between September 2001 and October 2002, 15 cases were of total posteromedia aspect of the upper descending aorta and the rt. correction of Tetralogy of Fallot. age ranged from 1 year to 24 years laryngeal nerve was recurrent around it. The ductus was doubly (mean 12) with male female ratio of 2:1. Preoperative workup was ligated. Patient had an uneventful postoperative recovery. done by Echocadiography and cardiac catheterizaion when indicated. Conclusions: Patent ductus arterious in unusual locations merit Three patients had major aortopulmonary collaters, but none had detailed evaluation regarding the anatomical relationships, for coronary artery anomalies. Routine cardiopulmonary bypass successful surgical management. techniques were used with cold blood cardioplegia in all. Collaterals were ligated surgically in the same sitting. None of the patients had transanular patches, two however needed RVOT patch. Transatrial resection of RVOT muscle bundles and closure of the VSD was An unusual presentation of anomalous left pulmonary artery with ring occluded ductus 166 combined with pulmonary valvotomy and patch reconstruction of Sanjay Kumar, Ravi Pillai pulmonary artery. Decision about further intervention was taken after Oxford Heart Centre, The John Radcloffe Hospital, Oxford, UK coming off bypass and pressure studies. Results: All but one had subsystemic RV pressure. One patient Introduction: Pulmonary sling is an anomaly in which the left required reexploration for bleeding. Two patients (13%) died. All of pulmonary artery (LPA) arises either from the posterior surface of the rest are doing well in post op follow up at 1-12 months with steady the right pulmonary artery, or from the main pulmonary artery and regression of RVOT gradient. courses to the left lung between the psoterior surface of the trachea Conclusions: Transatrial transpulmonary approach for repair of and the anterior surface of the esophagus. We present a clinical case tetralogy seems to be feasible with acceptable outcome even in a low of a 2.5-year-old child with a left pulmonary artery sling who volume center. developed tracheal compressive symptoms following coil occlusion

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of ductus. We discuss the difficulties in establishing the diagnosis and Methods: 3 Patients with critical LMCA lesions were operated treatment options for this well-recognized clinical entity. between Feb 2002 to Sep 2002. One seventy two year male is active Case Report: A two and half years old girl was referred with h/o smoker with recent anterior MI, and tight distal main, other with recurrent stridor & SOB in infancy. She was found to have heart carotid lesions and one female with calcified distal LMCA with distal murmur in neonatal check, which was tought to be VSD, and kept critical stenosis with calcified Aorta and severe LV dysfunction under review. At 14 months bronchoscopy revealed a very small R subjected to OPCAB. Inverted T- shape pericardiotomy which was bronchus with narrow lower 3rd of trachea. Contract CT scan revealed extended to the right and to the Diaphragm to the back of I.V.C. till tracheal stenosis with pulm art sling. At the age of 2 years transcatheter the right phrenic nerve. Octopus II and star fish stabilizers and intra occlusion of PDA was done. Her stridor gradually become worse and coronary, shunts were used. at 2 years 10 months of age she had relocation of LPA and division of Results: The active smoker developed Hypoxia 24 hours after PDA. The reimplantation of LPA was done at the ductus site of extubation and developed SVT and required prolonged ventilation transection of PDA. for recovery. No patient developed renal, Neurological complication. Results: Post operative ICU course was uncomplicated. At 6 Conclusion: In selected patient with critical LMCA and high risk months she has good exercise tolerance and minimal inspiratory off pump CABG can be performed with acceptable results. stridor. Comments: The tracheobronchial compression by vascular structiures in childhood is uncommon and may be masked by nonspecific respiratory symptoms, resulting in an often delayed diagnosis. Once imaging studies have clearly delineated the causal OPCAB and On-pump CABG: A comparision in pathologic vascular structures e.g. pulmonary sling and ring occluded the eldery 169 ductus in present case, surgical correction is often straightforward Arul Vikaykumar, P Babu, Ramesh Paul, LF Sridhar, and effective. AR Raghuram, MR Girinath Apollo Hospital, Chennai Objective: CABG in the elderly is known to be associated with increased perioperative morbidity and mortality. This comparative, Impact of cellsaver system on Off pump CABG retrospective study was conducted at our institution to analyze the EV John, PG Koshy, Basisht Mishra, AR Raguram, 167 various perioperative outcomes of 'Off-pump and On-pump CABG' LF Sridhar, MR Girinath in elderly patients. Apollo Hospital, Chennai Methods: Two cohorts of elderly patients, above 70, years of age, who underwent CABG in the period 2000-2002, were selected. A total Aim: As the blood loss during off-pump CABG can be of 114 patients who had undergone OPCAB were compared against considerable, a study of the impact of cellsaver system on it seemed 185 CABG patients operated using cardiopulmonary bypass. appropriate. Results: The preoperative risk factors, namely myocardial Methods: From January 2002 to September 2002, per-operative infarction, LV dysfunction, incidence of hypertension, hyper- cellsaver system was used in 42 patients (Gp. A) during off-pump lipidemia, diabetes mellitus and other medical discorders and number CABG. As it adds to the total cost, the use was restricted to those who of smokers were well matched in both groups. Blood loss and the can afford it. This gorup was compared to same number of patients requirement of blood and blood products (FFP and platelets) were operated without cellsaver system (Gp. B). Patients were matched significantly lower in OPCAB group (more than 750ml drainage in for Number of grafts, Body surface area and Pre-operative PCV. the I post-opday 15.8% Vs 20.5%). Inotrope usage is significantly lower Results: The average post-operative blood loss over 24 hrs. (387ml (42.98% Vs 85.94%) in the OPCAB cohort. Postoperatively, the Vs 402ml), the average number of blood products used over 5 days incidence of both atrial fibrillation and other arrhythmias were (0.81 units Vs 0.93 units), re-exploration rates (2.4% Vs 2.4%) and significantly lower in the OPCAB group (12.3% vs. 20%, p<0.05). The coagulation parameters including indices of hemolysis and same group also had a statistically significant lower incidence of low defibrination are NOT significantly different between the two groups. cardiac output (4.4 Vs. 21.6%, p<0.05), renal failure (2.6% Vs 6.5%, Conclusion: This study concludes that cellsaver system used p<0.05), stroke and neurological complications (1.8 Vs 3.8, p<0.05). during off-pump CABG provides no additional benefit while adding Conclusion: The results of this retrospective, comparative study to the cost. have been encouraging, showing lesser perioperative morbidity in the elderly patients undergoing OPCAB. The long term follow up results of these patients are awaited, and may give us further insight to this issue.

Off pump CABG in critical LMCA lesion and high risk subsets – Safe option 168 VVK Bharadwaja, M Krishna, KK Dev Off pump re-do coronary artery bypass surgery Yashoda Super Speciality Hospital, Hyderabad P Babu, EV John, GN Prabhu, AR Raghuram, LF Sridhar, 170 Background: Off pump CABG has its poven benefits in low risk MR Girinath groups in the form of reduced hospital stay, low requirement and Apollo Hospital, Chennai post operative and neurological events. Many authors reported its Aim: This study was done to show the feasibility of doing Re-do use fullness also in high risk subsets. i,e low ejection fraction, renal coronary artery bypass surgery off pump with good results. failure, old age, and critical carotid lesions and patients with history Methods: The data of 30 patients who underwent Off pump re- of cerebro vascular accident Only a few reports available in patients do CABG at this institution between September 2001 and September with critical LMCA with high risk subsets. We are sharing our limited 2002 was analyzed. experience in these subsets of patients with our way of minimizing Twenty-eight patients were males and two were females. Age haemodynamic compromise. ranged between 47 and 78 years (mean: 62.5 yrs.). The time duration

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between the first and re-do operation was between 4 months and 17 Hepato-cellular carcinoma masquerading as RA years. The number of anastamoses performed was between 1 and 4 myxoma – A case report 173 with a mean of 2.2 grafts per patient. Abhijeet, LN Achar, Trushar Gajjar, Saibal Neogee, Nimisha, Results: The perioperative mortality was 2 out of 30 patients. The Rekha Matta, Neelam Desai incidence of postoperative arrhythmia, development of new renal Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, impairment, postoperative blood loss, inotropic requirement and Anantapur (AP) neurological complication were significantly less. A 20-year-old male patient presented with signs & symptoms of Conclusion: Off pump method is a suitable option for re-do CABG CCF 2D Echo examination revealed a large intracardiac mass with low mortality and morbidity and good intermediate term results. occupying entire RA & extending into IVC & Hepatic veins. Diagnosis of RA myxoma was entertained. After antifailure line of treatment patient was taken up for excision of the mass. The histo-pathology report revealed metastatic carcinoma most probably hepatocellular carcinoma. Patient markedly improved symptomatically after the CABG in left main coronary artery stenosis operation. Thus it was felt that this is a rare presentation of Off pump vs On pump 171 Hepatocellular carcinoma with intracardiac extension. Rajendra Nahar, Suresh T Bhagia, Basisht Mishra, AR Raghuram, LF Sridhar, MR Girinath Apollo Hospital, Chennai Background: Left main coronary artery disease is considered as A case of shone's syndrome definite indication of CABG regardless of symptomology. It is KC Sekhar, S Mastan, Afroz Farooqi, Vijay Kumar, AN Srinivas 174 independent predictor or postoperative in morbidity and mortality. Apollo Heart Centre, Waltair Main Road, Visakhapatnam Off pump has shown decreases in morbidity and early recovery. We analysed our data to determine whether OPCAB be used in patient An eight year old boy with complaints of repeated respiratory with critical LMCS. tract infections, failure to gain weight and heart murmur was referred Methods and Results: Between January 1998 to October 2002, 396 to the cardiac OPD and investigated. He had feeble lower limb patients with significant Left main coronary artery stenosis (> 50%) pulsations and low blood pressure and had Grade 4 PSM and MDM underwent coronary artery bypass grafting, out of which 273 patients over mitral area. Echocardiogram showed MS, coarctation of aorta were done on pump and 123 off pump. The patients in the two groups with VSD and PDA. He was taken up for a two stage surgical were comparable in preoperative variables. In off pump LIMA to LAD correction. Ligation of PDA with prosthetic patch aortoplasty via left grafts was done first in most cases. Average number of grafts are posterolateral thoracotomy was first performed followed by mitral 3.4(+0.9) in both groups. Hospital mortality is 2/123 in off pump and valvuloplasty and VSD closure by midsternotomy, three days later. 8/273 in on pump group respectively. The incidence of atrial The value of PA catheterization in this patient and chest fibrillation and blood transfusion requirement is significantly less in physiotherapy to tackle collapse of left lower lobe after 1st stage off pump group. surgery due to patch 'weeping' will be highlighted. Conclusion: Off pump CABG can be safely performed even in Incidence of Shone's syndrome is 0.2 to 0.4% of all CHD and is high risk subset like critical left main and help in redusing morbidity thought to merit a poster presentation. and cost.

Vascular entrapment disease-popliteal Philatelic display of 03 Frames (A-4 X 1`2 sheets artery occlusion 175 per frame) on 'Heart, Circulation and your Health' 172 B Neelakandan, T Jayanthi, Kanthimathi KC Sekhar 95 Sixth rd, Kanagasabai Nagar Chhidambaram, TN Apollo Heart Centre, Waltair Main Road, Visakhapatnam A rare case of popliteal artery occlusive disease due to This exhibit, unique of its kind in the world, is a topical collection strangulation by the muscle (adductor magnus) is being presented of philatelic material on heart, circulation and health. It received a for its rarity and clinical interest. A 52 year old man presented with Silver Medal at "KERAPEX" exposition in 1993. The subject is history of Boyd class III claudication in the right lower limb below developed as follow: the knee. He was a smoker. A clinical diagnosis of chronic arterial occlusive disease of TAO type was diagnosed. An angiogram revealed (a) Heart and Emotions an occlusion at the femoropopliteal junction with good distal runoff. (b) Heart and stress He was taken up for surgery with the plan of performing (c) Anatomical aspects of the heart-sufrace, cut and x-ray femoropopliteal bypass with reversed saphenous vein. The femoral (d) Circulation artery was exposed and was found to have good pulsations. Then the (e) Blood pressure poplital artery was opened and dissected. It was not pulsatile. Then (f) Blood when we tried to maneuver the reversed saphenous vein for grafting (g) Vital oxygen and when we tried to create space for the same, we widened the hiatus (h) Rheumatic heart disease in the adductor magnus by blunt dissection. This maneuver resulted (i) Congenital heart disease appearance of pulsations in the popliteal artery distally. Then we (j) Coronary heart disease partially divided the adductor magnus to make free the whole of the (k) Drugs for the heart femoral artery and the poplirteal artery to lie continuously free of the (l) Surgery on the heart adductor magnus. This resulted in good pulsations. Still we performed (m) CPR a vein graft anatmosis bypassing the segment of narrowing which (n) Future developments on the anvil we had seen in arteriogram.

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Cutaneous metastasis from carcinoma bronchus – without delay. We here present the demographic profile of he patients A case report 176 with acute limb ischaemia, the aetio-pathogenesis among Indian Prashant P Prabhu, M Madhav Kamath, Bhuvnesh Kumar, patients and to formulate an optimal management protocol. S Ganesh Kamath Methods and Results: This retrospective study was conducted Kasturba Medical College & Hospital, Manipal, Karnataka from 1997 to 2002, 47 patients with acute limb ischaemia were treated. A 47 year old male, a chronic smoker presented with one month The age ranged from 35 to 65 years (Mean : 65.5±5.4 years), 30 were history of haemoptysis. He was evaluated with bronchoscopy, x-ray female (63.82%). The most common etiology was rheumatic heart chest and CT scan chest. The only positive finding was a right lower disease (90.4%). Fifteen patients were in atrial fibrillation. Most of the lobe shadow on the CT which was subjected to a CT guided FNAC patients presented after 48 hours (85%), they all underwent and reported to be Adenosquamous carcinoma. Bone scan showed a embolectomy with or without fasciotomy. The commonest site of hot spot in the (R) 9th rib. The patient was subjected to a right lower obstruction was external iliac and femoral artery (95.5%). The in- lobectomy and extra periosteal resection of the 9th rib. HPE of the patient hospital moratlity was 10%. Of the survivors, 25% required resected specimen showed adenosquamous carcinoma while below knee amputaton for non alvagable limb. Rest of the patients lymphnodes and rib were free of secondaries. One month post- were discharged with salvaged limb although functinal recovery took operatively, patient reported with 4 painful subcutaneous nodules of 1-3 months in many patients. which 2 were on the back (one close to the incision of surgery), one on Conclusion: The most common etiology is rheumatic heart disease the right forearm and one on the right thigh. One nodule on the back in our subset of patients. The limb salvage rate can be improved by was biopsied and HPE was secondary deposits from adenosquamous judicious use of embolectomy with or without fascotomy. carcinoma. The patient was then referred to Oncology and following chemotherapy the subcutaneous nodules disappeared. Cutaneous Vascular emergencies in operating room metastasis from carcinoma bronchus is a very rare entity. Clinical Manisha Lal, AK Jain, AK Agarwal 179 presentation, review of literature will be presented. Balrampur Hospital, Lucknow Introduction: This presentation deals with vascular emergencies occuring in general surgical and orthopaedic operating theatres and Calcified loculated chronic empyema – their management. A case report 177 Method: All the cases dealt with by the vascular surgeon (first Prashant P Prabhu, M Madhav Kamath, Bhuvnesh Kumar, author) during a period of 24 months from July 2000 to date, have S Ganesh Kamath been described. Kasturba Medical College & Hospital, Manipal, Karnataka Results: The cases included a ruptured pseudoaneurysm of aorta (mistaken for pseudopancreatic cyst), ruptured femoral a A 33 year old male presented with streaky haemoptysis and low pseudoaneurysms occuring from injury to femoral a from insertion grade fever of a week's duration. Past history of similar complaints 6 of an external fixator, ruptured popliteal a. aneurysm (mistaken for years back. Then, he had undergone a right thoracocentesis and about an abscess in popliteal fossa), avulsion of superficial femoral a. during 150 ml of fluid of unkonwn quality had been aspirated. No relevant dissection of a large thigh tumour, broken hemodialysis catheter reports available pertaining to first illness. Recovery from illness was migrated into femoral v., crushing of brachial a, and renal vascular complete till the present episode. There was no additional positive pedicle slip. All these could be tackled successfully. history. Conclusion: *The operating vascular surgeon has to make a quick On examination patient was afebrile and air entry was decreased decision about what vessels have to be repaired and which can be on the right side of the chest. He was found negative for Kochs. Chest ligated. x-ray showed well-defined calcified elliptical opacity in the mid and * General surgical operating rooms at the district hospital level lower zone on the (Rt) side extending from the 5th rib to the 10th rib should be equipped with basic vascular instruments. posteriorly. CT scan showed loculation in the lateral and posterior * In management of these injuries, anaesthetic support, packing, aspect with calcific rim all around except at the hilum filled with fluid. good exposure, correct suture, and correct postop care is important Rigid bronchoscopy showed no endorbronchial lesion. for optimal patient outcome. Intercostal drainage of the right pleural space was done with difficulty and about 400ml of sandy fluid was drained. Investigations done in view of hydatid disease tuberculosis and malignancy were negative. The repeat CXR showed persistence of cavity and failure of lung expansion. Empyemectomy was done. The empyema sac had a Bidirectional glenn: Thoracic route one cm thick calcific shell and contained 100 ml of purulent fluid. K Hazari, S Gupta, A Choudhary, A Maheshwari, D Chaturvedi, 180 HPE reported as chronic empyema with calcified wall and no AFB. Charnajeet Kaur, Gagan Shrivastava, TS Mahant Post-operative course was uneventful New DelhiHospital, Lucknow Chronic loculated empyema are rarely reported now-a-days. Rest Bi-directional Glenn's shunt is the intermediary procedure while of the details and review of literature will be discussed. treating the patients with univentricular physiology. Sometimes, it is the only treatment that can be offered to these patients. Classically this operation is being done by midsternotomy approach. After this Acute arterial obstruction: A six year experience approach, redo surgery (at the time of total correction - modified fontan Jeevan Pillai, Mohammad Mubeen, Surendra Kumar Agarwal, 178 operation), give problems due to adhesions. To combat this problem, Nirmal Kumar Gupta people are doing it by right postero lateral thoracotomy approach Department of CVTS, Sanjay Gandhi PGIMS, Lucknow throught the 4th intercostal space. After retracting the lung laterally the RPA, SVC is nicely visualized. The dissection, exposure and Introduction: Acute arterial obstruction of limbs represents one anastomosis are relatively easier. As all the dissection is extra of the most dreaded events in the emergency surgery and requires pericardial there is almost nil chance of adhesions. In last one year rapid and precise diagnosis in order to provide appropriate treatment (1.9.2001 to 10.9.02) we offered this operation for three children.

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1. 12 month old boy having Tricuspid Atresia, ASD and small VSD. procedures were performed with external stabilizer (Medtronic, saturation increased from 80% to 92% and CVP increased from 12 Octous III). The conduits included internal mammary artery (IMA) mm Hg to 15 mm Hg. in 270 patients, right gastoepiploic artery in 16 patients, radial artery (RA), either right or left or both in 200 patients. Total 486 conduits 2. 2 year 2 month old boy = CCHD with Tricuspid Atresia with ASD, were used (1.8 conduits/patient). Total 676 anastomosis were VSD and hypoplastic RV. Saturation increased from 74% to 91 % and constructed (2.6/patient). Grafting technique included IMA sequential CVP increased from 17 mm Hg to 23 mm Hg. 75 patients (28.5%), RA sequential 70 patients (26.6%), RA double 3. 4 year 6 month old patient – CCHD with Tricuspid Atresia with sequential in 15 patients (5.7%), division of RA into two grafts in 15 PDA, mild MR and ASD. saturation increased from 77% to 92% and patients (5.7%), T grafts in 20 patients (7.6%) and Y graft in 15 patients CVP increased from 17 mm Hg to 23 mm Hg. (5.7%). Though we have not done total correction so far in such treated Results: The post operative incidence of AF was seen in 60 patients patient but we presume that as we have not opened pericardium, the (22.8%), CVA in 2 patients (0.7%), re-exploration 4 patients (1.5%), dissection and procedure will be much easier at the time of total transient ARF 10 patients (3.8%), deep sternal wound infection nil correction or TCPC. and readmission (30 days) for angina in 5 patients (1.9%). The peri operative mortality was 6 (2.3%). Peri operative IABP was necessary in 23 patients (8.7%). The rate of peri operative MI was in 4 patients (1.5%). Conclusion: TAR can be done with maximum graft economy in Pre operative intra aortic balloon pump for high beating heart using creative grafting technique with excellent result. risk Off pump coronary artery bypass surgery 181 GR Shivani, S Juneja, J Singh, R Ghadiok, OP Yadava Department of Cardiac Surgery, Dharma Vira Heart Centre, Sir Ganga Ram Hospital, New Delhi Total arterial revascularisation in poor LV function Introduction: Dislocation of heart required for exposure and Sanjeeth Peter, Mahpaekar Mashhadi, Manoj Subramaniam, 183 construction of distal anastomosis often produce haemodynamic David Thomas instability when performing coronary artery revascularisation without DDMM Institute of Cardiology and Cardiovascular Surgery, using cardiopulmonary bypass (CPB). This is particularly more in Nadiad hearts which are already energy depleted and severely ischaemic. As Background: CABG surgery in patients with poor LV function (LV a result short term circulatory support with IABP during peri operative ejection fraction <30%) is challenging. This is a study to see if TAR period may be required. can be achieved in patients with poor LV function and to see the Method: In our centre from Oct. 2001 to Sept. 2002 in one year 425 outcome of this surgery. off pump coroanry artery bypass (OPCAB) surgeries were performed. Method: Of a total of 343 patients presenting for CABG between Of these 425 patients, 65 patients were high risk patients (severe LV July 2000 and October 2002, 108 had an LVEF of <30%. A transthoracic dysfunction, (EF <20%), diffuse triple vesel coronary artery disease, echo was used for assessment of the LV function. All underwent TAR. Acute MI, redo CABG with other high risk factors, coronary care The LV function was assessed by a transthoracic echo post operatively dependency, haemodynamic/electrical instability). In all patients 8 at 3, 6 and 12 months. Fr. IABP was used by percutaneous sheathless technique. In 24 Results: The 108 patients had an average pre operative LV of 25.6 patients, IABP was inserted pre-operatively (Group A), 41 patients (15–30) and required an average of 3.2 anastamoses (1-5). 62 of the did not receive pre op IABP (Group B). 108 patients underwent off pump surgery. There were 4 deaths–2 due Results: There was no mortality in Group A (0/24) whereas 6 to post operative pneumonia and 2 due to low cardiac output. The patients died in Group B (P value <0.05). No patient required IABP was used in 3 patients. A follow up echo showed improved LV conversion to emergency CPB in group A while 4 patients were function in 93 (89%) patients at the first follow up echo, while the rest converted to emergency CPB in Group B. 24 patients out of 41 patients showed improvement at 6 months. TMT was done in 84 (77%) patients in Group B required IABP at some stage peri operatively (19 intra and was negative in all. operatively & 5 post operatively). Further, ICU stay and hospital stay Conclusion: TAR is possible even in patients with poor LV was significantly longer in Group B. function. Improvement in LVEF is seen early in a majority of patients. Conclusion: We conclude that prophilactic IABP use in high risk Long term angigraphic studies will help assess the use of TAR in patients undergoing OPCAB reduces morbidity and mortality. patients with poor LV function.

Total arterial revascularisation with minimum Obstructed TAPVC management by a double patch conduits using creative grafting techniques technique 184 182 PS Seetharma Bhat, K Ashok Kumar, Kiran, AN Prabhudeva G Shivanani, A Sharda, R Ghadiok, OP Yadava Department of Cardiac Surgery, Dharma Vira Heart Centre, Sri Jayadeve Institute of Cardiology, Bangalore Sir Ganga Ram Hospital, New Delhi Total anamolous pulmonary venous connection is a rare congenital Introduction: For total arterial revascularisation (TAR) harvesting heart disease. One of the sites of obstruction in the pathway of of multiple arterial grafts is associated with prolonged operation time pulmonary venous blood to left atrium is at the site of pulmonary and incresed trauma. Besides there are no arterial grafts left for future venous connection to common pulmonary venous chamber. Diagnosis redo surgery. We report our experience of TAR using creating grafting of this may be difficult pre-operatively. techniques to use minimum arterial grafts. We had a case of TAPVC with obstruction at the site of right upper Method: Between Oct. 2001 to Sept. 2002 in one year 425 patients and lower pulmonary venous connection to common pulmonary underwent off pump coronary artery bypass (OPCAB) surgeries, of venous chamber. 7 Kg. Baby was taken up for surgery on urgent basis which 260 patients (60%) were done with arterial conduits only. All in view of deteriorating clinical condition. Under CPB a heart shaped

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pericardial patch was used to increase the size of pulmonary ostea. Conclusion: The use of harmonic scalpel has definitely been of The margin of the same patch was sewn to opened left atrial and advantage especially in terms of surgeon's comfort, reduces patient right atrial margins. ASD was closed with another patch. Patient made morbidity and possibly improves graft quality. Are we prepared to smooth recovery. meet this expense? At 2 years of follow up the right pulmonary ostea are widely patent. This technique is simple effective and reproductible.

Pulmonary thromboendarterectomy for chronic Beating heart surgery in patients with renal thromboembolic pulmonary hypertension- 187 dysfunction 185 Our experience TS Mahant, S Gupta, A Choudhary, K Hazari, A Maheshwari, Sreedhar Reddy, BS Sanjay, R Prabhakar D Chaturvedi, Charnjeet Kaur, Gagan Shrivastava Sagar Apollo Hospital, Bangalore New Delhi Introduction: Pulmonary Hypertension due to chronic Patients of CAD with renal dysfunction are a group of patients thromboembolism is a relatively rare disorder diagnosed in India. who had high mortality and morbidity in comparison to the patients Without intervention the rate of survival is poor. who are not having renal dysfuncion. These problems have been Methods: Between September 2000 to September 2002 we had 3 reduced to some extent by beating heart surgery. In last two years male patients who underwent pulmonary thromboendarterectomy (1.1.2001 – 30.09.02), 279 patients (with Serum Creatinine >1.4mg%) for chronic thromboembolic pulmonary hypertension. All the three were subjected to OPCAB. 19 of them were on haemodialysis. Age patients were in NHYA Grade III and Grade IV with a mean was ranged between 52-76 years. 11 patients were on IABP due to pulmonary artery pressure of 72, 80 and 60 respectively. In all the cardiogenic shock. 12 patients were candidates for redo CABG. 54 patients the right Arial pressure was elevated and the right ventricular patients were more than 70 years old. 12 more patients were put on ejection fraction was Normal or Elevated. All patients underwent a pre-op IABP due to severity of CAD & LV dysfunction. Our routine preoperative angiography. protocol was that we put intraoperative peritoneal dialysis catheter These 3 patients underwent surgery on Cardiopulmonary bypass in all patients having less than 600 ml/day urine output. LIMA was with moderate hypothemia. The aorta was not clamped and the used in 214 patients. RIMA was used in 54 patiens. LRA was used in pulmonary artery was opened after dissecting out the right and left 68 patients. The average number of graft/patient was 2.6±1.6 (1 to 5). pulmonary artery right up to the branches. A fogarty catheter was Post operatively 109 patients required peritoneal dialysis. Amongst passed and any thrombus was extracted from the branch pulmonary these 52 patients were switched over to haemodialysis. Nephrologist arteries. An endarterectomy was done for the main and right and left was looking after all of them. Post operative hospital stay was 15±5 pulmonary arteries. days. Overall mortality was 2.5% (7 patients). We conclude that the Results: All patients did well in the postoperative period. Mean postoperative mortality and morbidity was much less in comparison pulmonary artery pressure fell to 40,32 and 28 in the immediate to the patients operated on CPB (prior to beating heart surgery era). postoperative period. Postoperatively all patients underwent an Encouraged by these results now days we have opted the protocol angiography which showed good flow in the pulmonary arteries. All that OPCAB to be the preferred choice until and unless it had to be the 3 patients were seen on an average for 6 months in the converted into on CPB CABG. postoperative period and all were in NHYA class I. Conclusions: Pulmonary thromboendarterectomy for chronic thromboembolic Pulmonary hypertension is a life saving procedure with good postoperative results. What is the cost of dissection of the internal mammary artery? - A comparison of the harmonic 186 scalpel with the cold steel scalpel D Janardhana Reddy, Paul R Ponraj, KV Muralidharan, P Balasubramanian, Ajit K Tharakan, PSN Raju Effect of different thoracic incisions on pulmonary Vijaya Heart Foundation, Chennai function tests 188 Background: The internal mammary graft (IMA) is the conduit of RS Dhaliwal, Anil Chandra, Ramakrishna, Gangadhar, Sajji choice for coronary artery bypass opeations. Moreover, in patients Department of Cardiovascular & Thoracic Surgery, PGIMER, with a single vessel disease, the value IMA dissection is all the more Chandigarh important. This has traditionally been done using steel scalpel and Introduction: Different types of thoracotomies – anterolateral, metallic clips. Since the advent of the harmonic scalpel there has been posterolateral and median sternotomy alter the pulmonary physiology several advantages including easier and faster dissection, less blood and chest wall mechanics significantly. This prospective study was loss and lower incidence of wound infection. We have compared the done to compare the effects of these three approaches on post operative cost of internal mammary artery dissection using these two methods. lung functions in the Indian patients. Methods: Over 1300 patients have undergone beating heart Material & Methods: 60 patients undergoing cardiac and thoracic coronary artery bypass over the last 3 years. Since 1998, we have used operations through three different approaches of median sternotomy, the harmonic scalpel for dissection of the internal mammary arteries. anterolateral thoractomy and posterolateral thoracotomy were divided We evaluated the cost of the two methods including that of the into 3 groups of 20 each. Each patient was subjected to pulmonary machine, the probe, and the metallic clips in a randomly selected function tests within 2 wks before surgery and one and six wks after period during June 2002. surgery. Results: The mean cost for each patient when we used the cold Results: Forced vital capacity (FVC), Forced Expiratory Volume steel scalpel and harmonic scalpel were 1.7% and 5.4% respectively (FEV), Peak Expiratory Flow rate (PEFR) and Forced Expiratory Flow of the total cost of surgery for harvesting a single internal mammary (FEF) were significantly impaired in all groups but showed artery and 3.4% and 5.4% for bilateral mammary arteries. improvement at 6 wks after surgery.

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Conclusions: There was minimum and short term impairment of Look before you eat!! PFT with quick recovery to pre operative status in the median R Vashisth, BC Roy, N Maity, S Dey, A Chakravarti, I Guha, 191 sternotomy group. Anterolateral thoracotomy had less deleterious A Dey, S Chakraborty effects on post-op PFT as compared to posto lateral thoracotomy which Department of Th & CV Surgery, Medical College, 88 College Street, caused maximum impairment of PFT. Kolkata Introduction: False aneurysm may present in some peculiar way. We had a case of false aneurysm arising from abdominal aorta that presented a diagnostic dilemma. A rare case of cardiac rhabdomyoma (Case report) Material and Method: The patient was an 18 years old boy Santanu Dutta, Dibkar Das, Uday Naramyan Sarkar, 189 presenting in the internal madicine dept. with haematemesis and Susheela Mittra malaena, a pusatile abdminal lump was detected and the patient was IPGME & R, Kolkata referred to us. Patient had severe palor with Hb of 4gm% Scout film X-ray revealed a small foreign body inthe abdomen. CT showed a Cardiac rhabodomyomas are the most common tumor in infants small metallic foreign body (?wire) within a false aneurysm. Close and children. They are usually multiple in nature, arising from left questioning elicited the history of taking rice flakes (muri) from cane ventricle and leads to still birth or perinatal death. bucket where metallic wire pieces are used. A provisional diagnosis A 5 months old 5 kg. weight female child presented in O.P.D. with of ingested piece of wire burrowing through G.I. tract into aorta was complain of inability to suck breast milk properly and failure to thrive. made. On exploration the piece of wire was removed from within the On examination a soft systolic murmur was heard over parasternal anneurymal sac, rent in abdominal aorta as also fourth part of region in left 2nd–3rd interspaces. Echo-cardiography revealed a mass duodenum repaired. Piece of Surgicel was sandwitched between the over rt. ventricular wall suggestive of Cardiac rhabdomyoma and no two to prevent recurrence. other mass was detected in any other chamber of the heart. All Results: Recovery was uneventful. preoperative investigations were performed to rule out any other Inference: False aneurysm may present in disguise and we have associations of cardiac rahbdomyoma like tuberous selerosis, facial to be alert not to miss them. angiofibroma etc. The baby was taken up for resection of rt. ventricular mass on cardiopulmonary bypass. On rt. atriotomy the tumor was removed from rt. ventricular free wall through tricuspid valve orifice. Post operative period was uneventful except the patient developed early An interesting case of tracheal reconstruction feature of congestive cardiac failure due to post operative rt. A Chakravarti, S Mukherjee, T Saha, NC Garai, A Mandal, 192 ventricular dyskinesia which subsided on conservative treatment. S Dey, I Guha, A Dey, R Vashisth, S Chakraborty Would was healthy. The baby was discharged with sucking the breast Department of Th & CV Surgery, Medical College, 88 College Street, milk without any exhaustion. Kolkata The tumor was found to be 1cm. diameter, nodula, firm and whitish Introduction: Tracheal reconstruction is an uncommon problem in colour. Histipathology report revealed cardiac rhabdomyoma which that thoracic surgeons have to encounter. We had an interesting case was confirmed by immuno staining. Successful management of this who had both tracheal & oesophageal injury as a result of bamboo rare cardiac rhabdomyoma is being presented. pole impaled in the neck following an accident. Material and Method: The patient came with accidental tracheostomy, oesophageal laceration and posterior dislocation of cervical vertebrae, fortunately without neurologic complication. For oesophageal injury cervical pharyngostomy, gastrostomy and feeding jejunostomy were done and the oesophagus healed. An indecent needle prick!! Pharyngostomy could be closed down. Because of lacerated tracheal I Guha, BC Roy, S Mukherjee, N Maity, J Banerjee, S Dey, 190 injury, patient had to be kept with tracheostomy tube which resulted A Chakravarti, A Dey, R Vashisth, S Chakraborty in tracheal stricture. The affected tracheal segment was dissected out, Department of Th & CV Surgery, Medical College, 88 College Street, resected, and end to end tracheal anastomosis was performed using Kolkata standard technique. Patient was extubated on table. The chin was stitched with skin overlying manubrium using heavy sutures. Introduction: False aneurysm may present in some peculiar way. Results: The post-op period was uneventful. Patient has now gone We had a case of false aneurysm arising from LV that presented a back to his old profession of truck driving. diagnostic dilemma. Inference: Tracheal injury, though gruesome, may be tackled if Material and Method: The patient came to internal medicine with approached methodically. jaundice and a routine USG revealed mass in left thorax with a small SOL in liver - ? hydatid. No history of trauma/cough/haemoptysus/ fever. CXR showed a round opacity adjoining left heart border. CT with contrast revealed communication with LV cavity. ECHO and MR Myxoma – "Plop in the heart" angio demonstrated a huge false aneurysm arising from LV near its R Vashisth, BC Roy, S Mukherjee, NC Garai, S Dey, 193 apex and pressing on the RVOT. A Chakravarti, I Guha, A Dey, S Chakraborty Surgical exploration confirmed this finding. The sac was opened Department of Th & CV Surgery, Medical College, 88 College Street, under CPB and the rent in LV wall repaired. On close interrogation Kolkata patient gave a history of left chest aspiration about 25 years ago. Results: The patient is doing well and comes for regular follow- Introduction: Myxoma is a relatively common variant of the rare up at monthly interval. disease of cardiac tumours. Left atrium is usually involved with a Inference: False aneurysm may present in disguise and we have stalk attaching the tumour to the fossa ovails. Next common is to be alert to not to miss them. involvement of right atrium.

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Material and Method: We have experience of 9 cases of Results: NIBP systolic values versus ABP systolic values showed myxomas, 7 arising from L.A. and 2 arising from R.A. Standard CPB no significant difference at 6 am, 12 pm, 6 pm, and 12 mid nights with bi-caval canulation with hypothermia to 28° C and cold respectively, (6 am P value 0.1907, 12 pm P value 0.4211, 6 pm P value crystalline cardioplegia. RA opened, fossa ovalis excised with a free 0.4648 and 12 mid night P value 0.4846 respectively). Similarly, there margin around the attachment of stalk and pulled out, taking the was no statistical difference at any time period in the diastolic values. tumour with it. In large LA myxomas (3/7) bi-atrial approach was This was seen regardless of the age, sex or weight of the patient. used. In one L.A. myxoma the tumour originated from posterior Conclusion: Non-invasive blood pressure monitoring is a safe and wall of LA body, the surrounding wall was excised, tumour removed efficacious tool with high accuracy to measure blood pressure after and L.A. repaired. Similarly, in RA tumours part of R.A. wall was high-risk surgey. This would suggest that aggressive dellning can be excised and repaired using pericardial patch. practiced in such units to decrease the incidence of infections, decrease Results: One patient died of arrhythmia following excision of ICU stay and enable a reduction in costs after such procedures. L.A. myxoma. No embolic episode/recurrence. Inference: Atrial myxomass should be removed as soon as possible after diagnosis and the surgery gives good result. A boy with SVC syndrome Surendra Kumar Agarwal, Mohammed D Mubeen, 196 Spontaneous pneumothorax? – 5 minutes please!! Amrendra Singh, Nirmal Kumar Gupta A Dey, KS Das, S Ahmed, S Dey, A Chakravarti, I Guha, 194 Department of CVTS, Sanjay Gandhi PGIMS, Lucknow R Vashisth, S Chakraborty Introduction: Malignant diseases account for well over 85% of all Department of Th & CV Surgery, Medical College, 88 College Street, SVC obstruction. Less than 5% of cases of SVC syndrome are caused Kolkata by bening diseases, usually a large substernal goiter, chronic fibrosing Introduction: Spontaneous pneumothorax is a rather common mediastinitis, or a thrombus with-in the vessel itself. Here we report problem faced in our day to day practice. Classically patients have to a rare case of SVC syndrome due to venous thrombosis as a result of be admitted and put on water sealed drain. We are using vacuum high venous pressure and stasis consequent to constrictive pericarditis. suction under fluroscopy to treat the patient as OPD cases. Methods and Results: An 18 year-old boy presented in March Material and Method: Patients were put on fluoroscopy table, 2002 witha 4-week history of generalized swelling of body, more on wide bore needle attached to vacuum suction tube via a 3-way the left arm with facial puffiness. Cardiac examination revealed stopcock, I.V. line and waterseal bottle is inserted via 2nd ICS in MCL. mufiled heart sounds. Chest radiography revealed cardiomegaly with Vacuum is switched on simultaneous with fluoroscopy. Lung right pleural effusion. Color Doppler of neck veins revealed extensive expansion is immediate and clearly visible on fluoroscope. After 5 thrombosis of left brachiocephalic and axillary veins. 2-D Echo was minutes fluoroscope is switched on again to exclude the accumulation suggestive of constrictive pericarditis. a computed tomography scan of air which indicates admission for formal I.C. drainage. If lung is of thorax showed thrombosis of bilateral internal jugular veins, left inflated after this 5 minutes period, the needle is taken out and patient brachiocephalic vein and upper part of superior vena cava (SVC) with discharged. evidence of thckened pericardium (8mm) all around the heart. Results: We have treated 32 cases, of which 2 needed formal I.C. Results: One patient died of arrhythmia following excision of L.A. drainage. myxoma. No embolic episode/recurrence. Inference: This is a easy, safe and effective technique of managing He was taken up for surgery and through a primary median spontaneous pneumothorax reducing hospital stay and limiting sternotomy a subtotal pericardiectomy was performed. Bllateral expenditure. pleural effusions were drained. He recovered with swelling of limbs and face subsiding over a period of 15 days. Hiesopathlogy of resected pericardum revealed granulomatous disease suggestive of tubercular pericarditis. Efficacy of non-invasive blood pressure Conslusion: Tubecular constrictive pericarditis a well known entity monitoring in comparison to invasive blood 195 in the Asian subcontinent, but its presentation as SVC syndrome is pressure monitoring unknown, to the best of our knowledge there is no reported such case CN Raghunath, Usha Rani, Amit Varma in the literature. Naryana Hrudayalaya Institute of Medical Sciences, Bangalore Background: Surgical repair for congenital heart disease in the neonatal period and infancy is becoming the norm with procedures being performed at an increasingly lower age. There is always a desire Carotid body tumors : A report of 5 cases and to wean the patient from invasive lines due to the attendant infection our surgical approach 197 Surendra Kumar Agarwal, Nikhil Singh, Mohammad Mubeen, risks. Occasionally, long-term sustainability of these arterial lines is Amrendra Singh, Gaurav Agarwal, Nirmal Kumar Gupta also an important issue. Department of CVTS & Surgical Endocrinology, SGPGIMS, Aim: To gauge the efficacy of Non-Invasive Blood Pressure (NIBP) Lucknow monitoring in comparison to Invasive Blood Pressure (IBP) lines in children <10kg. Introduction and Aims: Paragangliomas of the head and neck are Methods: 50 Consecutive infants <10 kg who underwent cardiac uncommon neoplasms arising from the extra-adrenal paraganglia and surgery were studied and blood pressure readings were documented include carotid body and glomus vagale tumors. The purpose of this both by traditional and correct sized NIBP cuff techniques at the same study is present our approach to the mangaement of patients with time. Current protocol regimes were standardized and adhered to for carotid body tumors emphasizing the role of malignancy and all study subjects. Four readings of blood pressure were done at fixed preoperative embolization. six hourly intervals on the 1st postoperative day. The age of the patients Methods: Between 1999 and 2002, 5 patients with Carotid body ranged between 2 days to 3 years, of these 22 were below 5 kg. tumors were treated.The age ranged from 16.66 years (man:28±15

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years). There were three males and two females. ALl of them presented Extra cardiac total calvopulmonary connection as an assymptomatic cervical lateral mass.The preoperative evaluation (fontan operation) after glenn shunt in 200 included computed tomography and digital substaraction an adult – A case report angiography in all. All of them underwent successful subadvential Koduru Venkata Ramana, T Suresh, Anand Agarwal, excision of the tumor. In one of these patients preoperative DV Ramana, RV Kumar, Rajagopal embolization had been performed. There was no operative mortality Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad and no major neurological deficit/stroke. Temporary cranial nerve While classical and bi-directional Glenn Shunts are routinely used injury occurred in two patients. Local lymph node involvement was for palliation in cyanotic children with univentricular physiology, most found in one patient establishing the diagnosis of malignancy. There centers are now offering Fontan operation, either following Glenn were no local recurrence on mean follow up of 22 months. Shunt or as a primary surgery. Most Surgeons are now performing a Conclusions: Surgical excision remains the treatment of choice modified Fontain operation, a lateral tunnel TCPC and recently an for Carotid body tumors and can be performed without major riske extra cardiac TCPC as a first time complete palliation for infants and and with low morbidity and mortality. Preoperative embolization is children with univentricular hearts. The advantages of EC-TCPC helpful by diminishing intraoperative bleeding, and malignancy include good hemodynamics and less arrhythmias. though rare, justifies early management. We have performed and extra cardiac TPCP in a 23 year old man, 8 years after he underwent a bi-directional Glenn shunt for single veriticle and plmonary stenosis. He has become increasingly cyanotic and symptomatic. Pre-operative cath data showed normal PAP, PCWP, Pseudoaneurysms of the aorta following cardiac surgery: A report of 2 cases 198 PVR and normal AV valves and good LV function. We performed an Mohammad Mubeen, Jeevan Pillai, Surendra Kumar Agarwal, extra cardiac TCPC on cardio pulmonary bypass at normothermia, Ashok Kumar Srivastava, Nirmal Kumar Gupta without cardioplegia, using a 20 mm Gore-tex tube graft. He made an Department of CVTS Sanjay Gandhi PGIMS, Lucknow excellent recovery and is in NYHA Class I and repeat cardiac catheterization showed well functioning TCPC. Introduction: Pseudoaneurysm of the aorta is a rare (<1%), but potentially fatal complication of cardiochoracic surgery. Most pseudoaneurysms are associatd with aortic valve or coronary artery bypass graft surgery and are often mycotic in nature. Although rare, a pseudoaneurysm can occur without clear evidence of infection. Methods and Result: Here we report two cases of pseudoaneurysms. In first case the pseudoaneurysm was located in the ascending aorta and was related to arterial cannulation of Double breasted repair of the mitral valve ascending aorta at the time of primary atrial septal defect repair. In Ravindra Setty, Jai Raman, Keichi Tambura, Brian Buxton 201 the second case pseudoaneurysm developed in the descending aorta Austin and Repatriation Medical Center, Melbourne, at the site of aortic attachment of ductus arteriosus in a operated case Australia of patent ductus arteriosus. Both cases were operated successfully under deep hypothermic ciruclatory arrest. Background: Mitral valve repair is an extablished technique in Conclusion: We conclude that patients who previously had cardiac the treatment of mitral regurgitation. This repair when used in selected surgery presenting with unusual cardio-respiratory symptoms should patients can be a good alternative for the other techniques. be aggressively evaluated for pseudoaneurysms. Surgical repair is Patients and Methods: Between July 1995 and July 1999, 24 necessary in symptomatic or life-threatening cases with continuously patients with severe symptomatic mitral regurgitation due to a improving operative morbidity and mortality localized flail segment of the posterior leaflet of the mitral valve were selected to undergo this type of double breasted repair. 16 patients were in NYHA Class III, 6 in class IV and 2 were on ventilation for pulmonary oedema at the time of surgery. Operative Technique: Quadrangular or triangular resection is Giant fusiform aneurysm of right coronary artery – performed to the prolapsing segment of the posterior leaflet and this A case report 199 is limited to as small part as possible around the redundant portion. M Abid Geelani, Akhil Rastogi, V Trehan, Amitabh Verma, The two vertical edges are folded down respectively to the posterior Sridhar Kale, Vishnu Datt, A Banerjee annulus in the double breasted fashion. The more redundant edge is GB Pant Hospital, New Delhi put over the other one. This is sutured in a continuous manner using Ectatic coronary arteries are frequent finding in coronary 5-0 prolene. All patients had a mitral annuloplasty ring. Patients angiograms. But aneurysm of coronary artery specially of fusiform underwent intra-operatively transoesophageal echocardiography. variety is a rare finding. Here we present a case of giant aneurysm of Results: 22 patients were weaned off cardiopulmonary bypass with fusiform variety arising from right coronary artery (RCA) of trivial or no regurgitation while 2 patients had mild regurgitation. atheromatous etiology in a young male of 32 yrs, without There were no conversions to mitral valve replacement intra dyslipidaemia. He developed inferior wall myocardial infarction operatively. All patients had trans thoracic echocardiography because of embolization of thrombus from aneurysm to distal coronary perfromed between 2 to 50 montsh (mean of 28 months) 22 patients artery. Diagnosis was reached by coronary angiography. had trivial or no mitral regurgitation while 2 patients had mild to Transoesophageal echocardiography was also done. During surgery moderate mitral regurgitation. All patients were in NYHA Class I at an aneurysm of 5-8 cm in diameter and 10 cm in lenght, originating 1 follow-up. cm distal to RCA origin, situated in right atriventricular groove was Conclusion: Double breasted repair of the posterior leaflet of the found which was full of thrombus of various generations. Ligation at mitral valve may be performed safely with good early and both ends, clot evacuation, plication of aneurysm and bypass grafting intermediate term results. to distal RCA was done. Postoperative period was uneventful. Patient **Ravindra Setty is presently a cardiac surgeon attached to Narayana is doing well after four months of surgery. Hrudayalaya Institute of Medical Sciences, Bangalore.

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An unusual right atrial mass Right thoracotomy approach for eroding RS Dinesh, Sanjay Dhaded, PV Rao, Pravin Kumar, 202 ascending aortic aneurysm 204 Rajnish Garg, Devi Prasad Shetty SK Pranav, Pawan Kumar, D Kulkarni, C Raghavendra, Naryana Hrudayalaya Institute of Medical Sciences, Bangalore Uday Jadhav, AG Tendolkar LTMMC & LTMGH , Sion, Mumbai Introduction: Of all the unusual causes of right atrial mases, none is rarer than an infected pacemaker system. Background: Right Thoracotomy approach has been previously Methods: On investigation of pyrexia of unknown origin in a 51 described for ascendg aortic aneurysms in situations where a standard year old male who had multiple courses of antibiotics, a large right media sternotomy is not possible without substantial risk. atrial mass was detected. He was referred to our institution in right Material & Methods: A 43 years old male patient presented with heartfailure and septic shock. Along with positive blood cultures, this a midline painless swelling over the upper chest of 4-month durations, suggested infection of a permanent pacemaker lead. The diagnosis which appeared rather acutely and was progressive. (Positive family was confirmed by echocardiography and dynamic CT scans. Surgical history - His brother underwent endoaneurysmorrhappy for a explantation of the infected pacemaker system was performed on descending thoraco-abdominal aortic aneurysm subsequently.) cardiopulmonary bypass as an emergency procedure. Examination revealed a pulsatile 10cm×10 cm mass over the Results: The patient made a remarkable recovery and was manubrium sterni. discharged from hospital in three weeks, apyrexial and with negative CT scan confirmed an ascending aortic aneurysm which had blood cultures and in sinus rhythm. eroded the manubrium sterni. patient tested VDRL reactive although Conclusion: This rare case is presented for its unusual clinical no h/o high-risk behavior could be elicited. picture, the complex surgical procedure needed for its treatment and It was decided to approach the aneurysm through a lateral the successful outcome. approach as midline approach was considered to risky. Endoaneurysmorrhapy was done through a Rt lateral thoracotomy with retrograde cerebral perfusion and total circulatory arrest. The procedure went on uneventfully. Pt is presently on regular follow up. Duration of follow up- 9 months. Conclusion: Right Thoracotomy approach gives adequate exposure of the ascending aorta and was found to be a useful appoach in the management of an aneurysm eroding the manubrium sterni.

Mediastinal fibromatosis – Case report R Maruti Vara Prasad, Roy Thankachen, Bhawna Parihar, 203 Vinayak Shukla, Roy John Korula Department of Cardiothoracic Surgery Christian Medical College, Vellore Tumors of fibrous tissue origin are rare in the mediastinum constituting 2% of all mediastinal tumours. We present a case of 34 year old gentleman who presented to us with complaints of right sided chest pain, dyspnoea on exertion and Midline redo surgery Pawan Kumar, D Kulkarni, SK Pranav, C Raghvendra, cough for the past six months, associated with difficulty in swallowing. 205 Uday Jadhav, AG Tendolkar On examination, the patients had signs of superior venacaval LTMMC & LTMGH, Sion, Mumbai obstruction manifested by congested neck veins and facial edema. Examination of the respiratory system revealed diminished air entry Background: We present the technique followed at our centre for in the entire right hemithorax. The examination of other systems were a midline redo opearation, which has been successful for all the normal. patients. The chest radiograph PA view showed a large homogenous Material & Methods: A total of 25 midline redo operations have opacity in the right hemmithorax occupying the upper and midzone been performed at our centre over the past 21/2 years. completely, and lower zone partially with contralateral mediastinal 20- for MV surgery, 4- Aortic valve surgery, 1- TOF shift and splaying of the ribs. The mediastinal window of a non Technique followed is as follows: contrast enhanced CT scan showed a large predominantly l Aprotinin was given to all homogenous mass in the right hemithorax with mediastinal shift to l IIiac/femoral artery cannulation. contralateral side. Fibreoptic bronchoscopy showed extrinsic l Midline incision, cut wires & keep. compression of the right main bronchus. A CT Scan guided FNAC l Drain the patient from the recirculation line, watching was reported as benign neurogenic tumour. haemodynamics. The patient underwent a right posterolateral thoracotomy and l Sternotomy with wires underneath as guard excision of the mass. Intra operatively, a huge mass occupying the l Free heart flush to the periosteum aided by elevation of the entire right hemithorax compressing the right lung and shifting the sternum with towel clips. trachea to opposite side was found. There were no adhesions between l Open pleurae bilaterally. the lung and the mass. The entire tumour was removed except for the l Expose RA & SVC for venous cannulation apical portion where the mass was adherent to the subclavian vessels l Opt for a trans RA approach (for MV surgery) and brachial plexus. Results: Mortality = 0 (O%) The right lung expanded well following surgery. The Biopsy Reexploration (for bleeding)=01 (4%) revealed fibromatosis of the right hemithorax. Conclusion: Using a rigid protocol a patient with a previous Patient was doing well on follow up. midline surgery can undergo a redo midline surgery safely.

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MV myxoma– Case report Unusual cause of constrictive pericarditis Pawan Kumar, SK Pranav, D Kulkarni, C Raghvendra, 206 C Raghvendra, Pawan Kumar, SK Pranav, D Kulkarni, 208 Uday Jadhav, AG Tendolkar, Uday Jadhav,AG Tendolkar LTMMC & LTMGH, Sion, Mumbai LTMMC & LTMGH, Sion, Mumbai Introduction: Myxomas are the most common tumors of the heart A 29-year-old male underwent pericardiectomy for tuberculous and occur most frequently in the left atrium, arising from the fossa constrictive pericaarditis. Histopathology of pericardium revealed ovalis. A myxoma originating from the mitral valve is extremely rare. large cell lymphoma, and this was confirmed by bone marrow biopsy. A case is described of a large myxoma arising from the anterior leaflet Case Report: A 29-year-old male was admitted with complaints (AML) of the mitral valve, which was treated by surgical resection. of progressive dyspnoea on exertion class IV along with aorexia, Case Report: A 25-year-old man presented with the complaints of intermittent fever and cough with mucoid expectoration. On exertional dyspnoea, palpitations & h/o repeated syncopal attacks examiation patient had all features of constriction. Erythrocyte for 6 months.Transthoracic echocardography revealed a 5.2×3.3 cm sedimentation rate was 104 mm in 1st hour. Plain chest X ray revealed mobile hetero-geneous discrete mass within the left atrium, the a mild cardiomegaly with a right-sided pleural effusion, 1000 ml of attachment of which could not be determined. The patient was taken which was tapped. Pleural fluid analysis showed an exudate with 80 electively for surgery thru' mid sternotomy, trans RA approach. The RBCs and 940 leucocytes (70% lymphocytes & 30% polymorphs) per fossa ovalis was free of any attachment of the myxoma, instead, it hpf and no malignant cells. Sputum AFB was negative on 3 consecutive was found firmly attached to the atrial surface and the free edge of days. Patients was started on a 4 drugs anti-tuberculous treatment. the AML measuring 7×7×4 cm. There was rupture of the strut chorda Trans-thoracic echo revealed thickened pericardium with features of the AML. The myxoma & the MV was excised & MVR performed. of constriction. 1 month after starting AKT, he was taken up for Histopathology of the resected specimen confirmed myxoma. pericardiectomy thru' a median sternotomy. Thick pericardium was Postoperative course was uneventful and he was discharged on the noted which was firmly adherent to both sternum and myocardium. 6th postoperative day. Sub-total pericardiectomy was performed, extending from the right phrenic nerve to left phrenic nerve anteriorly. Post operatively patient maintained stable haemodynamics on ionotropic support (Inj. Adrenaline 0.03 mcg/Kg/min & Inj. Dopamine 3 mcg/kg/min). On 10th postoperative day, ionotropic support was weaned off, however he could not be weaned of ventilator. Histopathology of the resected pericardium showed lymphoma. A bone marrow biopsy was performed which revealed infiltration of large cell lymphoma with TOF with pulmonary atresia with ALCAPA - myelofibrosis. Chemotherapy was started with CHOP regimen A case report 207 (Cyclophosphamide, Adriamycin, Oncovin & Predniosolone). Patient SK Pranav, Pawan Kumar, D Kulkarni, C Raghavendra, was extubated on 20th post-operative day. Patient succumbed to the Uday Jadhav, AG Tendolkar illness on post-operative day 35. LTMMC & LTMGH, Sion, Mumbai Background: One of the rare alternate sources of pulmonary blood supply in case of TOF with pulmonary atresia is an ALCAPA with flow running from the RCA branches via tye ALCAPA to the MPA. Material and Methods: We present a 7 year old boy who presented with h/o cyanosis, spells and squatting episodes in addition to frequent LRTI and failure to thrive since ifancy. Examination revealed a continuous Gr 4/6 murmur heard all over the precordium. Echo revealed Tetralogy of Fallot, Single large malaligned non restrictive Complete A-V canal defect with dextrocdardia subaortic VSD with bi directional shunt, Pulmonary atresia, with with CCTGA– A case report Anomalous origin of LCA from MPA with confluent pul artery 209 K Madan Kumar, Irineu, Chiran Babu, Sai Chander, Anil Kumar, branches. Cardiac cath showed an ALCAPA-Large RCA giving rise J Balachander, M Nachiappan, KSVK Subba Rao to a number of large intra myocardial collaterals & then forming the JIMPER. Pondicherry LMCA which is draining into PA. Root aortogram – Pul. A opacifies from coronary fistula from LCA. Ectatic Proximal LCA seen followed Complete A-V canal defect (Rastelli type B) is a rare congenital by PA; Confluence visualized. anomaly especially if it is associated with CCTGA, situs inversus and Perioperative Findings - the MPA was atretic, Coroary arteries- dextrocardia. It is very important for a cardiac surgeon to recognise RCA was arising from aorta Dilated conal and RV branch seen this anomaly and have appropriate orientation to do the repair. communicating across IV groove and forming the LAD through We came across an eighteen year old male patient with situs multiple channels, PDA branch was dilated, going across the crux, to inversus totalis with dextrocardia with complete A-V canal defect with constitute the LC artery; Thus formed LAD and LCx were seen CCTGA. He was admitted with complaints of dyspnea for 5 yrs. forming a single trunk and opening into distal MPA, A thrill was Clinical examination and investigation revealed situs inversus totalis palpable over the MPA. All thrills were obliterated by pressure over with dexocardia with complete AV canal defect. RCA. Intra-operatively (Median sternotomy, aortic and bicaval Results: Patient underwent an extracardiac Fontan procedure after cannulation, right transatrial approach) he was found to have ligation of the ALCAPA. Patient is doing well and is currently under dextrocardia, CCTGA, both cornaries arising from anterior sinus, regular follow-up. complete AV canal defect and OS ASD. Dacron patch closure of VSD, Conclusions: TOF with pulmonary atresia is relatively less reconstruction of both AV valve, pericardial patch closure of common common and rarer still is an ALCAPA feeding the MPA. This case is ASD and direct closure of OS ASD was done. He had stormy post presented for its rarity & complexity, the diagnostic difficulties posed operative period. Recovered completely and discharged on the 20th and its management. postoperative day. At 18 months of follow up he is doing fine.

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Spictra membrance oxygenator– Results of VATS-Our experience with 320 patients unicentric clinical evaluation 210 Bhabatosh Biswas, Rajarshi Basu, Rupak Bhattacharjee, 212 R Sankarkumar, SD Baiju, M Anbarasu, SP Murugu, Ashis Patra, Subir Basuthakur, Srikumar Sarkar, KS Neelakandhan Amitava Chakraborty SCTIMST, Trivandrum Vivekananda Institute of Medical Sciences & Calcutta Medical Research Institute, Kolkata Introduction: Spictra Membrane Oxygenator, the collaborative effort of SCTIMST & SPIC has a unique OMEGA Flow design. After Introduction: Application of video endoscopy to general thoracic laboratory and animal trials, with Ethics Committee approval, the surgery has changed the approach to many disorders of chest. device was taken up for Unicentric Clinical Evaluation. Between 6th Avoidance of thoracotomy and shorter hospital stay are main reasons March and 1st November 2002 twenty-five operations each were for increasing usefulness of VATS. performed with SPICTRA (Test) & other current models (Control). Methods: We have performed 320 VATS procedures from January Methods: The mean CPB & ACC times were 117 & 71 minutes in 2000 through October 2002. 196 were males and 124 were females. Test and 113 & 70 minutes in Control. The lowest temperature obtained 253 (79%) were diagnostic and 67 (21%) were therapeutic procedures. was 20ºC in control. Diagnostic procedures were performed for 185 pleural diseases and Blood gases, hematological (Hb, PCV, TC, DC, ESR, Platelets & 68 pulmonary diseases. Therapeutic procedures were performed as Reticulocytes) and Biochemical (BUN, Creatinine, LFT, Electrolytes, bullectomy (14), decortication for old clotted haemothorax (18), LDH & CPK) parameters did not show any statistically significant decortication for early empyema (8), thymectomy (12), chest trauma differences. (9), pericardiectomy (4) & PDA (2). 16 cases (5%) required conversion Results: There were no complications or mortality related to the to thoracotomy. There were 35 (11%) complications. 1 patient with Device. Non-device-related complications included Bleeding (3 in Test old clotted haemothorax with multi systemic problems died. Median & 1 in Control), Wound Infection (3 in Test & 2 in Control), Complete post operative stay was five days. Heart Block (0 in Test & 1 in Control) & ICU psychosis (1 in Test & 0 in Conclusion: Indications of VATS can be extended to majority of Control). thoracic surgical procedures with increasing experience. Mortality and In Test group one DVR patient died due to VF, while three Control morbidity are acceptable. Some cases need conversion to thoracotomy patients died (1 CABG case due to VF & 2 TOF cases due to Multi- to complete the procedure successfully. VATS as diagnostic modality Organ Failure). in undiagnosed pleural and pulmonary pathology constitute the Conclusions: The SPICTRA Membrane Oxygenator has majority of cases. performed well in our study & is awaiting a Multicentric Clinical Evaluation soon.

Tracheo-inominate artery fistula following tracheal resection and reconstruction 211 VR Santhosh, RK Sasankh, CS Vijayashankar, Rajan Santosham Santosham Chest Hospital, Chennai Background: Tracheo-inominate artery fistulae are potentially Intra aortic balloon pump – Indications & outcome lethal complications following tracheal reconstruction surgery, in our hospital 213 BR Jagannath, P Srinivasa Reddy, B Kiran Kumar, tracheostomies and following prolonged ventilation. Pankaj Kumar Srivastava Case Report: A 35 year old male underwent tracheal resection and Southern Railway Hqrs, Hospital, Ayanavaram, Chennai end to end anastomosis for adenoid cystic carcinoma of the trachea thro' a cervical approach. On the 8th post operative day patient Introduction: Intra aortic balloon pump is a mechanical device to developed bright red hemoptysis of about 400 ml. Urgent contrast assist failing heart. There are many indications of insertion of IABP CT scanning revealed an irregularity of the innominate artery at the but basic principle remains the same i.e. to support the failing heart. level where it crosses the trachea. Patient was immediately shifted to Material & Methods: We have conducted a retrospective study O.T. Prior to induction bronchoscopy was performed which showed from January 1994 till date to assess the indication & outcome of IABP a haematoma at the suture line. After Et intubation and GA cervical insertion. 198 patients had IABP support either preoperatively, intra incision was made and R common carotid artery was exposed and operatively or postoperatively. 14.5% patients were female, average taped. Sternotomy was performed and ascending aortaexposed. A 8 age of patients was 54.17% years (range 30 years – 75 years). Majority mm Gortex ringed graft was placed from the ascending aorta. After of the patients had CABG without or with associated procedures like constructing the proximal anastomosis a Prohit-Inara shunt was DORS' aneurysm repair, AVR & MVR. 13.04% patients had pre op placed thru' the graft into the divided end of the right common carotid. rest angina & 26% had unstable angina. Left main disease was present Anastomosis between the right common carotid and the graft was in 18% cases. Average no. of grafts per patient was 2.71. In initial years completed with the removal of the shunt and deairing. The mortality was <80% which has come down to about 55% in last 3 haematoma was exposed, the iominate artery, R common carotid and years. Indications for inserting balloon was low arterial blood pressure, brachocephalic arteries were ligated individually. A sternomastoid increasing pulmonary artery pressure or weaning from CPB in flap was used to protect the innominate artery blow out. majority of cases. Details of indications, weaning & duration of IABP Results: The patient had an uneventful post-op period and was support will be highlighted during presentation. discharged. Conclusion: IABP has been instrumental in reducing the mortality Conclusion: A high index of suspicion is required. A contrast CT in patients with failing heart. In the recent years morality in patients and a "carefully performed" bronchoscopy are useful. Some form of having IABP has also come down due to better monitoring, better cerebral protection is mandatory. Surgery offers the best chance of machines & most important being the lower threshold for inserting survival. the balloon.

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Minimally invasive cardiac surgery using were the victims of physical trauma. The donor age ranged from 2 to an indigenously develped retractor system 214 54 years. The hearts were obtained within 24 hours of death. The Anil Bhan, A Vikram, Pravin Saxena, P Venugopal recommendations of the American Association of Tissue Banks were All India Institute of Medical Sciences, New Delhi followed for procurement, harvesting and storage of the tissues. Till Background: Lower hemisternotomy is a popular minimally March 1995, homografts were antibiotic preserved and were used invasive approach to correct cardiac lesions. Since June 2000, we within 6 weeks of procurement. Subsequently, cryopreservation is started the programme of minimally invasive approach for a variety being used. of cardiac lesions. For the same we have indigenously designed a Results: Out of 452 hearts, 944 (444 nortic, 440 pulmonary and 60 retractor system. mitral) homografts were procured. 20 valves were damaged during Methods: Total of 50 patients were operated through this approach. procurement. 296 homografts were discarded for various reasons, The cardiac lesions corrected include Atrial Septal Defect (ASD) in 41 including positive serum markers or positive culture for infective patients (82%), Ventricular Septal Defect (VSD) in 5 (10%) and Mitral agents (n=170), wear and tear during storage (n=28), improper sizing Valve replacement (MVR) in 4 (8%). The results of ASD closure in 41 or thawing (n=25), and expiry of antibiotic preservation (n=27) or patients done through this approach were compared with the control interruption of cryopreservation (36). 361 homografts were used for group of patients who underwent ASD closure through full length various valvular procedures (145 Ross procedure, 167 homograft aortic sternotomy. valve replacement, 37 homograft mitral valve replacement, and 12 Results: In patients in whom ASD closure was done, the mean Ross II procedure). 235 homograft conduits were used in various CPB and Aortic cross clamp time in lower hemisternotomy group were procedures for congenital heart disease and included conduit repair significantly longer, 35±14.2 min and 23.3±10.8 min respectively for TOF or pulmonary atresia (n=117) trancus arteriosus repair (n=42), compared to 23±3.9 min and 14±3.5 min in full sternotomy group Fontan procedure (n=12), Rastelli procedure (n=24) and other (n=40). (p<0.001), mean ventilation time, blood loss, ICU and hospital stay Conclusion: Availability of homograft increases the surgical were significantly low (p<0.001) in patients who were operated options in difficult subset of patients. It is possible to run a homograft through full length sternotomy. valve bank with minimum cost. However, cryopreservation is more Conclusion: Lower hemisternotomy is a safe mode approach in expensive but it provides an opportunity to store the valves for an both the paediatric and adult patients and the indigenously designed indefinite period and thus maintain an uninterrupted supply of retractor system is simple and reusable equipment, which helps in homografts. improving operative exposure and ease of surgery.

Intracardiac myxomas: Long-term surgical results Do we undercool or overheat the brain during M Hote, A Bhan, SK Choudhary, UK Chowdhury, B Airan, 215 cardiopulmonary bypass? 217 AK Bishoi, A Sampath Kumar, U Kiran, KK Talwar, P Venugopal H Kaukuntla, DK Harrington, I Bilkoo, T Clutton-Brock, All India Institute of Medical Sciences, New Delhi TJ Jones, RS Bonser Cardiothoracic Surgical Unit, Queen Elizabeth Hospital, Objectives: The present report analyzes the long-term outcome Birmingham, United Kingdom following excision of intracardiac myxomas. Patients and Methods: From January 1976 through September Background: Brain cooling is an essential component of aortic 2002, 120 patients (age range 6 to 70 years) underwent surgical excision surgery requiring circulatory arrest. Inadequate cooling may of primary or recurrent intracardiac myxomas. Symptom duration potentiate brain injury. Conversely, brain hyperthermia during ranged from 1 week to 8 months. The chamber of origin was LA in rewarming phase of cardiopulmonary bypass may lead to neurological 101 (82.5%), RA in 16 (13.3), LA and RA in one, LA and RV in one, and injury. Conventional temperature monitoring sites may not reflect the LV in one. Three patients were in one family. The surgical procedure core brain temperature (Tº). We compared Jugular bulb venous included complete wide exicision. temperatures (JB) during deep hypothermic circulatory arrest and Results: There were 3 early deaths. Late follow up is 95% (111/117) normothermic bypass with Nasopharyngeal (NP), Arterial inflow (AI), complete. There was one non-cardiac late death. In non-familial group Oesophageal (O), Venous return (VR), Bladder (B) and Orbital skin 3 patients had recurrence of myxoma (reoperated). All these three (OS) Tº's. patients had recurrence within 2 years. Two of the 3 patients with Methods: 18 patients undergoing deep hypothermia (DH) and 8 familial myxomas had recurrence. patients undergoing normothermic bypass (mean bladder Tº— Conclusion: Surgical exicision of intracardiac myxoma gives 36.29ºC) were studied. For DH, cooling was continued to 15ºC NP excellent short-term and long-term results. However, the possibility (mean cooling time - 66 minutes). At predetermined arterial inflow of recurrence warrants long-term echocardiographic follow up. Tº, NP, JB and O Tº's were measured. A 6-channel recorder continuously recorded all Tº's using calibrated thermocouples. Results: During the cooling phase of DH, NP lagged behind the AI and JB Tº's. All these equilibrated at 15ºC. During rewarming, the JB and NP lagged behind AI and JB was higher than NP at any time Homograft valve banking: The AIIMS experience point. During normothermic bypass, although NP was reflective of SK Choudhary, A Sampath Kumar, B Airan, B Bhan, AK Bishoi, 216 the AI and JB Tº trends, it underestimated peak JB Tº (o=0.001). At the UK Chowdhury, P Venugopal end of bypass, peak, JB was greater than the arterial inflow Tº All India Institute of Medical Sciences, New Delhi (p=0.023). Background: Homografts play an important role in cardiovascular Conclusion: If brain venous outflow Tº (JB) accurately reflects brain surgery. We present our experience of a decade in homograft tissue Tº, NP Tº is a safe surrogate indicator of cooling. During rewarming, banking. all peripheral sites underestimate brain Tº and caution is required to Methods: Hearts were obtained either from the cadaveric donors avoid hyperthermic arterial inflow, which may inadvertently, result (n=440) or from cardiac transplant recipients (n=12). Cadaveric donors in brain hyperthermia.

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Wythenshawe experience of lung transplants and individuals, creating awareness, promotion of organ donation J Thekkudan, S Lashmanan, N Yonan, AK Deikaniya, KB Carroll, 218 and transplantation activities. CT Leonard, CS Campbell, D Greenhaugh ORBO has established a network with Government & Private Manchester, UK Hospitals in Delhi, which later on will be expanded nationally in Methods: Wythenshawe Hospital is a tertiary referral centre in metropolitan cities and then internationally. NGOs active in similar Manchester, UK. We have an active cardiopulmonary transplant fields are collaborating to reach wider segment to create education programme. We have been performing lung transplants for 11 years, and awareness about organ donation. The paper discusses existing a total of 189 cases including heart-lung, double and single lung scenario of organ donation, transplantation activities and future transplants. We fully analysed 169 cases, looking at our current strategies in Delhi. practice. The other 20 cases are included in the demographics diagnosis and survival data. Results: The median operative time for single lung transplants is 4 hours 5 minutes, for heart-lungs it is 6 hours 10 minutes and 7 hours One-stage surgical treatment of cardiac and for double lungs. Bypass was instituted in single and double lungs pulmonary echinococcosis 220 V Arun, S Balachandran, S Visvakumar, R Alagesan, for high pulmonary pressures, difficulty in ventilation and "sick" M Varadarajan patients. The median lenght of total ischaemic times was 3 hours 50 Cardio Thoracic Surgery Department, Govt. General Hospital, minutes for a single lung transplant, 4 hours for the heart-lung Chennai transplants and 5 hours 30 minutes for the last lung to be implanted on a double lung transplant. The ischaemic time was related to the Background: Hydatidosis is a significant health problem for length patients of time were ventilated but not to mortality. 10 cases underdeveloped and developing countries. Cardiac involvement is required intra-aortic balloon pumps – of which only 1 survived. 35% rare and early diagnosis and treatment is important. are extubated within 24 hours, 65% within 3 days and 77% in 1 week. Case Report: A 35 years old farmer presented with productive The median ICU stays are: 5 days for left single lungs, 8 days for right cough and haemoptysis. X-ray chest revealed bilateral multiple lungs, 8 days for heart lungs and 14 days for double lungs. 19% of the pulmonary nodules. Echocardiogram revealed a large thick walled total cases had a tracheostomy. multiloculated cyst in the interventricular septum with expansion into The operative mortality for single lung is 3%, with survival the right ventricular cavity without any inflow or outflow obstruction. decreasing from 70% for 1 year to 46% at 3 years and 31% at 5 years. Ultrasound abdomen was normal. Double lungs have an 8.5% mortality in the first week with survival Through median sternotomy, with minimal handling of the heart, decreasing from 53% for 1 year to 28% at 3 years and 21% at 5 years. CPB was established with bicaval cannulation. At moderate systemic Heart-lung have a 40% operative mortality but the 1 year survival is hypothermia, aorta and pulmonary artery were crossclamped. 62.5%, with 3 year and 5 year survival are 45% and 37.5% respectively. Antegrade cold blood cardioplegia given, and through right atrial Re-transplantation in the opposite lung was performed in 4 cases. 3 approach cystectomy and capitonage was done. had the same lung retransplanted, one of these survived ICU. On CPB during the rewarming phase both pleural cavities were opened. The deep cysts in the lung were injected with hypertonic saline and the superficial cysts were excised. HPE confirmed the germinal epithelium of hydatid cyst. Organ retrieval banking organization (ORBO) Conclusion: Treatment of hydatid cyst is surgical, whatever the Aarti Vij, Chanderkanta, Balram Airan, KK Talwar, 219 location maybe. Median sternotomy gives adequate access to bilateral P Venugopal pulmonary and cardiac cysts. The risk of rupture of cardiac cysts with All India Institute of Medical Science, New Delhi intracavitary expansion makes surgery an emergency undertaking. Medical advances in the field of transplant immunology; surgical management and organ preservation have made the transplantation of vital organs, a viable approach to the management of diseases causing irreversible organ failure. Double stricture of trachea–Surgical management R Anto Sahayaraj, N Nagarajan, A Sukumar, Rajan Santosham The Transplantation of Human Organs Act 1994 and the 221 Government General Hospital & Madras Medical College, Transplantation of Human Organ Rules provide for the regulation of Chennai removal, storage and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealings in human Background: Tracheal stenosis is a particularly difficult problem organs and for matters connected therewith or incidental thereto. The both for the patient and the surgeon moreso when the trachea is act recognizes the concept of brain death and gives legal sanction for strictured in two segments. cadaver organ donation. Case Report: A 30-year old female presented with stridor and a Donation and transplant coordination is a very complex process tracheostomy-in-situ. The patient had ingested a corrosive poison 6 that requires the synchronized involvement of large number of months back following which tracheostomy was done for establishing different health care professionals, specialists and organizations in airway. order to be successful. Hence, Ministry of Health & Family Welfare, Bronchoscopy and CT scan showed two strictures – one small Govt of India has set up Organ Retrieval Banking Organization segment of stricture in the subglottitic region and another long (ORBO), first nodal centre and national facility for the country at All segment about 3 cms above the carina. The lower end of the India Institute of Medical Sciences (AIIMS), New Delhi, with a purpose tracheostomy tube abutted the lower end of the lowe stricture. The of encouraging organ donations, fair and equitable distribution of trachea intervening between the two strictures was normal. Surgical human organs and optimum utilization of human organs. excision of the lower strictured segment (about 3 cms) and dilatation The organization maintains the waiting list of terminally ill patients of the upper stricture were done as the intervening trachea (about 5 requiring transplants, donor registration, matching of recipients with cms) was normal. A Montgomery T-tube was placed in the trachea donor, co-ordination from procurement of organs to transplantation, with the upper limb just above the vocal cords and the lower longer dissemination of information to all concerned hospitals, organizations limb placed across the tracheal suture line.

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Results: The postoperative recovery was uneventful. Results: There was an overall mortality of 12 cases post operatively Conclusion: This case is presented to highlight the way the two (8 patients had pre-op inotrope support). All 72 cases had inotrope strictures were managed conserving the normal intervening trachea. support post operatively (started electively) Hospital stay varried from Subglottitic stenosis of the trachea is a difficult area to treat surgically 9 days to 28 days with average stay of 15±2. Prolonged stay was and dilation with stenting is an useful therapeutic option. needed for tapering of inotrope. Conclusion: This study reflects incidence, management and prognostic value of constrictive pericarditis.

TVMC-an incremental risk factor for subsquent MVR? 222 A Irineu, Pereira, Chiran Babu, Sudhir M Bhat, Anil Kumar, J Balachander, M Nachiappan, KSVK Subba Rao Our experience of transaxillary approach for first JIPMER, Pondicherry rib resection to relieve thoracic outlet syndrome 224 Rakesh Chittora, RM Mathur, CP Srivastava, KK Kushwaha Background: Mitral Valvular Stenosis continues to be prevelant Department of Cardiothoracic and Vascular Surgery, in the lower-socio-economic classe in developing countries. Trans- SMS Hospital, Jaipur ventricular Mitral commissurotomy (TVMC) has proved to be a cost- effective means of palliation in a significant proportion of the surgically Introduction: The rationale of first rib resection to relieve thoracic treated patients. outlet compression is that the first rib forms the denominator common Aims: To evaluate TVMC as an Incremental risk factor for to all cause of nerve and artery compression in this region. Present subsequently indicated Mitral Valve replacement (MVR). study shows that transaxillary approach for first rib resection is simple, Materials and Methods: During a five-year period between July safer which allows quick resection. 1997 and July 2002, 125 patients underwent Isolated MVR. Patients Methods: Between January 97 and August 2002, 45 cases of thoracic undergoing MVR for Lutembacher's Syndrome, Ischemic or Infective outlet syndrome, between age range of 5 years and 65 years were Mitral regurgitation Acute post BMV/TVMC mitral regurgitation, studied. Male to female ratio was 1:2. Incidence was almost equal on Thrombosed prosthetic mitral valve or as component of Double valve both side. 21 patients had neurological symptoms, 13 had vascular procedures were not included in the study. Patients undergoing mitral symptoms and 11 had both neuro-vascular symptoms. Ten patients valve related procedures viz. LA thrombectomy and LA plication were were having bilateral disease. Six patients were having gangrenous included in the study. Of the 125 patients undergoing Isolated MVR, changes in finger tips or hand. Three patients were approached 33 had prior TVMC, three of whom had undergone the procedure through supraclavicular approach and 42 through transaxillary twice. approach. Only cervical rib was resected through supraclavicular Observations: Both the TVMC and Non-TVMC study groups approach. In all transaxillary approach, first rib was resected showed comparable sex distribution. Age at MVR was approximately commonly and in 24 cases cervical rib was also resected. Vascular 10 years later in the TVMC group (40-50 years) than the non-TVMC intervention was done in 22 cases. (Brachial Embolectomy in 21 cases group (30-40 years). Incidence of Pulmonary Artery Hypertension in and subclavian arterioplasty in one case). TVMC group (60%) was comparable to Non-TVMC group (56%). LA Result: All patients except one had symptomatic relief on next clot occurred in 22% TVMC against 14% Non-TVMC group. AF in day and full recovery in one-to-two weeks time. One case had lower 68% in TVMC group against 46% Non-TVMC group. ACC and CPB brachial plexus injury, which lead to right hand paresis, not showing times were comparable in both 30-day mortality was 2 (6.6%) in TVMC recovery after 6 months follow-up. Average blood loss was 50 ml. in against 4 (5.6%) Non-TVMC group. transaxillary approach and 90 ml in supraclavicular approach. No Conclusion: TVMC is a safe and cost-effective procedure in the wound infection was reported. Intercostal tube was inserted in 2 cases suitable cases of Mitral Valve Disease offering good palliation and on table following pleural rupture and in 4 cases in post operative poses no incremental risk to subsequently indicated Mitral valve period. replacement. Conclusion: Transaxillary approach found to be a rapid, safer and easier approach with negligible blood loss, good exposure of the rib, major vessel and nerves. It doesn't require muscle cutting and repairing. It gives good cosmetic scar and there is no postoperative shoulder disability noted. Pericardiectomy in constrictive pericarditis – A study of 72 cases 223 Sanjeev Devgarha, Vikas Ahlawat, Ramgopal Yadav, Vinay Naithani, Anil Sharma, CP Srivastava Department of CTVS, SMS Medical College, Jaipur Vascular injuries of limbs, Govt. medical college, Introduction: Constrictive pericarditis is a common entity came Jammu experience 225 Gurjit Singh, Arvind Kohli, Shyam Singh across by cardiac surgeons. Patients present with dyspnoea, oedema, CTVS Unit, Govt. Medical College, Jammu Jaundice, Ascitis, and loss of appetite. Methods: This study was carried out in Deptt. of CTVS, SMS Aim: A retrospective study w.e.f. 1994 till date analyzing the cause Hospital, Jaipur from January 1998 to August 2002. In our study of 72 of injury outcome and complications of Vascular Trauma of Limbs cases, 57 cases had constrictive pericarditis, 11 cases had Effuso was assessed. constrictive pericarditis and 4 cases had pyopericardium. Age limit Methods: Profiles of 68 patients, 47 males and 21 females, in age was from 12 years to 55 years with average age of 32±4. Out of 72 group between 2 years – 70 years were analyzed. cases 51 were males, 21 were females. History of tuberculosis and There was early presentation (< than 6 hrs) in 28 cases, whereas in ATT was present in 29 cases. 20 patients have full course of ATT while 40 cases there was delayed presentation. The injuries were penetrating 9 cases were defaulters. Surgical approach was left thoracotomy from (including splinder injuries) in 48 cases and blunt in 20 cases. Isolated 4th ICS and left phrenic to near Rt. phrenic excision of pericardium vascular trauma was present in 24 patients, 44 cases were aggrevated was done. by concomitant bone fracture, nerve injuries and soft issue damage.

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Most frequently injured vessel were the superficial femoral artery in The cold upper limb 20 cases in lower limb and brachial artery in upper limb in 18 cases. R Vashisth, A Mandal, T Saha, KS Das, NC Garai, S Dey, 228 Saphenous vein interposition graft was done in 16 cases, prosthetic A Chakravarti, I Guha, A Dey, S Chakraborty graft in 2 cases, end to end anastomosis in 30, lateral arteriorraphy in Dept of Th & CV Surgery, Medical College, 88 College Street, 10 patients. 3 patients required venous patches, 3 patients required Kolkata embolectomy and 4 required embolectomy with ligation. Venous Introduction: Generally, when we speak of ischaemic limb, it is repair was done in 6 cases, 10 patients required fasciotomy. the lower limb that comes to our mind. However, upper limb Results: Blood flow was restored in 38 patients collateral ischaemia is not so infrequent a condition. The objective of this compensated in 18 patients, 2 patients required second look graft presentation is to highlight the various methods and pathological embolectomy, 7 patients required primary and 3 secondary conditions presenting as upper limb ischaemia. amputations were performed, 2 patients died. Material and Methods: The study is a retrospective analysis of 52 Conclusion: Objective of treatment in all cases of vascular injuries cases of upper limb ischaemia, acute or chronic in nature. These 52 should be early revascularization, critical clinical assessment is cases were spread over a period of 4 years and included pathological important in selecting patient for delayed revascularization. conditions such as cervical rib, scalenus anticus syndrome, vasospastic conditions (Raynaud's) and embolus obstructing a major vessel. Results:

Empyma thoracis — "A down to earth disease" Pathology Operative modality No. A Dey, A Mandal, T Saha, KS Das, NC Grarai, S Dey, 226 1. Cervical rib Cervical rib excision (cervical 31 A Chakravarti, I Guha, R Vashisth, S Chakraborty approach) ± cervical sympathectomy. Dept of Th & CV Surgery, Medical College, 88 College Street, 2. Scal. Antic. Synd. Scalenotomy (ant.±med) ± cerv. 13 Kolkata sympathectomy Introduction: Empyma thoracis is a common problem faced by 3. Vasospastic Cervical sympathectomy (trans-axillary) 6 the physicians and surgeons in a day to day practice. 4. Embolic Embolectomy 2 Material and Method: In the period between September 1998 and obstruction September 2002, 196 cases of empyma thoracis were encountered. All Conclusion: Upper limb ischaemia is a relatively common the cases underwent tube thoracostomy, of which 32 cases had condition and needs adequate suspicion for diagnosis and promptness decortication, partial thoracoplasty (an on-table decision of non- in management where different surgical modalities play an important obliteraton of chest cavity after decortication) were done in 5 cases. role. Primary thoracoplasty were done in 4 cases and 5 had an Eloesser flap. Result: Six patients had to undergo secondary wound closure for wound infection. All others had uneventful recovery with fully functional lungs. Inference: Empyma thoracis - a down to earth disease has to be Adenosine as an adjunct to cardioplegia treated energetically. Milind Umre, Ajay Saraswat, Sanjeev Kalra, HC Sachdeva, 229 RP Singh, Meenakshi, Kishan Kumar, Vikas Kapoor, Jagdish Prasad Department of Cardiothoracic and Vascular Surgery, Vardhman Sternal reconstruction – Handshake with Mahavir Medical College & Safdarjang Hospital, New Delhi plastic surgeons 227 Objective: To evaluate beneficial effects of adenosine on S Dey, S Gupta, T Saha, BC Roy, KS Das, A Chakravarti, myocardial protection when used as an adjunct to Cardioplegia. I Guha, A Dey, R Vashisth, S Chakraborty Dept of Th & CV Surgery, Medical College, 88 College Street, Methods: Hundred consecutive patients subjected to open heart Kolkata surgery were included in the study. In every alternative patient Adenosine was used as an adjunct to Cardioplegia & these were Introduction: Sternal reconstruction is one of the common meeting included in Group-I. It was injected into the root immediately after ground for Thoracic and Plastic surgeons. The defect arising out of clamping of Aorta prior to starting St. Thomas Cardioplegia. In the sternal excision due to infective malignant condition may need delicate other group (Group-II) cardiac arrest was induced with St. Thomas plastic surgical methods. Cardioplegia alone. Time taken for inducing cardiac arrest, duration Material and Method: We have experience of thirteen cases of of surgery, rhythm at removal of Aortic cross clamp and related sternal reconstruction in our center. Of these 13 cases, 8 had sternal parameters were noted. osteomyelitis with mediastinits and sternal tumour constituted 5 cases. Results: In Group-I patients where adenosine was used along with In infected cases, after mediastinal and sternal debridement, Cardioplegia (except patients who had AR) showed significant bilateral pectoralis major and myocutaneous flap was advanced and reduction in the time taken to induce cardiac arrest which was almost used to cover the defect. instantaneous (Mean of 2 sec.). Whereas in Group-II patients the time In sternal tumours, the sternum was widely excised and latissimus taken for inducing cardiac arrest ranged from 50 sec to 3 minutes. In dorsi myocutaneous flap brought to cover the defect. Raw areas on 95% of Group-I patients the rhythm at removal of cross clamp was the back was covered with split thickness skin graft. NSR with other factor remaining same. Whereas 80% of those in All the patients of sternal reconstruction were put on artificial Group-II had VF and required DC shock to revert to NSR. ventilators for 24 to 48 hours. Conclusion: Adenosine due to its hyperpolarizing action on SA Result: One patient had minor superficial wound infection, others node induces instantaneous cardiac arrest. The spontaneous NSR, had eventful recovery. obtained on the removal of aortic cross clamp in majority of patient Conclusion: Myocutaneous flaps can be used judiciously to cover (in Group-I) is probably due to high energy (ATP) levels remaining sternal defects. stored in the heart as reported in related references.

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Constrictive pericarditis – What is the ideal no recovery. Amongst the 4 patients with partial recovery; three had expsoure? 230 persistent paresis of which one patient had a coexistent nerve injury. I Guha, BC Roy, T Saha, N Maity, S Dey, A Chakravarti, Limb could be salvaged with a transmetatarsal amputation, in the A Dey, R Vashisth, S Charkaborty fourth patient. Thus in 32 patients (91.5%) limb salvage was Dept of Th & CV Surgery, Medical College, 88 College Street, achieved. The 3 patients which did not improve had acute on chronic Kolkata disease & needed a below knee amputation. Fasciotomy was needed Introduction: Constrictive pericarditis is quite a common disease to relieve edema only in one patient. 3 patients, although limb that we come across. Mostly the etiology is tubercular and mostly ischemia was relieved, died due to acute myocardial infarction they present late. There are different approaches to this ailment. Some postoperatively, unrelated to the procedure. use the median sternotomy, some anterolateral thoracotomy. Conclusion: Controlled reperfusion in prolonged acutely Material and Methods: We studied 41 patients in a span of 2 years. ischaemic limbs using a hypersomolar hypocalcemic & alkalotic Of this, 18 were females rest males. Age ranged from 12 to 50. All reperfusion achieves good limb salvage rates with reduced incidence patients were approached by the anterolateral thoracotomy with a of systemic complications. slit in the sternum transversely and good exposure was achieved in all. All cases were done without cardiopulmonary bypass. We have used anterolateral thoracotomy extending medially to slit the sternum transversely. In cases of median sternotomy the approach to SVC and IVC is easy but approach to LV is limited. In case of anterolateral Vascular trauma, a three years JIPMER experience thoracotomy it is just the opposite. In cases of anterolateral M Gopalakrishnan, Irineu Pereira, Sudheer M Bhat, S Jagdish, 233 thoracotomy with a transverse slit of sternum the approach to both is M Nachippan, KSVK Subba Rao easy. Jawaharlal Institute of Post-graduae Medical Education and Research, Pondicherry Result: All patients fared well. All had relief of symptoms and an uneventful post operative convalescence. Aim: To study the pattern of presentation, to evolve an assessment Inference: Anterolateral thoracotomy with a transverse split of method and management protocol and to evaluate the outcome of sternum is a good exposure technique to tackle constrictive vascular trauna. pericarditis. Method: Study was conducted between July 1999 and June 2002. 59 patients were studied. Cause of vascular trauma was road traffic accident in 37 (62.7%), assault 11 (18.6%), iatrogenic 10 (16.9%) and work place accident 1 Debulking of cardiac sarcomas (1.6%). PS Seetharama Bhat, Ashok Kumar, Kiran, AN Prabhudeva 231 Brachial artery was involved in 19 (32.2%), ulnar 17 (28.8%), radial Sri Jayadeva Institute of Cardiology, Bangalore 8 (13.5%), femoral 8 (13.5%), subclavian, dorsalis pedis, profunda femoris in 1 each. Femoral vein ws injured in 6 (10.2%), popliteal vein Cardiac sarcomas are rare clinical entities. They may be mistaken in 2 (3.4%), and basilc vein in 1 (1.7%). for myxomas or clot even by experienced echocardiographer. 2 cases Four patients had to be amputated because of extensive of cardiac tumors underwent emergency surgery for pulmonary skeletomuscular crush injuries. edema. Preoperative diagnosis was mitral restenosis with LA clot in Embolectomy was done in 6 (10.16%), end to end repair in one (closed mitral valvotomy 5 years earlier) and sessile left atrial 21(35.5%), saphenous vein graft in 6 (10.16%), repair of part of the myxoma attached to appendage in the other. circumference of vessel wall in 2 (3.38%). No intervention was done The tumor in left atrium was debulked to clear the left ventricle in 3 (5.0%). inflow under cardiopulmonary bypass. Results: 39 patients recovered good vascularity. Both the patients were discharged on 9th P.O. day after a stormy 23 patients could be followed upon long term ad 17 (73.9%) of initial post operative period. Histologically both the tumors were them had good vascularity. sarcomas. Chemotherapy was started. Qualitatively they had better Conclusions: In vascular trauma the viability of the limb depends life for 4 months. Both the patients died within 6 months with wide on early intervention. However application of simple clinical skills spread metastasis. and minimum investigations are sufficient to make proper diagnosis Pulmonary edema caused by sarcoma confined to within the left and prompt intervention with good results. atrium can be managed by debulking.

Results of modified reperfusion for patients with A three year study of chest trauma at JIPMER from prolonged acutely ischaemic limbs 232 August 1999 to July 2002 234 TR Rajesh, VB Pai, S Jana, V Kumar, VS Lad, CB Kulkarni, Kishore, Joshi, Irineu A Periera, BV Sai Chandran, S Jagadish, JV Khandekar, NB Agarwal, AM Patwardhan M Nachiappan and KSVK Subba Rao Department of Cardiovascular & Thoracic Surgery, K.E.M. Hospital, JIPMER, Pondicherry Parel, Mumbai Aim: To study the pattern of occurrece of types, mode, Method: Controlled reperfusion in patients with acute ischaemia manifestations and outcome of chest injuries and its associated injuries. of prolonged duration of the limbs achieves good limb salvage rate & Methods and Observations: All the 394 patients sustaining reduces the incidence of systemic complications like renal failure, injuries, who were referred to Cardio-thoracic department from the shock and arrhythmias. 38 patients with prolonged acute limb Casualty room were evaluated as the cases during the period of study. ischemia underwent controlled reperfusion with hypocalcemic, Among these, 335 (85%) were males and 59 (15%) being females with hyperosmolar, hyperglycemic, oxygenated blood. age ranging from 8 months to 78 years with preponderance (68%) in Results: Out of 35 survivors, 28 patients (80%) achieved a complete the age group of 21-50 years. Mode of injury was road traffic accidents, limb recovery, 4 patients had a partial recovery & 3 patients showed fall, assault, crush, bull gore, and others in 183 (46.5%), 113 (28.7%),

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71 (18%), 14 (3.6%), 11 (2.8%) and 2 (0.6%) cases respectively with were female. Twenty patients were in class IV and 8 patients were in type of injury being blunt in 342 (86.8%) and penetraing in 52 (13.2%) class III NYHA who had LA size ranging from 5 to 6.5 cm with LAA cases. The chest injuries manifested as fracture of ribs (61.7%), clot in 8 patients. pneumothorax (23.4%), hemopneumothorax (20.1%), hemothorax These patients who underwent mitral valve surgery using (10.2%), flail chest (5.3%), lung injury (1.8%), sternal fracture (0.8%), conventional CPB moderate hypothermia and simultaneous RF and subcutaneous emphysema (25.1%). Of these 162 (41.1%) were ablation of AF. The RF lesion was delivered at the base of LA managed only with analgesics and observation; 205 (52%) required appendage, encircling left and right pulmonary vein along with inter intercostals drainage; ventilation, thoracotomy and laparotomy were connecting lesion using thermaline surgical ablation catheter. EPT is required in 9 (2.3%), 4 (1%) and 14 (3.6%) cases respectively. a Rf power generator and design to maintain a preset lamp of 70° by Conclusion: Road traffic accidents is the commonest cause of chest adjusting the delivered FR energy as necessary. The ablation time on injury with high male predominace especially in the age group of 21- an average was 20-25 minutes. 50 years. Fracture of ribs is the commonest manifestation. Most of Results: Of the 25 patients who had chronic AF, 23 were these are managed with conservatively withmortality rate of 2.3%. successfully ablated. Boty PV and LAA lesions were demonstrated to be necessary to ablate AF. Conclusion: This technique of RF ablation is simple, safe and useful for patient with chronc AF undergoing mitral valve surgery. "Moving objects in the heart"– A surgeon's The initial results are encouraging. One year follow up revealed 92% perspective – A JIPMER experience 235 of these patients had converted and remained in sinus rhythm. Irineu A Pereira, Madhan Kumar, BV Sai Chandran, Anil Kumar, J Balachander, M Nachiappan, KSVK Subba Rao JIPMER, Pondicherry Background: "Moving Objects in the heart" – organic or inorganic Adenosine for inducing immediate cold blood objects or abnormal pathologies of the heart having motion cardioplegic arrest 237 A Dayal, D Khurana, V Krishna, RK Verma, A Suryavanshi, independent to that of cardiac contraction are rare interesting D Shah, R Trehan, RN Pandey, JL Sahni conditions. LPS Institute of Cardiology, Kanpur Aims: To highlight the varied echocardiographic and pathologic presentations of "Moving Objects in the Heart" Method: A study was conducted at our institute on 20 patients to Materials and Methods: During a 30-month period from Jan 2000 assess the role of adenosine as an adjunct to cardioplegic solution. In to June 2002, 17 patients with "Moving Objects in the Heart" underwent the study group (n-10), adenosine was administered as bolus of 6 mg admission for surgery. These comprised 9 cases of Atrial Myxomas 7 in the aortic root immediately after aortic cross clamping alongwith in the RA and 2 in the LA, one case of RA thrombus, one case of 'Ball- cold blood cardioplegia. In the control group (n=10) cold blood valve thrombus in the LA. One inoperable LA tumour, and five cases cardiplegia was used without adenosine. Important parameter of Valvular vegetations –2 prosthetic and 3 native valvular vegetations. monitored were: time to asystole in seconds end recovery of normal Observations: All patients were evaluated and planned for sinus rhythm following release of aortic crossclamp. Alongwith emergency or Semi-emergency surgery. Barring a case of suspected haemodynamic stabiliy of the patients was also assessed. LA myxoma which was found to be a bronchogenic carcinoma with Results: The results showed marked reduction in the time to extension to the heart and associated with distant metastases, and achieve asystole in the study group (2.5±1.5 seconds) as compard to another LA myxoma who expired hours before planned excision; all the control group (20±3 seconds), restoration of sinus rhythm was other patients underwent successful surgery and are doing well on achieved in the study group at (40.5±30.50) seconds while in the control follow-up. group it was achieved at 150.50±10.5 seconds. The haemodynamic Conclusion: "Moving Objects in the Heart are rare conditions of parameters measured at 10, 30 & 60 minutes after the termination of varied differential diagnosis with interesting echocardiographic and cardiopulmonary bypass, the heart in study group showed significant pathologic presentations with potentially dangerous outcome improvement in performance. There were no deleterious effect mandating aggressive management. noticed. Conclusion: So we conclude that adenosine given as an adjunct to cold blood cardioplegia helps to achieve a quicker asystole and a faster recovery of sinus rhythm with no untoward effects and thus indicate a better myocardial preservation. Endocardial radiofrequency catheter ablation of chronic atrial fibrillation in patients undergoing 236 mitral valve surgery Ramesh Kumar Bapna, ZS Meharwal, Y Mishra, V Kohli, Manisha Commonest cardiac tumour Mishra, Rajneesh Malhotra, Naresh Trehan AG Ahangar, AM Dar, MA Bhat, GN Lone 238 Escorts Heart Institute and Research Centre, New Delhi Deptt. of CVTS, SK Institute of Medical Sciences, Srinagar Introduction: Atrial fibrillations (AF) a common and troublesome Aim: The main aim was to know the pattern of presentation of arrhythmias that often has adverse prognosis due to fast ventricular cardiac tumours, commonest histopathological variant and the results rate and loss of atrail systole leads to thrombo-embolism. In the present of management thereof. study, we attempted ablation of AF using only left atrial lesion created Methods: 23 patients operated for primary cardiac tumours are with new temperature controlled surgical (Radio Frequency) RF probe. presented. Males out numbered females Dyspnea was the common Objective: is to demonstrate efficacy of RF ablation of chronic AF Symptom. Anaemia, asthenia and tumour plop was observed in in patient undergoing mitral valve surgery and long term efficacy of majority. Echocardiography was the investigation of choice. RF ablation in maintaining sinus rhythm. Preoperative diagnosis of atrial tmour was available in 22 patients. Methods: In this series of 25 patients who underwent RF ablation Median sternotomy was used in 21 patients and thoracotomy since December 99, the age ranges from 20-60 years. 60% of patients approach in 2 patients. Majority of the tumours were arising from

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interatrial septum. Right atriotomy approach was used in majority of Tracheal stenosis: Resection and end to end the patients. Complete excision of the tumour with its base was done anastomosis safe and long lasting 240 in all atrial tumours. Atrial myxoma was the commonest cardiac VVK Bharadwaja, AM Krishna, KK Dev tumour found in 22 patients. Yashoda Super Speciality Hospital Hyderabad Results: Mitral valve and tricuspid valve repair wad done in 3 Introduction: Post intubation tracheal stenosis through uncommon patients. One patient could not be weaned off bypass, 2 died in is not rare. Repeated dilations result in restenosis. Resection and end postoperative period one died in follow up. In 19 patients follow up to end anastomosis has risk or recurrent laryngeal nerve injury of 3 months to 16 years has been uneventful with no recurrence. especially if stenosis is high. We are presenting our experience in 4 Conclusion: Thorough evaluation of patients is needed in 2nd cases. through 3rd decade of life if they present with features of changed Methods: 4 patients were operated between Nov 2000 to Sep 2002. postural dyspnea, TIA, and thromboembolic episodes. We One patient had large tracheo oesophageal fistula following prolonged recommend, normothermic perfusion and surgery on priority in all ventilation. The length of trachea resected was from 2 cm to 4.5 cm. In episodes. We recommend, normothermic perfusion and surgery on two cases resection of trachea & crico tracheal anastomosis were done priority in all such patients. and in other two cases resection and end to end anastomosis of trachea was done. Results: Post extubation vocal cord showed normal movements. No patient developed restenosis on follow up. Conclusion: End to end anastomosis of tracheal stenosis for post intubation tracheal stenosis is a safe and long lasting procedure with out any morbidity and mortality.

Thoracic duct Cyst: Rare tumour-rare presentation- Surgical results in bronchiectasis an analysis of 128 A case report patients 241 239 Thomas Stephen, Roy Tankachen, Bhawna Parihar, VVK Bhardwaja, GM Subramanyam, KK Dev Vinayak Shukla, Roy John Korula Yashoda Super Speciality Hospital Hyderabad Department of Cardiothoracic Surgery, Christian Medical College, Background: Thoracic duct cyst Tumour are rare cysts of Vellore mediastinum. Eight cases were reported in the literature, out of which Background: Bronchiectasis still remains a serious problem in seven diagnosed post operatively. All reported intra thoracic location developing countries. We reviewed the morbidity and mortality rates cyst. We are presenting one such cyst which had intra abdominal and outcome of surgical treatment for bronchiectasis. extension. Patient & Methods: Between 1992 & 2000, 128 patients (86 males Case Report: 64 years male admitted with dysphagia for both & 42 females) underwent pulmonary resection for bronchiectasis. The solids and lquids since 6 months. No history of SOB. No other positive mean age was 32.9 years (range 5-66 years). The indications for surgery history. On examination thin built patient with normal general was repeated infections in 66 patients (51.56%), massive haemoptysis physical examination and chest and cardio vascular system in 44 patients (34.37%) and destroyed lung in 18 patients (14.06%). examination. Pet abdominal examination revealed healed midline scar Mean duration of symptoms was 6.9 years (6 months to 22 years) and and no mass lesion included cough with purulent sputum in 30 (23.43%), haemoptysis in On investigation chest X-ray revealed mass lesion in left 28 (21.87%) and both together in 69 patients (53.9%). The disease was hemithorax and upper GI scopy revealed external compression of bilateral in 22 patients (17.18%) and lower lobes were involved in 114 oesophagas in its mid thoracic part. CT and MRI scan revealed cases (89.06%). Surgical treatment included lobectomy in 85 (67.18%), homogenous single cyst in the left thorax. Extending from aortic arch pneumonectomy in 42 (32.81%) and combined lobectomy and to L2 vertebra, and through arotic hiatus. No other mass could found. segmentectomy in 1 patient. Left postero lateral thoracotomy revealed cystic mass from aortic Results: The operative morbidity and mortality were 23 (17.96%) arch going through right crus of diaphragm in to the abdomen. The and 0 respectively. Follow up was complete in 108 patients for a period cyst was excised in toto. Post operative period uneventful. of 4.8 years (2 to 10 years). Overall 70 patients (64.81%) were Histopathological examination consistent with Lymphatic cyst. Patient asymptomatic after surgical treatment. Symptoms improved in 22 came for recent follow up. CXR showed no recurrence. (20.37%) and was worse or same in 16 patients (14.8%). Thoracic duct cyst are rare and usually present with dysphagia Conclusion: Pulmonary resection for bronchiectasis can be done and diagnosis was post operative. They usually present in the throax. with low morbidity and almost nil mortality. Its more effective in In this case the similar presentation but rare to extent into abdomen, patients with localized diseased and when possible complete resection and looks like entire thoracic duct is involved in the cyst formation as should be performed. it extended from L2 vertebra to the aortic arch which is a normal course of thoracic duct. To our knowledge this presentation is not reported. Results: Mitral valve and tricuspid valve repair wad done in 3 patients. One patient could not be weaned off bypass, 2 died in Use of bioabsorbable PGA sheets (NEOVEIL) for suture reinforcement in pulmonary surgery postoperative period one died in follow up. In 19 patients follow up 242 Rajan Santosham, VR Santhosh, Ravi Subramanium, of 3 months to 16 years has been uneventful with no recurrence. Rajeev Santosham, RK Sasankh Conclusion: Thorough evaluation of patients is needed in 2nd Santosham Chest Hospital/Apollo Hospitals, Chennai through 3rd decade of life if they present with features of changed postural dyspnea, TIA, and thromboembolic episodes. We Background: The main problem in pulmonary surgery is air-leak recommend, normothermic perfusion and surgery on priority in all (Bronchial closure, Pulmonary resections, Bullae plications, and episodes. We recommend, normothermic perfusion and surgery on Broncho-pleural fistula.) To reduce the air-leak we have used priority in all such patients. Bioabsorbable PGA sheets.

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Materials and Methods: Bioabsorbable PGA non-woven fabric bronchial arteriogram was normal. Patients who had documented TB sheets (neoveil) was used in 25 cases in pulmonary surgey. 16 of them were placed on Anti-tubercular treatment. were used for closure of broncho-pleural fistula-both in empyema (9 Result: In the surgical group we had 7.68% (2/26) mortality. One cases) and in post resection bronchial stump (7 cases). 9 of them were patient died immediate postoperatively because of persistent used to reinforce bullae plication. desaturation, another patient died on the 8th postoperative day due Neovil is made from polyglycolic acid and has the following to sudden cardiac arrest. In the BAE group one patient died of rebleed characteristics: as result of anticoagulation started to treat his MI. * soft non-woven fabric with elasticity Conclusion: We achieved near 100% control of the acute episode * absorbed for about 15 weeks. of bleeding with BAE, except in one patient. Surgical resection was * good compatility. not undertaken in any of these patients at the initial stage. None of * coloured with green dyestuff. the patients developed thrombolic complications related to the gel * sterilized with EOG. foam particles. Patients who exhibited parenchymal disease Results: Our initial results have been very encouraging. underwent surgical resection either as lobectomy or pneumonectomy. Conclusion: Bioabsorbable PGA sheets (NEOVEIL) is very useful With the development of Bronchial artery embolisation procedure, in suture reinforcement in pulmonary surgery. the necessity of surgical intervention for control of the bleeding has been markedly reduced.

Elephant Gore injury chest – Case report B Jayaraman, Ganesan, Ganesh Babu 243 Bronchogenic carcinoma below 40 years of age Coimbatore Medical College Hospital, Coimbatore AG Ahangar, AM Dar, GN Lone MA Bhat 245 Penetrating injury of the chest is more common with domestic Deptt. of CVTS, SK Institute of Medical Sciences, Srinagar animals but the penetrating injury of chest with the jumbo's tusk in Aims: Bronchogenic carcinoma is generally considered a disease an old man and the surgical correction is a rare incident which is being of 4th through 7th decade. The aim of the study was to know the presented here. occurrence of this dreaded disease below the age of 40 years, to devise 70 years old man, who is a cowherd by occupation grazing his ways and means to detect such problems at the earliest so that they animals in the forest area adjoining his village was attacked by the can be managed in better way. tusker and was thrown up and away for about 10 feet with the tusk Methods: 27 patients below 40 years are presented, 20 patients entering left chest. After first aid in the local small hospital, he was were heavy smokers. Symptoms were cough, infective pathology, transferred to our teaching hospital where he underwent emergency chest pain, dyspnoea, haemoptysis, in addition to bone pain, pleural chest surgery for the gaping hole of 4" × 3" gap in the left chest wall effusion, hoarseness, superior vena cava obstruction were the clinical torn lung. He was operated with lung suturing and the chest wall and radiological findings. Bony metastasis and pathological fractures correction. We adequate blood transfusion and intensive care attention were the presenting features in two patients. Pre-operative tissue he survived the shocking incident. diagnosis was available in 18 patients. Clinical and radiological evidence of inoperability was evident in 8 patients. Surgical procedures included lobectomy in 12 patients, pneumonectomy in 5 patients and radical pneunonectomy in 2 patients. Two patients died in postoperative period. Squamous cell Management of hemoptysis : Bronchial artery carcinoma was commonest histological variant. Eight patients in embolization vs surgical resection 244 operable group had died within 6 months of diagnosis. A Chandra, A Mohan, V Naik, D Dilip, MH Rao, P Rao, MSR Murthy Results: In the operative group 10 patients were alive at one year, Department CVT Surgery, Emergency Medicine, Radiology, & 8 patients were alive at 2years and 6 patients were alive at 3 years of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, follow-up. The overall survival at 5 years of follow-up was a dismal Tirupati 5.26 percent. Conclusion: The primary education/diagnosis with regard to such Background: Massive life threatening hemoptysis in patients with a disease is mandatory, that is the only way of detecting/managing tuberculosis may occur in absence of fungal infection because of the such patients at an earlier stage and prolonging their life span. erosion into the bronchial artery or more rarely secondary to pulmonary arterial bleeding caused by rupture of Rasmussen's aneurysm in cavitary tuberculosis. The management of massive hemoptysis and the timing of surgical intervention pose difficult Thoracic empyema in children: Is open thoracotomy prolems. still a good treatment option? 246 Methods: We had 83 patients (M:F 68:15; age range 10-68 years) Ramana Rao Dhannapuneni, Christos Alexiou, Anuj Goyal, who presented with hemoptysis, between Nov. 1998 and October 2002. Kostas Kotidis, Richard Firmin, Mark Hickey Of these 38 patients were managed conservatively, of which 11 were Department of Cardiothoracic Surgery, Glenfield Hospital, found to be sputum AFB positive. 26 patients underwent emergency Leicester, UK surgical resection : 20 had lobetomy & 6 had pneumonectomy to control hemoptysis. Of these 7 patients were sputum AFB positive & Background: The management of paediatric empyema remains one patient in addition had HIV. In 4 patients an elective tracheostomy controversial. Our aim was to review the outcome following open was performed following surgery. Remaining 19 patients underwent thoracotomy for empyema in children and to provide a framework of bronchial artery embolisation (BAE). The precedure involved data against which other treatment modalities can be compared. identification of the lobar origin of the bleeding by bronchoscopy, a Methods: Forty-four children (median age 8.3 years) undergoing bronchial arteriography was done to identify the bleeding area & the surgery for thoracic empyema between 1993 and 2002 in our unit were appropriate vessel was embolised with gel foam. In 3 patients the studied.

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Results: All children had fever at presentation. The median time Conclusions: LVRS is an effective palliative treatment for dyspnea from onset of symptoms to admission was 8 days. Six patients had a and poor exercise tolerance in highly selected patients. Although the chest drain inserted before they were referred. The median time from duration of palliation is unknown, our results show that improvements admission to surgical referral was 3 days and from surgical admission in pulmonary function, exercise, quality of life and degree of dyspnea to operation was 1 day. Open thoracotomy and debridement was are preserved over the first year. Only a minority of the patients performed in all, decortication in 26, lobectomy in 1 and a Monaldi screened were eligible for surgery. The 2 deaths in our series emphasize procedure in 1 patient. The median time to drain removal was 3 days the need for even further delineation of selection criteria. and to fever resolution was 1 day. The offending pathogen was identified in 17 cases. There has been no mortality. Six patients developed postoperative complications: Two had persistent lung abscess and underwent lobectomy, two exhibited pyrexia and had Mediastinal tumours- 35 years experience further decortication, one required re-intubation for hypoxia and one RS Dhaliwal, Anil Chandra, Rama Krishna, D Mohan, SS Rama, 248 re-exploration for bleeding.The median ITU and hospital stay was 2 Shayam, Harjinder Singh, RK Suri, JS Gujral hours and 6 days respectively. One patient developed recurrent Department of CVT Surgery, PGIMER, Chandigarh empyema and underwent further decortication 3 months later. One Introduction: A retrospective study was done to analyse clinical patient developed recurrent empyema and underwent further features, location of tumour, histologic types and epidemiologic profile decortication 3 months later. There have been no other late and to formulate a management protocol. complications and/or re-admissions. At latest follow-up all patients Methods: 265 patients of mediastinal tumours were managed over were doing well. a 35 yrs period from Jan 1968 to Oct 2002. The clinical features were- Conclusion: Open thoracotomy with or without decortication myasthenia gravis Pain chest, dyspnoea, cough dysphagia and chance remains the gold standard for the management of paediatric finding on x-ray chest. They were investigated hematologically and empyema: Timely performed, is associated with low morbidity and radiologically by chest x-rays, ultrasound and CT Scan and MRI.. provides rapid resolution of symptoms. If, however, advanced FNAC guided by these radiological techniques was done. Then pulmonary sepsis co-exists a more protracted postoperative clinical patients underwent surgical exploration and resection or debulking coarse is possible. The late outcome is excellent. or biopsy was done depending upon operability of the tumour. Radiotherapy or chemotherapy was considered in inoperable cases. Results: Incidence of mediastinal tumours was highest in 3rd-4th decades. Anterosuperior tumours were predominant (71%). Thymomas were the most common tumours (46%). Myasthenia gravis was present in 50% of patients. Complete surgical resection was Lung volume reduction surgery for the treatment of possible in 65% patients. emphysema 247 Conclusions: FNAC (Fine Needle Aspiration Cytology) is a very Sabyasachi Bal, Sanjeev Chandna, Randeep Guleria, useful and cost effective modality. Based on histology (FNAC) Rakesh Kumar, Lokesh Kashyap unnecessary major thoracotomy can be avoided in malignant tumours From the Departments of Surgery, Medicine, Nuclear Medicine and like lymphomas. Most benign mediastinal tumours can be safely Anaesthesiology, All India Institute of Medical Sciences, New Delhi resected with good prognosis. Malignant lesion carry a poor prognosis. Objective: To evaluate lung volume reduction surgery (LVRS) and its effectiveness in improving pulmonary function, exercise capacity Trespassed bullet and quality of life in a population of emphysema patients referred to B Jayaraman, Ganesan 249 and screened in a single centre. Coimbatore Medical College, Hospital, Coimbatore Methods: Patients with severe emphysema, significant dyspnea and impaired exercise capacity interfering with quality of life. Introduction: Mediastinum is a fibrovascular structure in the chest Unilateral LVRS was performed through a lateral thoracotomy. which separates the two pleural cavities with all the vital structures Pulmonary function tests preoperative forced expiratory volume in in its major vessels and the trachea with its major branchi form the the first second [FEV1], residual volume [RV], 6-minute walk (6MW) main constituents of the mediastium. Any structure crossing this distance, quality of life (Medical Outcomes Study 36-item short-form spetum should injure any of the vital structures. We present few of health survey) end degree of dyspnea (Medical Research Council of the penetrating injuries in which the bullets and rod have crossed the Great Britain dyspnea scale and the baseline and transitional dyspnea mediastinum without injuring any of these vital structures. indices) were assessed before LVRS and at 6 and 12 months after. Case Reports: 14 years old girl sustained accidently the bullet Results: Ninety seven patients were assessed for LVRS, or whom injury from the pistal and the bullet entered the right infraclavicular 28 were selected for surgery. Homogeneous distribution of disease area trespassed the mediastinum and got lodged in the left side of the was the most common reason for exclusion. Of the 28 patients operated mediastinum over the heart. Thouh there was mild haemothroax in upon, 1 died of acute cor pulmonale on the fourth postoperative day the right chest which was treated with ICD the patient having refused and 1 died of recurrent exacerbations of chronic obstructive pulmonary surgery was discharged against medical advise. Subsequently after a disease and chronic respiratory failure at 315 days postoperatively. In month she was seen by the cardiologist with the embedded bullet in the surviving patients, the mean preoperative FEV1 increased from the LV which was not removed since she was not willing. 0.70 L before surgery to 1.10 L at 1 year, with a mean relative decrease 27 years old lady who met with a bus accident was injured by the of 57%. The mean RV decreased from 5.57 L to 3.59 L, with a mean railing rod which went through the chest in the right 2nd intercostals relative decrease of 37.6%. The 6 MW distance increased from 302.7 space and exit in the left interscapular area. Thoracotomy revealed a m to 356.9 m at 1 year, with a mean relative increase of 21.6%. Quality small nip of the left side of the upper third of oesophagus which was of life and degree of dyspnea were improved significantly at 1 year appropriately treated and the patient survived. after LVRS. Of the 5 patients on intermittent oxygen at home before Conclusion: These amazing trespassing injuries of the surgery, 4 were able to reduce their requirements but not to discontinue mediastinum have miraculous surviving patients with escape of vital oxygen. structures of mediastinum.

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Sternal tumours-Reconstructive methods in anterosuperior mediastinum and 43% had in posterior B Jayaraman, Ganesan, R Vijayakumar 250 mediastinum. 45 (36%) underwent right thoractomy, 48 (38%) Coimbatore Medical College Hospital, Coimbatore underwent left thoracotomy and 32 (26%) underwent midline sternotomy. Introduction: Sternal tumour form the rare group of tumours of Results: Commonest tumour was Thymoma (28%) followed by chest wall. Malignant tumours of the sternam after excision pose Neurogenic (25%), Germ cell (15%) and others (31%). Only 40% of problems in reconstruction of the chest wall which have to be stable. patients had some kind of symptoms at the time of presentation, We present cases which belong to malignant as well as benign group commonest being chest pain (50%), Myasthenia Gravis (35%) and which needed reconstruction after excision. Dyspnoea (8.8%). Case Reports: 43 old man with manubrial growth of 13 months Post operative histopathology revealed 28 cases of benign duration presented with pain and dyspnoea. Tumour extending to thymoma, 5 cases of malignant thymoma, 28 cases of neurogenic jugular notch and confined to manubrium alone was excised in to tumour. 13 cases of dermoid cyst, 9 cases of cystic hygroma, 6 cases of after HPE confirmation of Biopsy as chondrosarcoma. Rib excised was bronchial cyst 1 case of esophageal leiomyoma and case esophageal split and used to cover the defect with pectoralis major muscle cyst. coverage in front. Pt recovered with no ventrilator support. There were 2 mortality in this series. Both were cases of malignant 18 years old boy presented with soft presternal swelling to general thymoma. 1 died on 6th post op day and the other after 6 months. surgeon who referred to us as lipoma of chest and it was subsequently Conclusion: Mediastinal tumours are not as rare as it was thought proved to be TB sternum with cold abscess with CT scan showing to be. Majority are asymptomatic commonest tumour is thymic mass destroyed sternum in middle piece of the body. Same was excised and aggressive surgical approach gives gratifying results. after complete clearance of pus and debris with rib graft and pect muscle coverage. 2 other cases presented as lipoma chest wall proved to TB and pyogenic abscess and appropriately treated. An intersting case of cardiac tamponade Senthil Kumar Subbian, Jayaraman, RK Sasankh, Naidu, 253 Rajan Santosham Santosham Chest Hospital, Chennai Mesothelioma pericardium B Jayaraman, Ganesan 251 Background: The occurrence of dermod cysts in the mediastinum Coimbatore Medical College Hospital, Coimbatore is not particularly rare. But its rupture in to the pericardium causing cardiac tamponade is definitely rare. Introduction: Among the Malig tumours of the chest Case Report: A 58 year old female was referred to the emergency mesothelioma a pleural cavity is unusual. Still rarer is mesothelioma service as a case of cardiac tamponade with class IV symptoms. 2D arising from the mesothelium covering the heart. Normal pericardium, echo showed pericardial effusion and a pericardiocentesis was done. pleura are embriologically related since they form the common Thick viscous foul smelling material was aspirated. C.T. Scan chest pleuroperitorneal canal lining earlier. showed an anterior mediastinal mass with mixed echogenicity and Case Report: 43 years lady residing for 20 years in Podhanur, cbe foci of calcification extending into the pericardium. A provisional (which has asbestos sheet manufacturing industry) presented to the diagnosis of a teratoma bursting into the pericardium was made and hospital with effort intolerance, chest pain and pedal oedema. Routine was taken up for surgery. On induction, the patient developed check up showed features of constrictive pericarditis and was referred hypotension and bradycardia. Emergency left anterolateral for surgical correction. She was operated and found on table no definite thoracotomy done and the pericardium was decompressed. Frozen plane of cleavage between the pericardium and myocardium. section biopsy revealed that tumour was a mature teratoma. Attempted further dissection showed infiltration into myocardial Pericardiectomy and total excision of the tumour was done. layers to variable depths. Results: The patient was discharged with an uneventful HPE of the specimen showed to be mesothelioma of pericardium. postoperative period. Pt is being treated with chemotherapy now. Pt with clinical and Conclusion: C.T. Scanning helps in suspecting the condition and operative features suggestive of constrictive pericarditis but absence prompt surgical intervention is curative. of definite plane of cleavage and the myocardial infiltrates should suggest the possibility of mesothelioms pericardium.

Video assisted thoracoscopic thymectomy: Initial experience 254 Mediastinal tumours: Army hospital (R&R) Nikhil Singh, Gaurav Agarwal, Amit Agarwal, Robbie George, experience 252 AK Verma, SK Mishra D Ganguly, V Ravishankar, G Ganguly, SS Sidhu Deptt. of Endocrine Surgery, Sanjay Gandhi PGIMS, Lucknow Dept of Cardiothoracic Surgery, Army Hospital (Research & Referral), Delhi Introduction: Video assisted thoracoscopic surgical (VATs) thymectomy is gradually gaining acceptance as an alternative to the Background: Mediastinal Tumours are often a diagnostic dilemma. standard trans sternal approach for thymectomy for myasthenia No age or sex escapes. Many are detected on routine chest X-ray for a gravis. medical examination or work up for an unrelated surgical procedure. Methods: Case records and follow up data of seven patients who The commonest mediastinal tumours are Tymoma (30%) and underwent VATs thymectomy for systemic myasthenia were reviewed. Neurogenic (25%). Patients with hyperplastic thymus or benign thymomas were Methods: In Army Hospital (R&R) 125 cases of different types of considered for VATs. Male to female ratio was 3:4 and the mean age mediastinal tumours underwent surgery in last 10 years. 80% were was 28.42 yrs. A right-sided approach was used in all patients. A male. Age group ranged from 6 to 72 years. Commonest distribution similar evaluation of seven age, sex and thymic pahology matched (68.8%) was in the age group of 21 to 40 years. 36% of cases had tumour transsternal thymectomy patients was done.

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Results: Complete thymectomy could be achieved in all seven Results: There was an early mortality (deaths occurring within 30 patients, this was confirmed by examination of the thymic bed and days of operation) in 8 cases (9.52%). Early mortality was related to the resected specimen. There were no intra operative complications. preoperative disability of the patients. The first three patients required ventilatory support, the rest were Post-operatively, NYHA classification of patients at six months extubated in the theatre. There was one post op complication in the after operation showed improvement in functional class with 48 form of pulmonary edema. Mean length of hospital stay was six days. patients in either class I or II and 4 patients in class III. For evaluation of the effect of VATs thymectomy on disease progression, the three patients with follow up of more than one year were considered. One each patient had complete remission, partial remission (needing < 25% of pre op dose of anti-cholinesterase) and Dysphagia lusoria: New surgical approach no benefit. In comparison, the hospital stay, need for analgesia, Jitesh Tolia, Habib Tarief morbidity and treatment costs were higher in trans sternal group, 257 Mohammad bin Khalifa bin Salman al Khalifa Cardiac while the remission rates were similar. Centre, BDF Hospital Bahrain Conclusions: VATs apparoach has the advantage of better cosmesis, shortening hospital stay, lesser analgesic requirements, no Introduction: Dysphagia is an uncommon condition for the complications of sternotomy and similar outcomes as open trans- physician. sternal thymectomy. Case Report: We are presenting one 42 years old lady who presented with progressive dysphagia for the solid and liquids which was for nearly 6 years. She was a known case of hypertension and also has history of Hubble-Bubble smoking. A Thoracic duct injury with abdominal trauma She was investigated. Ba-meal, oesophagoscopy, and selective right Sanjeev Devgarha, Vikas Ahlawat, Ramgopal Yadav, 255 subclavian angiography was carried out which confirmed the Vinay Naithani, Anil Sharma, CP Srivastava Department of CTVS, SMS Medical College, Jaipur diagnosis of dysphagia lusoria. The surgical approach to tackle this problem is controversial. Introduction: Thoracic duct injuries and thoracic duct fistula are We performed left lateral thoracotomy for the division of the fatal if left alone. Thoracic duct injuries are usually seen after thoracic ligamentum arteriosum and translocation of the right subclavian surgeries. Case presented here has been consequence of traumatic artery. abdominal injury - a unique presentation. This surgical technique offers simple and satisfactory result. Case: A 38 years old male had history of stab injury with sharp weapon (entry wound - Rt. hypochondrium, Exit wound - Lt side of midline below coastal margin) CXR (PA view) showed Rt. sided hazyness. ICDT was put in 5th ICS and about 700 ml of chylous fluid was drained. Posterolateral thoracotomy was then done about 2.5 liter Cervical oesophagoplasty with buckamjiam flap chyle drained. Lung was encased in thick pleura for which A Chakravarti, S Gupta, N Maity, A Mandal, S Dey, I Guha, 258 decortication was done. Thoracic duct couldn't be identified. It was A Dey, R Vashisth, S Chakraborty then identified by instilling milk through RT. Over and over suturing Dept. of Th & CV Surgery, Medical College, 88 College Street, was done with prolene 3-0, ICDT put in and closure done in layers. Kolkata Results: Chyle stopped coming. Patient had symptomatic Introduction: Short segment stricture of cervical oesophagus is a improvement. There was wound dehiscence due to infection in post- distinct clinical entity challenging the surgeons. We had 9 patients op period for which resuturing was done and patient recovered. M:F = 2:7, 7 acid stricture and 2 anastomotic stricture. A Buckamjiam Conclusion: A case of traumatic thoracic duct injury is presented. fasciocutaneous flap was used in all these patients with good results. Patient had post traumatic thoracic duct injury without injuring aorta Material and Method: A left sided deltopectoral Buckamjiam and other structures which is unusual. Patient was managed fasciocutaneous flap was raised, rotated upon itself and attached to successfully and doing well at 4 months follow-up. slit-up strictured segment. Raw area was covered with partial thickness skin graft. After 3 weeks the flap was detached from the base and patient allowed oral feeds one week later. Result: All patients became asymptomatic and contrast studies showed wide passage. Pericardiectomy for chronic constrictive pericarditis Inference: In our experience Buckamjiam flap has proved itself to Ragin Patel, KN Bhosale, SA Potwar 256 be a good treatment option for patients with short segment stricture Department of Cardio-Vascular and Thoracic Surgery, of cervical oesophagus. JJ Group of Hospitals and Grant Medical College, Mumbai Methods: Eighty four patients were operated for constrictive pericarditis from 1-1-1992 through October 2002 at J.J. Group of Hospitals, Mumbai. 502 Cases of foreign body oesophagus – A mixed All the patients had hemodynamically significant pericardial bag of surprises 259 A Dey, T Saha, KS Das, NC Garai, A Mandal, S Dey, constriction preoperatively and pericardial disease was confirmed at A Chakravarti, I Guha, R Vashisth, S Chakraborty operation. Dept. of Th & CV Surgery, Medical College, 88 College Street, Kolkata Preoperatively the patients were either in NYHA class III (61 cases) or class IV (13 cases). Almost all the patients had enlarged liver, Introduction: In our set up it will be fair to say that our day's job majority with ascites and/or peripheral edema. seems half done if we don't get to remove a foreign body. The Pericardiectomy was performed through a left anterior commonest foreign body – there are two claimants for this position – thoracotomy (69 cases) or median sternotomy (15 cases). the denture and coins. Besides this others also come our way and

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never ceases to amaze us by their varied nature. The purpose of this Patients and Methods: During the previous 6 years, 9 patients study is to make ourselves as well as our colleagues aware of the (22-55 years) presented with tubercular pseudoaneurysm to us. Site dangers of impacted foreign bodies in the oesophagus. of involvement included ascending aorta (n=1), distal aortic arch (n=1), Material and Method: proximal descending thoracic aorta (n=1), distal descending thoracic Age Group Type of Foreign Body Method of Extraction aorta (n=1), Suprarenal abdominal aorta (n=2) and infrarenal abdominal aorta (n=3). Six patients had macroscopic focus of 1 – 10 years Coins (n=264) Foley's Catheter = 232 tuberculosis in the nearby vicinity, whereas all 9 patients had evidence Rigid 'scope = 032 of active/treated pulmonary pericardial tuberculosis. All these 30 – 70 years Dentures (n=182) Rigid 'scope = 178 patients had either received antitubercular therapy previously or were Thoracotomy = 004 receiving it at the time of presentation. Rapid deterioration in the 1 – 70 years Others (n=56) Rigid 'scope = 054 clinical status was the most marked clinical feature. All patients were Thoracotomy = 002 operated on. Graft interposition was performed in 5, patch repair in 3 and direct closure of the rent was performed in one patient. All Results: Out of 502, one patient died due to severe mediastinitis survivors received antitubercular therapy in postoperative period. who came with oesohageal perforation from an impacted denture. Results: All, but one survived the operation and were discharged Conclusion: Foreign body oesophagus can have fatal from the hospital. One patient who had preoperative cardio complications when impacted. It is our earnest request to all to spread respiratory arrest due to tubercular toxemia died soon after surgery. this message as far as possible specially to our dentist friends so that One patient developed recurrence at the original site after 8 months they don't venture into treating their patients with dentures with one and expired at reoperation. Remaining patients are symptom free at or two teeth. 8 to 72 months, postoperatively. Conclusion: A combination of chemotherapy and surgery yields gratifying results for the treatment of tubercular pseudoaneurysm. "Burdwan technique" of dilating oesopahageal stricture 260 S Dey, A Mandal, T Saha, KS Das, NC Garai, A Chakravarti, I Guha, A Dey, R Vashistha, S Chakraborty Dept. of Th & CV Surgery, Medical College, 88 College Street, Ascending aorta aneurysm with fistula into the Kolkata pulmonary artery: A case report 262 Nityanand Thakur, Naresh Kumar, Suresh Kumar, Mohan Gan, Introduction: This technique was introduced in Burdwan – a rural Mahadev Dixit Medical College – out of necessity and used in our center for dilating KLES Heart Foundation, KLES Hospital & MRC, Belgaum mainly tortuous and/or long segment stricture oesophagus. Thus 50 years old male presented with chest pain/cough and palpitation helping to make recurrent dilatations of oesophagus safer. for three months. Material and Method: In the years between September 1998 and On examination the patient was normotensive with pan systolic September 2002 about 28 cases of acid stricture were treated with this murmur at Left sternal border. technique. He was investigated for the same. A feeding gastrostomy is done and small dilator anchored with a EKG had Left axis deviation. Chest X-ray showed CTR 60% with silk is passed retrogradely through the gastrostomy end into the prominent ascending aorta and pulmonary artery. With plethoric lung mouth. The dilator is pulled out from the mouth by the fields. 2D Echo showed ascending aortic aneurysm 5.6 cm in diameter anaesthesiologist. Proximal end of the special 'dilator' (India rubber with grade I aortic requrgitation. There was continuous flow from tubes of increasing dimension attached consecutively upto size 36F) aneurysm into the pulmonary artery suggestive of fistula which was is attached to the gastric end of the silk. Anaesthesiologist pulls the confirmed on aortogram. The patient was taken for aneurysm repair string orally, while surgeon guides the 'dilator' through the cardia. and closure of fistula. The aneurysm was repaired by using Finally, the stomach incision is closed leaving tube gastrostomy (32F) interposition graft and fistula was closed by Dacron patch. Post- in place. One end of the silk is tied over the tube, which is taken out operative recover was uneventful. through a separate stab incision the skin. The cephalic end of the silk The case has been presented here for the rarity of existence of is passed through the nares and attached to an ear. fistulous communication between Ascending Aortic aneurysm and Result: Dysphagia is relieved in all patients. pulmonary artery. Inference: It is a safe method to dilate even a tortuous strictured oesophagus. The dilatations being done retrogradely, there is minimum chance of perforations.

Modified circuit for retrograde cerebral perfusion Milind Hote, Anil Bhan, U Kiran, R Gupta, P Venugopal 263 All India Institute of Medical Sciences, New Delhi Tubercular pseudoaneurysms of aorta A Smartin, SK Choudhary, A Bhan, B Airan, P Venugopal 261 Background: Since March 2000, for patients undergoing ascending All India Institute of Medical Sciences, New Delhi aortic or arch surgery under total circulatory arrest, we have employed a modified circuit for delivery of retrograde cerebral perfusion (RCP). Background: Tubercular pseudoaneurysm of aorta is a rare but Methods: Preoperative diagnoses have included type A aortic important complication of tuberculosis. With worldwide resurgence dissection & ascending aortic aneurysm ± arch involvement. a small of tuberculosis due to increasing incidence of drug-resistant plastic connector (3/8th inch) with a luer-lock side port was used tuberculosis and its association with acquired immuno deficiency and cardioplegia delivery line was connected to it for delivery of syndrome, the tubercular pseudoaneurysm has become a real clinical retrograde cerebral perfusion. Circulatory arrest time ranged from entity. 22-61 minutes.

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Results: All patients have survived the operation with no packs (head), thiopentone and avoidance of any glucose containing neurological deficit. Advantages of the modified circuit include easy solutions. and rapid assembly, better control on cooling of perfusate temperature Results: There were five hospital deaths. One patient had wheet and more complete deairing of the arch. procedure; died due to continuous postoperative bleeding with DIC. Conclusion: We believed that the modified circuit is a simple, safe, Second one was of ascending aorta and arch repair, developed effective and probably superior method to deliver RCP. extensive SDH and succumbed to it. In thorocoabdominal group there was one hospital death while distal arch group had 2 deaths. Conclusion: Deep Hypothermic Circulatory Arrest continues to be the main modality of cerebral protection. The major limitation of DHCA is the time constraint (i.e. 45 minutes), imposed beyond which Aortic root replacement with a composite graft – DHCA in isolation may not be safe Retrograde Cerebral Perfusion Angiographic flow-up 264 (RCP) may provide additional protection for brain viability. A Vikram, Anil Bhan, Sanjeev Sharma, Pravin Saxena, Considering the simplicity and safety involved more liberal use of AK Bisoi, SK Choudhary, UK Chowdhury, A Sampath Kumar, RCP as an adjunct to DHCA, irrespective of the duration of DHCA, Balram Airan, Panangipalli Venugopal in complex aortic lesions reconstruction is advocated. All India Institute of Medical Sciences, New Delhi Background: Bentall's procedure is the standard surgical management option for the aneurysmal diseases involving ascending aorta and the aortic valve. The progressive nature of the aortic disease Antegrade axillary artery perfusion for cerebral and the development of early and late procedure related complications protection in surgery of aortic arch and proximal 266 warrant a dedicated clinical and investigative follow-up. descending thoracic aorta Material and Methods: 125 patients underwent composite graft Avery Mathew, Gulam Ali, PV Rao, Pravin Kumar, Sanjay Banakal, replacement of the aortic root between January 1992 and August 2002. Devi Prasad Shetty Annuloaortic ectasia (AAE) was the most common lesion seen in 80 Narayana Hrudayalaya Institute of Medical Sciences, Bangalore patients (64%) and aortic dissection in 45 patients. Inclusion technique was applied in 72 patients. From June 2000, open coronary button Background: There are several techniques of cerebral protection technique with no wrap was employed and total of 53 patients were available for brain protection during surgery of the aortic arch or operated by this method 25 patients (20%) underwent repeat proximal descending thoracic aorta. Ascending aortic cannulation may angiographic study during follow-up visits. not be possible in all these patients. Selective right axillary artery Results: There were 9 (7.2%) early deaths and 8 (6%) late deaths. cannulation with low flow cerebral perfusion and hypothermia is an On angiographic study one patient operated by inclusion technique alternative method in this regard. We have used antegrade cerebral was detected to have pseudoaneurysm at the distal suture line and perfusion through axillary artery cannulation for some patients. another patient with inclusion technique had perigraft haematoma. Methods: Of 9 thoracic aortic aneurysms operated at our instituion In 6 patients there was evidence of disease progression in the between May 2001 and September 2002, four patients had antegrade remaining aorta. cerebral perfusion through a 7 mm. Polytetra-fluoro ethylene (PTFE, Conclusion: Use of simplified surgical technique and meticulous Gore-Tax) graft which was anastomosed to the right axillary artery. attention to control of bleeding, can achieve excellent early and late The venous return was either through the right femoral vein or results after Bentall procefure. Angiographic follow-up has futher through the pulmonary artery. All the four patients had to be re- substantiated this face. positioned for a left thoracotomy after the initial heparinisation and right axillary artery cannulation. The male: female ratio was 1:3 and mean patient age was 44 years. Results: All 4 patients had replacement of the proximal descending Retrograde cerebral perfusion as an adjunct to deep thoracic aorta. The mean antegrade low cerebral perfusion time hypothermic circulatory arrest in management of 265 (8-12 ml/kg/min) was 47 minutes. All these four patients had an aortic aneurysms uneventful recovery and were extubated in 12 to 24 hours. There were Pankaj K Mishra, Anil Bhan, B Airan, AK Bisoi, SK Choudhary, no neurological deficits. One patient had prolonged hospital stay due U Kiran, R Gupta, P VenugopalAll India Institute of Medical Sciences, to thoracotomy wound infection. One year follow up on these patients All India Institute of Medical Sciences, New Delhi reveal them in good health. Conclusion: The technique of low flow antegrade cerebral Introduction: Retrograde cerebral perfusion (RCP) is an adjunct perfusion through the right axillary artery is a useful alternate to (DHCA) while dealing with complex aortic lesions. Its aim is technique for surgery of the aortic arch or descending aorta. We discuss primarily to provide metabolic support, maintain cerebral our method in detail for this select group of patients. hypothermia and/or washout particulate emboli. Material & Methods: 66 patients of aneurysms of aorta who were operated from June 1997 to Dec. 2001 using DHCA were studied. In 52 patients RCP was used as an adjunct to DHCA for cerebral protection. After Dec. 1998 any patient undergoing Deep Hypothermic Surgical management of aortic aneurysms: Experience with 71 cases Circulatory Arrest (DHCA) was given Retrograde Cerebral Perfusion 267 SK Das, T Sanjay, K Srinivas Babu, C Subramanian, irrespective of the duration of DHCA. There were 52 males and 12 Aju Jacob, VV Bashi female patients. Age range was 17-62 years. Mean age was 46.7 years. Centre for Thoracic and Cardiovascular Care, MIOT Hospitals, 40 patients were subjected to surgical correction of ascending aorta Chennai lesions, 10 patients were operated for ascending aorta + arch lesions, 8 patients were cases of distal arch aneurysm, remaining 8 patients Patients and Methods: Between June 1996 and April 2002, 71 were operated for thoracoabominal aneurysms. Apart from RCP other patients underwent surgery for aortic aneurysms. Their ages ranged adjuncts to brain protection used were IV methylprednisolone, ice from 11 to 73 years, with a mean of 61.3 years. The male to female

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ratio was 7.9:1. There were 37 dissecting aneurysms, 25 were in Laparotomy revealed the left adrenal tumour with 1 cm size left Stanford A and 12 in Stanford B. Thirty-four had chronic aneurysms adrenal vein infiltration and the left renal vein involvement near IVC with variable etiology. Thirty-eight had elective surgery, 31 had urgent and entire IVC infiltration to the entire extent above. After the excision surgery and two patients had emergency surgery. In patients with of the adrenal tumour and establishing TCA with core cooling to the ascending aortic aneurysms, 15 (21%) had a Bentall procedure, 6 extent of 18 Degree C RA was opened and the entire tumour was patients had a replacement of the ascending aorta with valve cored out of the IVC and the abdominal part of IVC was also opened resuspension, Five patients had a combined aortic aneurysm repair down to its bifurcations and the entire tumour tissue was removed, with coronary artery bypass grafting. Seven patients had aneurysms Circulation was reestablished and the child weaned off the bypass involving the aortic arch, 4 patients had arch repair with the and made an uneventful recovery in the post op period. Kouchoukos technique and three had an elephant trunk procedure. Thirteen (18.3%) patients had a descending aneurysm repair, interposition graft repair was done in 12 and an aneurysmorraphy was done in one. Thoracoabdominal and abdominal aneurysm repair Cardio vascular trauma: Repair experience of was done in 28 (39.4%), repair with synthetic grafts with 107 cases 270 reimplantation of major vessels when they were involved. Raj Kumar Yadav, KK Kushwaha, RM Mathur Results: Mortality was 5/71 (7%). One patient had acute renal Department of CT Surgery, SMS Medical College Hospital, Jaipur failure. All surviving patients are on regular follow up ranging from (Rajasthan) 6 months to 5 years, one patient died of anticoagulant related bleeding Methods: Ours is the only centre in Rajasthan and adjoining areas one year after surgery, another patient developed prosthetic valve where Cardio Vascular Trauma is treated. From 1998 to 2002, 107 endocarditis which was managed medically. One patient has traumas were repaired in one of the two units in the Department. developed an aneurysm of the descending thoracic aorta three years Age range from 5-70 years with 68% of patients in 3rd & 4th decade after a Bentall's procedure and has refused surgery. of life. 95% were males. 58 patients had lower limb, 41 had upper limb, 3 had neck, 3 had shoulder and one each had cardiac & abdominal trauma. Popliteal artery was injured in 30 patients followed by brachial in 21 and femoral in 19. One patient had peneterating Massive venous thrombosis with floating IVC injury left ventricle. 3 patients had carotid artery injury, one had iliac thrombus surgical management 268 artery injury. N Vijaya Kumar, Naveen, KC Sekhar, SK Mastan, Afroz Farooqi Road traffic accidents were the cause in 77 patients followed by Vishakapatnam missile injury in seven, stab wound in six, camel bite was the cause in three patients. Pathologically complete transaction in seventy, A 56 years old male patient has been suffering from deep venous contusion in 20, partial tear in 5, multiple punctures in 3, accompaning thrombosis for three years. Improper anticoagulant treatment led to vein found to be injured in 35 patients. massive edema of both lower limbs. Color Doppler study has revealed Results: End to end anastomosis was feasible in 90 patients, venous thrombosis of both lower limb veins, iliac veins distal IVC saphanous vein inter position in 10 patients. All the repairs were done and a floating thrombus in the proximal IVC. The site and nature of after fixation of fracture or dislocation of bone. Significant warm venous thrombosis is not suitable for IVC filter or thrombolytic ischemia time & Nerve inj. were the main cause responsible for therapy. As the patient is at at high risk of developing massive complications (12%), limb loss, mortality (7%) and late functional pulmonary embolism, he was taken up for emergency surgery. disability (45%). Initially median sternotomy was done, heparinised and patient was put on right heart bypass to prevent any emboli entering pulmonary vasculature while manipulating IVC. Midline laparotomy was done and IVC isolated. On opening IVC, a 5x3 cm thrombus which is floating and pedunculated was evacuated. Peripheral venous A case of aortic transection following blunt injury thrombectomy was done for iliac and femoral veins. Post operatively RK Sasankh, CS Vijayashankar, John EV 271 patient recovered well. He was put on anticoagulants. Edema and Apollo Hospitals, Chennai symptoms subsided considerably by the first follow-up after three Background: Blunt injuries of the chest consequent to Road traffic weeks. accidents or fall from a height can result in serious decelerating injuries within the chest. Aortic transection is one of the well-recognized injuries. Case report: A 25 year old male fell from the 3rd floor of a building. Total circulatory arrest for non-cardiac cause: On clinical examination his vital parameters were within normal Case report 269 limits. There was a lacerated would on the scalp. Abrasions were B Jayaraman, Krishnan, Sudharshan present in the left side of the abdomen and over his hands and feet. St. Mary's Hospital, Coimbatore There were no obvious injuries. Spiral CT with contrast of the chest and abdomen revealed transection of the aorta at the left subclavian Introduction: Total circulatory arrest is being commonly employed level, which was contained. He also had transection of the tail of the to do open heart surgery in complex cardiac cases for better access pancreas. Patient was urgently taken up for surgery. A Hemashield and better surgical work. Here is a case where this technique was woven double velour vascular graft was used to repair the transection employed for non cardiac surgery. undr CPB. The abdomen was opened and a partial pancreatectomy Case report: 4 years old girl seen earlier for enlarged clitorius was with splenectomy was done being treated as adrenocortical syndrome with steroids since age of 6 Results: Patient was discharged after an uneventful post operative months. Repeated US Scan though initially missed the adrenal tumour, period. it was spotted by the CT Scan of the abdomen when it has become 4" Conclusion: Contrast spiral CT scans are very useful in picking dia with involvement of its vein, left renal vein and the entire IVC up these injuries and no further investigations are necessary. infiltration upto the IVC-RA junction with 1" of projection into RA. Immediate corrective surgery has good results.

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Infradiaphragmatic aortic obstruction in 2 cases – Surgery for ascending aortic aneurysms Retroperitoneal approach for bypass grafting 272 James Thomas, VK Gupta, Hemant Pandey, Shirish Parganonkar, 274 Rajarshi Basu, Goutam Sengupta, Subhankar Bhattacharya S Kalra, Ram Mohan, BK Mohanty, LC Gupta, S Padmavati IPGME & R, Kolkata National Heart Institute, East of Kailash, Delhi Background: Operative correction of Infradiaphragmatic aortic Objective: To evaluate the different techniques used in surgical obstruction is discussed. treatment of ascending aortic aneurysms. Case summary: Two cases are discussed in this aspect. First case Methods: Thirty eight patients were operated for aortic aneurysms is a 26 years old lady with intermittent claudication of both limbs and by a single surgeon in eighteen years in different hospitals. This absence of both lower limb pulses. On Doppler study she had included 14 patients with ascending aortic aneurysms, 4 aortic arch, turbulent flow with narrowing of lumen of abdominal aorta. Second 6 descending and rest abdominal aortic aneurysms. case is a 55 years old man presenting with similar clinical picture due In the earlier years, two patients with ascending aortic aneurysm to atherosclerotic blockage. In both cases aortogram revealed long had aortic valve replacement using prosthetic valve with segment obstruction of abdominal aorta. The young female had supracoronnary dacron tube graft replacement. Angiography in these normal distal aorta after its bifurcation. The male patient had two patients after 12 years shows functioning valve and no progress obstruction distal to iliac artery bifurcation. in disease. Six patients had modified Bental with button for coronary Both patients were taken up for bifurcation grafting from high-up implantation. Six had modification of this with insitu coronary aorta (i.e. supradiaphragmatic aorta in thorax) to both common iliac implantation with continuous suture on the aortic wall around the arteries in case of the female patient and to external iliac and femoral coronary without button. Associated procedure included CABG of arteries in case of the male patient. Retroperitoneal dissection provided single grafts in three patients excellent exposure and enough space foe placement of graft Results: Three were reopened for bleeding. One death in OR with confortably. The peri-operative period was uneventful and patients bleeding from torn and calcified right coronary artery in an elderly were found to do well at follow-up. patient. All other patients are alive and well. One patient had Conclusion: Surgical grafting is an effective means of treating dissection of the descending aorta after 12 years which was managed infradiaphragmatic aortic obstruction due to diverse etiologies. conservatively. Retroperitoneal appraoch gives good visualization and early None of the patients followed up had any thromboembolic related postoperative recovery. problems. Conclusions: Surgery for aneurysm of the ascending aorta can be performed with acceptable risk and long term satisfactory results.

Traumatic giant pseudoaneurysm of innominate artery 273 RS Dhaliwal, RamaKrishna, S Behra, D Mohan, S Goyal Deptt. of Cardiovascular & Thoracic Surgery, PGIMER, Chandigarh Introduction: Injuries to the branches of aortic arch are rare and may be caused by blunt, penetrating, blast or iatrogenic trauma. Giant Coarctation aorta with low EF Pawan Kumar, D Kulkarni, C Raghvendra, SK Pranav, traumatic pseudo-aneurysm of innominate artery is very rare. A 275 Uday Jadhav, AG Tendolkar successfully managed case of very large pseudo-aneurysm of the LTMMC & LTMGH, Sion, Mumbai innominate artery presenting with severe respiratory distress long after blunt injury to chest is reported. Background: Waldhausens subclavian flap aortoplasty has Case Report: A 20 years old male had blunt injury to right upper remained a gold standard operation for the relief of coarctation in chest 5 months back. A small swelling developed on medial end of neonates & infants. A preoperative reporting of a low EF is a common right clavicle. It increased in size suddenly for last 15 days along with finding. repiratory distress. On examination there was facial and right upper Material & Methods: No of patients = 06, Male/Female=03/03, limb swelling. A large 10 x 10 cms firm, globular, non pulsatile swelling Age= 2 months-9 months, EF fraction impaired, i.e., below 40% in=03/ present on right medial side of neck - lower border behind sternum. 06, Range of impaired EF=15% to 35% Trachea grossly pushed to left. Arch aortography showed a tear (5-7 All the patients, including those with impaired EF, underwent a mm) in the anterior wall of innominate artery just proximal to Waldhausens subclavian aortoplasty, with no extra precaution being bifurcation, contrast was leaking into a very large pseudo-aneurysm. taken for the later group. Surgery done through a right antero-lateral thoracotomy due to Results: The blood pressure always remained above 100 mm Hg. presence of pseudo aneurysm behind the sternum. A very large No ionotrope support was required at any time. The postoperative swelling was present compressing the SVC and distorting the anatomy. recovery was uneventful. The patients were kept empirically on ACE As distal vessel control was not possible so CP Bypass started by inhibitors for a period of 3 months. Ascending aorta and RA cannulation (single venous cannula). Temp Mortality=0% lowered to 22 C. Flow reduced to 300ml/min and pseduaneurysm Follow up=100% opened. There was large cavity full of partially organized clots which Duration of follow up= 6 months to 1½ years were removed Rent in the anterior wall of innominate artery repaired Conclusion: A significant number of neonates & infants with with four interrupted pledgetted sutures of 4-O prolene. Patent coarctation of the aorta present with a depressed pre-operatively rewarmed and CP Bypass weaned. Patient made an uneventful ejection fraction. This poses no threat to the morbidity & mortality in recovery without any neurological deficit. Oedema of face and upper the patient. Prophylactic ACE inhibitors are recommended for these limb subsided. At follow up after 6 months patient was normal. patients in the postoperative period.

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Spleno renal artery bypass-An alternate for renal Cardiovascular assessment by CVP pressure wave artery block and diseased aorta 276 form analysis 281 Raj Kumar Yadav, Sameer Sharma, Anand, KK Kushwaha, Mastan, KC Ekhar, N Vijay Kumar & A. Farooqi Rakesh Chittora, Rajiv Tiwari, RM Mathur Apollo Hospitals, Waltair Main Road, Visakhapatnam Deptt. of CTVS, SMS Medical College, Jaipur, (Rajasthan) Introduction: A 28 years male of aortoareteritis with bilateral renal artery block (Lt. renal 95%, Rt. renal 100% at origin) with refractory hypertension was managed by constructing an end to side anastomosis of splenic artery to left renal artery. Method: The patient was taken for aorto renal bypass. The aorta Surgical management of acquired ventricular septal defect and left renal artery were exposed through throacoabdominal 282 R Anto Sahayaraj, N Nagarajan, A Sukumar, Rajan Santosham approach. The abdominal aorta was found to be serverly diseased Government General Hospital & Madras Medical College, Chennai and calcified. As conventional bypass grafting was not feasible an alternative splenorenal artery bypass was performed after splenectomy and mobilization of splenic artery and an end to side splenorenal anastomosis was performed and good distal flow observed. Results: Patients blood pressure was maintained with Surgical treatment of atrial fibrillation using nitroglycerine & Sodium Nitroprusside since the hypertension radiofrequency modified maze procedure 283 persisted due to contralateral renal problem but the urine output Purushottam K Deshpande, Ajay Patil, DV Gupta, A Dani, increased considerably & blood biochemistry improved. Patient is SK Deshpande, Lata, Rathi awaiting contralateral nephrectomy. K.G. Deshpande Memorial Centre, Nagpur Conclusion: The splenorenal arterial bypass is good alternative for renovascular hypertension specially when the abdominal aorta is diseased and not suitable for grafting.

The electrocautery maze – How I do it and midterm Surgical Videos results 284 Prasanna Simha M, Shanmukh HC, Ravishankar Shetty, Anil D Prabhu, PSS Bhat, AN Prabhudeva Sri Jayadeva Institute of Cardiology, Bangalore Aortic root replacement by modified Bentall's Procedure 277 G Rama Subrahmanyam, KV Ramana Raju, D Prasada Rao Care Hospitals, The Institute of Medical Sciences, Nampally, Hyderabad KONNO procedure (aortoventriculoplasty + AVR) – In a case of severe annular and subvalvular aortic 285 stenosis, aortic regurgitation and severe LV dysfunction – A case report Endoscopic vein harvesing for CABG – Video Vipul Vaghela, Sajan Koshy, Sunil GS, R Krishna Kumar, Presentation 278 K Shivaprakash, Suresh G Rao D Renuka Rao, Ganeshakrishnan Iyer, Sanjay Kumar, Division of Paediatric Cardiac Surgery and Cardiology Amrita Vijay Dikshit Institute of Medical Sciences, Cochin Dept. of Cardio-Thoracic Surgery, Apollo Hospitals, Jubilee Hills, Hyderabad

Techniques and use of sequential grafting in TAR A case of left main coronary artery disease with Sanjeeth Peter 286 aneurysm of arch and descending thoracic aorta – 279 DDMM Institute of Cardiology and Cardiovascular Surgery, Surgical management Nadiad VV Bashi, SK Das, Srinivas Babu K, Subramanian C, Aju Jacob Centre for Thoracic and Cardiovascular Care – MIOT Hospital, Chennai

VATS thymectomy – Our experience 2 cases of augmentation thyroplasty for subglottic Bhabatosh Biswas, Rajarshi Basu, Rupak Bhattacharjee, Ashis 287 stenosis 280 Patra, Subir Basuthakur, Srikumar Sarkar, Amitava Chakraborty V Senthil Kumar Vivekananda Institute of Medical Sciences & Calcutta Medical Medical College, Jhajarea Research Institute, Kolkata

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Distal aortic arch aneurysm repair facilitated, and pulmonary hypertension was better controlled in Anil Bhan, P Venugopal 288 the post operative period. There were no neurological complications. All India Institute of Medical Sciences, New Delhi Conclusions: Thoracic epidural anesthesia in the pediatric cardiac surgical patient is an extremely valuable adjunct towards a less morbid and more favourable outcome.

Post-aortic valve replacement aortic dissection Anil Bhan, P Venugopal 289 All India Institute of Medical Sciences, New Delhi Tanscatheter embolization of bleeding duodenal ulcer in a post operative CABG patient - Case report 294 Abhijit Paul, Ashok Dhar, A Saha, E Rupert, A Raghuvanshi, K Sarkar Rabindranath Tagore International Institute of Cardiac Sciences, Truncus arteriosus repair Kolkata Anil Bhan, P Venugopal 290 All India Institute of Medical Sciences, New Delhi A 69-year old male patient underwent off pump Coronary Artery bypass grafting. He presented with shock, haematemesis and malena on the 10th postoperative day. Upper GI endoscopy revealed a bleeding duodenal ulcer. He underwent transcatheter embolization of Intravisceral bleeding with gelfoam. Intravisceral bleeding is a life- Arterial switch procedure threatening situation demanding fast and active steps to control it. Anil Bhan, P Venugopal 291 Transcatheter embolization of intravisceral bleeding is a swift, effective All India Institute of Medical Sciences, New Delhi and precise method of treatment without major operational hazards.

Alcapa – Repair using coronary button technique Anaesthesia for therapeutic interventional Anil Bhan, P Venugopal 292 procedures in paediatric acyanotic heart disease 295 All India Institute of Medical Sciences, New Delhi S Keshavamurthy, Sanjay Banakal, Rajnish Garg, Neeti Chandra, K Muralidhar Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Introduction: Children with congenital heart disease depend upon a delicate balance between pathophysiology and compensatory mechanisms. Anaesthesia for children with congenital heart disease undergoing therapeutic cardiac intervention is a distinct challenge. Thoracic epidural anaesthesia in pediatric cardiac Significant numbers of such patients undergo interventions in the surgery 293 hostile environment of the cardiac catheterization laboratory. This VK Sharma, M Luthra, R Kaushik, S Sharma paper analyses the anaesthetic management and problems associated Military Hospital Cardiothoracic Centre, Pune with the conduct of such procedures. Methods: 75 paediatric patients aged 3 months to 17 years and Introduction: Thoracic epidural anaesthesia has been successfully weighing between 3 kg. and 40 kg. underwent the following used in adult cardiac surgery where it provides exemplary post procedures under anaesthesia. Device closure of atrial septal defect operative pain, relief, effectively obtunds the stress response to surgery, (ASD) – 21, device closure of patent ductus arteriosus (PDA) –9, coil and improves myocardial performance. Its use in pediatric cardiac occlusion of PDA –19, balloon aortic valvotomy –8, balloon dilatation surgery is as yet, reported in only a few series. Pediatric patients with ± stenting for coarctation of the aorta – 7 and balloon pulmonary complex congenital heart disease frequently have severe pulmonary valvotomy–11. hypertension which gets aggravated in the post operative period due Following complete pre-operative evaluation, all cases were to repetitive noxious stimuli, acidosis, atelectasis, alveolar collapse premedicated with i.v. Inj. Glycopyrrolate 0.004 mg/kg and i.v. Inj. and pneumonia. The use of epidural anesthesia in this sub group of Midazolam 0.1 – 0.2 mg/kg. and anaesthesia was induced and patients was studied. maintained with Inj. Ketamine 1.5 – 4 mg/kg with supplimentary Methods: Thoracic epidural anaesthesia was used as an adjunct oxygen through a face mask after estimating shunt fraction. in ten patients undergoing closed and open heart procedures. The Haemodynamics and oxygen saturation (SpO2) were monitored and mean age and weight was 5.7 months and 4.4 kg respectively. A 20 G maintained. Average duration of the procedure was 30 to 45 minutes. epidural catheter was placed through the thoracic 2/3 or 3/4 Results: There were no in-hospital deaths. Dobutamine (3 mcg/ intervertebral space preoperatively, or before elective sternal closure kg/min) was required in 2 cases following balloon aortic valvotomy in the post operative period. A bolus dose of 0.25% bupivacaine 0.05 to counter cardiac depression. One case of ASD closure developed ml/kg/segment followed by a continuous infusion of 2µg/ml of pulmonary oedema following an anaphylactic reaction to contrast fentanyl with 0.125% bupivacaine @ 0.2-0.4 ml/kg was used. The injection, and in two other cases ASD closure had to be abandoned

following parameters were assessed: level of pain, PaO2, PaCO2, for technical reasons. In one case of PDA, coil embolisation occurred.

AsDO2,PaO2/FiO2 ratio, mean peak airway pressure, time to The coil was successfully retrived and a larger coil placed. extubation, hemodynamic parameters. Conclusion: Interventional procedures can be safely performed Results: Patients remained hemodynamically stable, had in paediatric patients with proper pre-operative evaluation and improved ventilator parameters and analgesia, earlier extubation was effective monitoring.

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Influence of colloid infusion on coagulation babies with DS presenting for cardiac surgery. during Off pump CABG 296 Methods: In this study, 10 babies with DS diagnosed to have Rajnish Garg, GD Madhusudan, SK Mohanty, Sridhar Murthy, various congenital cardiac diseases were compared with a similar Sanjay Banakal, K Muralidhar group of children without DS. Group A (n=10) was the study group Narayana Hrudayalaya Institute of Medical Sciences, Bangalore which included babies diagnosed with Down’s Syndrome having Introduction: It is a common practice to infuse colloids for congenital cardiac diseases & Group B (n=10) was the control group. maintaining the intra-vascular volume during off-pump CABG. Standard anaesthesia and surgical procedures were utilized. Problems However coloids may adversely affect coagulation and primary faced during the pre, intra and postopertive periods were studed. haemostasis. The aim of the study is to examine the influence of Results: The problems encountered in Group A (DS) were: differnet colloids on coagulation during off-pump CABG. increased secretions, 3 re-intubations/re-positioning of Endotrachial Materials & Methods: 30 patients scheduled for off-pump CABG Tube, and requirement of aggressive physiotherapy. Tachypnoea, were included in this prospective randomized study. These patients hypoxaemia, hypercarbia and high incidence of pulmonary artery were randomly allocated to three groups. Group I received 6% hypertension were seen in the same group. Pre op antibiotic: Gr A - 8; Medium Molecular Weight – Hydroxyethylstarch (200/.5), Group II Gr B - 5. No patients in either group presented difficult intubation. received 6% Low Molecular Weight – Hydroxyethylstarch (130/.4) Average CPB time in Gr A was 90 min & 85 min in Gr B. Average and Group III received 4% Succinylated gelatin during the cross clamp time Gr A was 53 min & 40.4 min in Gr B. Average period perioperative period. After anaesthetic induction colloid was infused of ventilaton in Gr A 67.8 hrs. and 42.8 hrs in Gr B. Average ITU stay in a dose of 7–8 ml/kg to maintain CVP 8–10 mmHg before the in Gr A was 7.8 days & 6.2 days for Gr B. Mortality was 2 patients in administration of heparin. Blood samples were taken before induction, Gr A while there was no mortality in Gr B. after colloid infusion but before heparin, 6 hours post-operatively and Conclusions: Though babies suffering from congenital cardiac 24 hours post-operatively. Hemoglobin, ACT, PT, APTT, Fibrinogen defects with Down’s syndrome present with numerous difficulties Von Willebrand factor, platelet count were measured/assessed at they can be successfully treated with proper care and careful specified intervals. Post-operative drainage and total volume of colloid management of the various complications that may arise during the infused upto 24 hours Post-operatively were monitored. Parameters course of their treatment. were statistically analysed. Results: 30 patitns underwent off-pump CABG. Among the coagulation tests Von Willebrand factor decreased to 67% from baseline in Group I as compared to 85% & 79% in Group II & Group III respectively. Von Willebrand factor levels remained lower than the baseline value in the first 24 hours in Group I whereas the factor levels were higher than the baseline values in other two Groups 6 hours Post operatively. There were no differences in other coagulation tests in between the Groups. Post operative drainage was significantly higher in Group I (856 ml) as compared to Group II (550 ml) and Group Influence of pre-operative heparin on platelets and III (582 ml). bleeding in patients undergoing off-pump CABG 298 GD Madhusudana, Rajnish Garg, Sanjay Banakal, K Muralidhar Conclusions: Based on the results 6% Low Molecular Weight – Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Hydroxyethylstarch (130/.4) is a good choice for maintenance of intravascular volume because of good volume expansion effect & free Introduction: Since it’s discovery in 1920, heparin has become a from impairment of coagulation. valuable component of medical therapeutics. The use of heparin in the dose of 5000 IU, 6th hourly is recommended in patients with unstable angina and in patients who have experienced anterior and anterolateral myocardial ischaemia. However, these patients are at the risk of developing heparin associated thrombocytopenia and subsequent complications. This study is conducted to examine the influence of preoperative heparin therapy in patients undergoing Off- pump CABGs. Methods: In a randomized prospective study comprising 100 patients between 35 to 65 years undergoing elective off-pump CABG, the patients were divided in to two groups of 50 each out of which Anaesthesia for cardiac surgery in patients with down’s syndrome: Our experience at Narayana 297 one group has received heparin 5000 IU 6 hourly preoperatively. Hrudayalaya Patients with coagulation and bleeding disorders were excluded from SK Mohanthy, Sanjay Banakal, Neeti Chandra, K Muralidhar, the study. In all patients, serial platelet count, ACT, PT aPTT and Devi Prasad Shethy Thrombin time were estimated up to 2 days postoperatively and all Narayana Hrudayalaya Institute of Medical Sciences, Bangalore were monitored for bleeding, intraoperatively and postoperatively till the drainage tubes are removed. Re-explorations and their findings Introduction: Trisomy 21 or Down’s Syndrome (DS) is a very were noted in both the groups if any. common genetic malformation with an incidence of 1 in 1000 to 1500 Observations: The average duration of Heparin in the preoperative live births. About 45-50% of these children suffer from cardiac defects. period was 3.87±2 days in those who received Heparin. The serial Atrio Ventricular (AV) canal defects account for approximately 60– estimations of platelet counts revealed decrease in platelet counts in 65% of these disorders. Ventricular Septal Defect, Atrial Septal Defect both the groups during postoperative days 1 and 2 compared to and Patent Ductus Arteriosus comprise another 20–25% of the cardiac preoperative levels. The platelet counts in the group that received malformations seen in DS while the remaining patients suffer from Heparin during preoperative period were not significantly less (p>.05) complex disorders like Tetralogy of Fallot or hypoplastic left heart compared to the group, which did not receive heparin during all the syndrome. This paper highlights the specific anaesthetic issues in days. The amount of bleeding during the intra-operative period and

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post-operative bleeding were comparable in both the groups and there Methods: 20 patients undergoing coronary surgery with or without was no significant difference between them. 3 patients in heparin the use of cardio-pulmonary bypass received HTEA (bolus followed group versus 2 patients in non-heparin group were taken up for re- by continuous infusion). To allow rapid emergence, intravenous exploration because of increased bleeding in the postoperative period propofol anaesthesia supplemented with isoflurane was and all the patients who were re-explored had specific surgical administered. The visual analogue scale was used to assess bleeders. postoperative pain. Intraoperative haemodynamics, postoperative Conclusion: Heparin can be used safely in the preoperative period spirometry and physiotherapy cooperation were assessed. HTEA was in patients with unstable angina for 3-5 days without deletetrious ceased after 72 hours. effects on platelets and bleeding. Results: A reduction in the heart rate (5-15%) and diastolic blood pressure (10-20%) were noted after administration of the bolus dose. Haemodynamics remained stable and none required pharmacological intervention. Majority of patients could be extubated within 1 hour. Pain scores were low both at rest and on coughing. Patients were able to perform spirometry and cooperated well during chest physiotherapy soon after extubation. The requirement of Anaesthetic considerations for video assisted supplemental analgesics was minimal. thoracic surgery using OLV+CAPNO 299 Conclusions: HTEA is safe in conventional and off pump coronary Thorax Technique surgery. Initiation of chest physiotherapy and spirometry is possible Sunil T Pandya, Kaukuntla Venu Gopal, Ambadas Diggikar soon after extubation because of good analgesia. Early extubation and Hyderabad fast tracking is easily achievable with use of HTEA. Background: We present outcome of patients with various underlying pleural/pulmonary/thoracic vertibra/sympathetic chain pathology undergoing diagnostic and therapeutic VATS under general anaesthesia with OLV (One Lung Ventilation) ± artificial intermittent tension capno thorax over a period of 5 years. Aim: To prove that in Indian setting VATS can be undertaken safely Anaesthetic management of redo coronary artery with OLV±capnothorax. To prove that proper pre-operative bypass grafting: Factors influencing outcome evaluation, preparation and judicious use of anaesthesia and 301 Murali Mohan Kari, Sri Ramulu Sompalli, Sathish Kumar monitoring limits post-operative morbidity and improve patient’s Missula, Bala Raju Ravirala, Lokeswara Rao Sajja, Gopichand Mannam outcome. Care Hospital, the Institute of Medical Sciences, Banjara Hills, Summary: We herewith present the outcome of 51 patients who Hyderabad underwent VATS for Various Lung Parenchyma/Pleural/Thoracic Vertebral/sympathetic chain pathology under general anaesthesia Background: Reoperative coronary artery bypass grafting is being with one lung ventilation (OLV)±intermittent±tension capno thorax increasingly performed nowadays. Reoperative procedures are over a period of 5 years. associated with increased risk in terms of morbidity, mortality and All patients had a complete preoperative assessment, received prolonged ICU stay. We analyzed the anaesthetic implications and preoperative chest physiotherapy in appropraite cases and were also perioperative management of these patients operated by us. counseled for open thorocotomy procedures were done under GA Methods: From July 1997 through October 2002 a total of 54 with OLV using a balanced anaesthesia technique with appropriate patients underwent reoperative coronary artery bypass grafting. monitoing. There were no mortality and one patient required open Demographic data: 50 were males and 4 were females. The age was thorocotomy. There was no significant post-operative morbidity. ranging between 50-76 years. The time interval between the primary Conclusions: VATS using OLV±Capno thorax is a safe procedure. CABG and redo procedure ranged between 3-18 years. These patients Proper pre-operative evaluation especially airway assessment, good were premedicated with opoid and benzodianzipines. Radial, femoral patient education and counseling and appropriate anaesthetic artery and pulmonary artery catheters were placed to prior to technique not only reduces post-operative morbidity but also induction of anaesthesia. Low dose dobutamine (1-4 µg/kg/min) was improper patient satisfaction. started and other inotropes and vasodilators are kept ready. Induction and intubation was done with fentanyl, benzodiazipines and non depolarizing muscle relaxants, maintained with opiods and isoflurane 0.5–1%. Fifty two patients were revascularised using intermittent ischaemic fibrillatory arrest technique, two patients underwent OPCAB procedure. None of our patients were on the intra aortic balloon pump (IABP) support prior to operation and did not required High thoracic epidural analgesia in coronary IABP support at the time of induction. Homologous fresh blood surgery – Our initial experience 300 transfusion was given to all patients (average 2.6 units/patient). Manoj Subramania, Sanjeeth Peter, Mahpaekar Mashadi, Aprotinine 10,00,000 Kallikrein in-activator units (KIU) was given to David Thomas 22 patients. DDMM Institute of Cardiology and Cardiovascular Surgery, Results: In hospital mortality was (1.9%). One patient had Nadiad perioperative MI and succumbled to it. Six patients required IABP Background: Epidural anaesthesia is a well established technique support at the time of weaning of bypass and two patients required which apart from providing good perioperative analgesia, attenuates IABP support in ICU. Average chest tube drainage was 700 ml. Average stress response and reduces myocardial ischaemia. A High Thoracic period of mechanical ventilation was 20 hours. Epidural Analgesia (HTEA) is patients undergoing coronary surgery Conclusions: Redo CABG can be safely performed with acceptable would provide perioperative analgesia and permit early extubation. morbidity and mortality with improved techniques of anaesthesia and We describe our initial experience with HTEA in coronary surgery. srugery and perioperative management.

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Anaesthetic management of off pump Design: A prospective study. CABG surgery—Our experience with Isoflurane 302 Setting: A tertiary care medical center. and Halothane Interventions: Fifteen patients underwent beating heart coronary R Bala Raju, Sathish Kumar Missula, Murali Mohan Kari, artery revascularization without endotracheal general anesthesia, Sri Ramulu S, Gopichand Mannam, Lokeswara Rao Sajja, J Vishwanath, between October 2001 to May 2002, using high thoracic epidural K Srinivas Murthy anesthesia and analgesia. All the patients underwent epidural Care Hospital, The Institute of Medical Sciences, Banjara Hills, catheterization on the evening before the surgery. Hyderabad Measurements and Main Results: 2 patients underwent Background: Off pump Coronary Artery Bypass surgery (OPCAB) anterolateral thoracotomy and underwent grafting from left internal has become a routine procedure in the surgical management of mammary artery to left anterior descending artery. The patients in all coronary artery disease. It has various advantages like fewer received 36 grafts (single n=5, duble n=3 triple n=3, quadruple n=4). incidences of neurological, renal, pulmonary complications of Cardio There were 3 female patients and 12 male patients with mean age of Pulmonary Bypass. This study is carried out to compare the 60.6±5.9 years. There was no conversion to general anesthesia, advantages of Isoflurane over Holothane in maintaining anaesthesia cardiopulmonary bypass, perioperative morbidity or mortality. Mean in the patients (pts) undergoing CABG. length of stay in the intensive care unit was 18±4.2 hours and hospital Methods: Between January 2001 through October 2002, a total of was 3.2±1.2 days. 675 pts underwent CABG of whom 151 pts were OPCAB. A hundred Conclusion: Our experience confirms the feasibility of performing consecutive pts were included in the present study and were grouped multiple coronary artery bypasses in conscious patients without into two. The hemo dynamic effects and the arrhythmogenic endotracheal general anesthesia. properties of Isoflurance and Halothane in the intra operative usage in OPCAB surgeries were studied in to two groups. Group-I consists of 50 pts who were induced with thiopentone, fentanyl as a narcotic analgesic, vecuronium as a relaxant and 1% Isoflurane for maintenance of anaesthesia. Group-II consists of 50 pts who were induced with thiopentone, fentanyl as a narcotic analgesic, vecuronium as a relaxant and 1% Halothane for maintenance of anaesthesia. The pts in both Induction with sevoflurane in patients with LV groups were comparable in demographic variables and the technique dysfunction undergoing CABG 304 of anaesthesia was standardized. Hypotension produced during Indrani Ghosh, Vinayak Kumar, M Paramita Trivedi Chatterjee, surgical procedure was corrected by infusion of IV fluids and Abhijit Paul, Manoj Sahu, Kunal Sarkar, Emmanuel Rupert dobutamine in both the groups. The hemodynamic parameters and Rabindranath Tagore International Institute of Cardiac Sciences, the incidence of arrhythmias in both the groups were compared. The Kolkata surgery was performed in all pts by using October-3, starfish for Aim: The aim of the study is to see the efficacy of sevoflurane as posterior vessels, and intracoronary shunts were used in distal an inducion agent in patients with left ventricular dysfunction grafting. undergoing coronary artery bypass grafting. Results: 16 patients in-group 1 developed hypotension grafting Methods: Sevoflurane is non-irritating to the airway, pleasant to [OM & PLBS] grafting which lasted for 3-5 minutes. 5 pts developed inhale with low blood/gas solubility and has good hemodynamic hypotenson during LAD & RCA grafting. 10 pts in group-1 developed profile. A randomized prospective study of 50 patients with left bradyarrythmias, 5 pts developed atrial arrhythmias, 1 patient ventricular dysfunction undergoing coronary artery bypass grafting developed ventricular tachyarrhythmia. 21 pts in-group II developed was studied. hypotension during posterior vessel grafting which lasted for 5-8 One group was induced with sevoflurane 2.5%, fentanyl 5 mcg/ minutes. 8 pts developed hypotension during LAD & RCA grafting, kg, midazolam 2 mg and pancuronium 0.1 mg/kg. The other group which lasted for 3-5 minutes. 15 pts in-group II, developed was induced with thiopentone sodium 3-4 mg/kg, fentanyl 5 mcg/ bradyarrythmias, 10 pts developed atrial arrhythmias and 5 pts kg, midazolam 2 mg and pancuronium 0.1 mg/kg. developed ventricular tachyarrhythmia. PA diastolic pressure was Hemodynamic parameters like, heart rate, blood pressure, central monitored and maintained between 15-20 mmHg. venous pressure, Pulmonary wedge pressure, cardiac output, cardiac Conclusion: Usage of Isoflurance for maintenance of anaesthesia index, systemic vascular resistance index, pulmonary vascular is safer compared to usage of Halothane during Off Pump CABG resistance index were monitored at preinduction, postinduction, post procedures. intubation, skin incision and post sternotomy. Results: Sevoflurane provides good hemodynamic stability when used as a induction agent in patients with poor left ventricular function undergoing CABG.

High thoracic epidural anesthesia as the sole anesthetic - is it a feasible alternative to general 303 anesthesia in off pump coronary artery bypass Anaesthetic management for tracheal surgery for performing multiple grafts? reconstructive surgeries 305 Murali Chakravarthy, Vivek Jawali, TA Patil, K Jayaprakash, Shanthi Malar, S Meenakshi, CR Janakiraman, IS, Naidu, NV Shivananda RK Sasankh, Rajan Santosham Wockhardt Heart Institute, Bangalore, Karnataka Chennai Objectives: The feasibility of the use of high thoracic epidural Background: Anesthesia for surgical repair is challenging because anesthesia as a sole anesthetic in patients undergoing beating heart of compromised airway. The Anesthetist and surgeon must jointly coronary revascularization, avoiding general anesthesia was studied. plan for the conduct of anesthesia.

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Materials and Methods: For the past 15 years we have done 132 ICU management of OPCAB patients tracheal reconstructions. The site and length of stenosis has to be Sathyavathi Sekar, Rajalaxmi, Vikneswari, Sagunthala, 307 assessed carefully preoperatively by bronchoscopy, CT scan and RS Sadasivam anesthetic induction planned accordingly. The critical stenosis can be Govt. General Hospital, MMC, Chennai initially dilated or tracheostomy can be done under LA, to secure Background: OPCAB is CABG performed without airway. We have never used CPB in any of our cases. After the initial repair, the tracheostomy tube is replaced by an Et tube. It is always Cardiopulmonary bypass and Cardioplegia. In comparison to ideal to extubate the patient on the tube to prevent suture infection conventional CABG, OPCAB is less invasive, resulting in reduced morbidity and mortality. and restenosis. In high strictures with tracheomalacia, it is mandatory Materials and Method: to use a Montgomery T tube and during the proceudre the tip of the The early clinical outcomes of 25 consective ET tube is hitched on the upper end of Montgomery T Tube. At the CABG patients were studied and the results compared with 25 conventional CABG patients. end of surgery we have to firmly hold on to the Montgomery T Tube Results: in the trachea before pulling the ET tube. The OPCAB group shows statistically significant Results: Except for one case of tracheal stenosis, which needed difference in the Ionotropic requirement [84% versus 100%; P <0.05], Blood loss [244±122 versus 572±265; P<0.05], Blood transfusion slash tracheostomy because of hypoxia, the conduct of anesthesia has been smooth in all our cases. There were no anesthetic related requirement [40% versus 92%, P<0.05], and duration of mechanical complications. Surgical complications include 1 quadriplegia and 3 ventilation [13.04±4.3 versus 20.7±11.99; P<0.05]. Conclusion: tracheo-innominate artery fistulas of which 1 was successfully OPCAB patients had low early major events with repaired. 4 cases of restenosis due to infection needed tracheostomy. faster recovery. Hence OPCAB is a good alternative to conventional Conclusions: Good anesthesia and pre-op anesthetic planning is CABG in selected subset of patients. very essential for successful conduct of Tracheal Reconstruction.

Autotransplantation as a method for LA wall Multi-modality cardiac output study: Comparison reduction in GIANT LA – A case report 308 of continuous cardiac output (CCO), pulse contour 306 Binu T Krishnan, Jeseentha PS, Mahadevan, V Satyaprasad Amrita Institute of Medical Sciences and Research Centre, Kochin output (PulseCO) noninvasive partial CO2 rebreathing cardiac output (NICO) with bolus Introduction: Giant LA has been a very complex and difficult thermodilution cardiac output (TDCO) measurement situation in patients with rheumatic mitral valve disease. By definition Namrata Kothari, Tenaz Amaria, Asmita Hegde, Alka Mandke, Nitu Mandke ganit LA is a left atrium which is more than 6 cm in diameter. Lilavati Hospital, Mumbai Case report: We report a case who had RHD with severe MR with giant LA (>12 cm) who underwent mitral valve replacement with Introduction: Cardiac output (CO) is one of the major determinants reduction of the left atrium by autotransplantation method. In this of organ perfusion. In off pump CABG surgery, dislocation of the heart case after delivering the cardioplegia the whole heart with its influences cardiac output rapidly. It is important for the attachments to Svc, Aorta, pulmonary artery, pulmonary veins were anaesthesiologist to have reliable tools for clarification of severed off and the heart was rotated and the excess LA wall was haemodynamic status quickly and accurately to avoid intolerable low excised. The heart was sutured back in place and it regained normal cardiac output states. In this study we compared thermodilution CCO, activity. The advantage of this method was that we could achieve a PulseCO & NICO technique of continous cardiac output measurement. better reduction in the LA wall size along with easier mitral valve Materials and Methods: 75 patients undergoing off pump CABG replacement. The patient is doing well postoperatively and was surgery were studied. Group A - PulseCO (n=25): measured by arterial discharged. waveform analysis algorithm. Group B - NICO (n=25): cardiac output

measured by CO2 partial rebreathing. Group C- CCO (n=25): CO measured continuously by thermodiluation method. Cardiac output measured by bolus thermodilution in all patients. Data pairs of continous and bolus thermodilution method obtained at different time points. (total pairs=729) were analysed using Bland Altman & regression plot analysis. ANOVA was applied to compare the groups. Nursing management in patients on CPAP Results: The CO measurements were comparable between ventilation with low PAO2 following 309 cardiothoracic surgeries different techniques and showed no statistically significant difference. Revathi K, BR Jagannath, V Kirthivasan P value (<0.001 for all bias). 2. The overall bias is close to zero & Southern Rly. Hqrs. Hospital, Perambur, Chennai hence negligible. 3. CCO shows best agreement with lowest bias of 0.01 L/min. 4. Over all precision are all comparable & very close to Backgrounds: CPAP is a non invasive supportive ventilation, each other. 5. During anastomosis all 3 techniques showed poor whereby intra-thoracic pressures are not allowed to return to ambient agreement with TDCO and showed higher CO than TDCO. pressures. This increased pressure helps to keep the alveoli open, 6. Comparing the difference in either CCO, PulseCO, NICO values increases functional residual capacity and enhance oxygenation as a v/s TDCO at 2, 4, 6 Ltrs/min. (y α x) all 3 techniques showed poor result of the enlarged surface area that is availoable for diffusion agreement to TDCO at low CO and better agreement at physiological without need for endo tracheal intubation. CO values. Methods: With the implementation of CPAP, oxygenation is Conclusions: All methods are statistically comparable and hence improved thus allowing the use of lower level F 102. inter-changeable for cardiac output measurement in OPCAB Surgery. A study conducted for the year October 2001 to September 2001 NICO is least expensive and easy to use. shows 25 patients required nasal CPAP. Main indication was low PAO2

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levels following extubation on the first or second post operative day. cardioplegic solution has to be prepared on the operative table and Among those, 21 patients had CABG, 3 patients had valve replacement the syringes to be immersed in ice-cold saline solution. The correct 1 had Bental procedure done. size of suture has to be given. In these small children there is less Results: All patients showed a significant increase in PAO2 on margin for error. Internal defibrillating paddles are to be selected initiation of CPAP. Weaning from CPAP was done by alternating CPAP depending on the size of the heart. with oxygen mask. 24 patients had improved PAO2 and could be Conclusion: It is important to be familiar with the steps of the weaned off CPAP, but one required re-intubation. procedures so that unnecessary delay is eliminated. The circulating nurse should also be familiar with the suture material and the other canulae required in these procedures to avoid unnecessary delay.

Intra–aortic balloon counter pulsation: An analysis of indications and nursing 310 management in cardiac patients for the last 8 years Role of scrub nurse in off-pump CABG C Kulanthaiammal, BR Jagannath, P Srinivasa Reddy, R Jaganathan, Lincy Joseph, Aleyamma Philip, Megline Sathya, Murugeswari, 312 Pankaj Kumar Srivastava Suni AJ, Julee Manoj, Sandhya S. Railways H. Qtrs. Hospital, Perambur, Chennai CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad Introduction: The intra-aortic balloon pump is a cardiac assist device designed to increase coronary perfusion and decrease Introduction: During the last few years many techniques have myocardial oxygen consumption. It is the most commonly used been developed for less invasive cardiac surgical procedures. Off support for failing heart in cardiac patients. pump coronary artery bypass grafting has emerged as an effective Methods: A retrospective study for a period of 8 years from Jan. alternative to conventional CABG using cardio pulmonary bypass. 1994 to Oct. 2002 has been conducted in our hospital. During this Methods: A total of 376 patients underwent multi vessel off - CABG period 198 cardiac patients required IABP support, which included by our team between 1998 July and October 2002. coronary patients, valve patients and CABG with associated Material and equipment required procedures. The period of IABP support ranged from 4 hrs. to 24 days. – Tissue stabilization systems - Octopus, STS In 91.34% patients IABP was inserted during surgery, in 4.83% patients – Cardiac positioner - Starfish it was instituted pre-operatively and in 3.83% patients during post – Intra coronary shunts operative period. The indications were weaning from CPB, high PA – Mist - Blower pressure, low ABP & LV failure. Wearing from IABP started after the – Suction lines one or two other than regular sucker. patients became stable. It was done by reducing frequency, – Warm saline flush Augmentation or both. In all the patients diastolic augmentation, – Temporary pacing cables systolic and diastolic pressures, Pedal pulse, colour of the foot and – Circulating nurses - 2 warmth were monitored. Conventional off–pump CABG differs from CABG as all the Results: Nursing management of these patients require additional anastamosis are made on the beating heart. Hence target artery knowledge about monitoring procedures, alarm and precaution when stabilization and blood less operative field are the prime requirement a patient is on IABP. for construction of meticulous coronary anastamosis. Results: To achieve this a scrub nurse has to be stable, calm and knowledgeable. It is important to assign duties and responsibilities of the individual members of the team to avoid confusion, delay and misunderstanding the major problem occurs when an emergency Role of scrub nurse in open heart surgeries cardiopulmonary bypass is to be instituted because of ECG Changes performed in children under 10kg weight 311 or haemo-dynamic compromise. It is highly desirable to have canulae Lincy Joseph, Aleyamma Philip, Megline Sathya, Murugeswari, [arterial, venous, suture material to be available in the operating room Suni AJ, Julee Manoj, Sandhya in addition to the tubing set for CPB. In our series only on four CARE Hospital, The Institute of Medical Sciences, Banjara Hills, occasions the patients are converted to conventional bypass. Hyderabad Maintenance of sterilization in the operative room during these emergency conversion is essential. There was no intra operative Introduction: Open heart surgery for the correction of congenital mortality. heart defects is more risky in small children with lower body weight compared to the children more than 10 Kg or adolescent. It requires more expertise, commitment and regularity in performing these procedures. Methods: A total of 70 children underwent open heart surgical procedures in our unit over the last 3 years. The precedures included Nursing care following intra-aortic balloon pump intracardiac repair of TOF, repair of TAPVC, repair of VSD, arterial insertion in cardiac surgical patients 313 switch operation. The problems associated with institution of CPB M Usha Rani, P Shaji, K Mary Jyosmin, PJ Jeena, Hanna Satish, because of smaller size and less space available at the operative site. Rohini Paul, Ratan Gupta, Jose Chacko Canulation – aortic and venous canulation. Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Results: In these children the arterial and venous tubing are of Objectives: To study the nursing management of patients having th the sarne size (1/4 inch size) leading to confusion between the arterial intra-aortic balloon pump (IABP) and identify issues and factors that and venous lines. help prevent complications and promote overall care. Cardioplegic canulae is smaller and needs precision in insertion Methods: We reviewed the medical records of 2400 patients, 80 of and fixation. Most of the times the cardioplegia is hand given and which had IABP insertion following cardiac surgery in our institution

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between May 2001 and September 2002. The primary indication for Optimal resource allocation in a busy cardiac IABP use was haemodynamic instability and/or myocardial surgical unit 315 ischaemia. The nursing protocols followed for these patients were Syed, Mini George, Jojimol Varghese, Janesh, S Sivasubramanian, studied. R Muralidhar, Devi Prasad Shetty Results: Continuous monitoring and documentation of Narayana Hrudayalaya Institute of Medical Sciences, Bangalore haemodynamic parameters (heart rate, blood pressure, left atrial and Background: Optimised utilization of scarce resources and pulmonary artery pressures, core and peripheral temperature, arterial infrastructure is most important in today's socio-economic situation. blood gases, electrolytes) and balloon settings (ratio, volume end In our institution we regularly operate upon 10 to 14 cardiac patients diastolic pressure, augmentation waveforms) were done in all patients. every day with limited infrastructure investment like instruments and Other steps in the protocol included maintaining airways patency by other equipment. We analyse our procedures and processes in endotracheal suctioning every 2 hours and SOS, encouraging planning and executing our daily operating lists. extubated patients to cough and take deep breaths, chest Methods: The operation list is finalized on the prior day. Patients physiotherapy every 6 hours, maintaining strict intake-output charts, are allotted to an operating room depending upon the availability of providing tube feeding for intubated patients or clear fluids and soft general equipment and staff. Surgical equipment is labelled and diet for extubated patients to sustain their nutritional status, and packed in advance in accordance with the nature of the operation assessing neurological level every 2 hours. On the limb where IABP planned. Our central sterilisation department is geared for a fast and was inserted, checking peripheral pulses, skin temperature, calf efficient sterilisation protocol which can feed the operating theatre as muscle tone and colour of the involved leg are important. Anti- and when required. coagulation status monitoring, keepting strict aseptic technique, Results: From November 2001 to October 2002, 3019 patients were changing patient position every 2 hours and reassuring the patient operated from a variety of cardiac conditions ranging from relatively and family are other essential components to caring for these patients. simple operations like ligation of patent ductus arteriosus to very Of 80 adult patients operated with IABP insertion, 64 survived. complex, lengthy procedures like aortic aneurysm repair, Ross Less than 5% had any complications related to IABP. procedures, arterial switch operation and re-do coronary artery bypass Conclusion: IABP is an effective method to improve cardiac output grafting. In 271 operating days, we had 1355 "operating room-days", in patients with poor ventricular performance. Appropriate with an average of 2.31 surgeries per OR-day. Throughout this period, knowledge of the technique and adequate nursing care is necessary we have never had to postopone more than 3 cases a week for reasons for effective management and successful outcome. of theatre delay, and none due to shortage of equipment or personnel. Our turnover time between cases in each OR ranges between 10 and 15 minutes. Conclusion: By planning and careful scheduling of patients among available operating rooms, efficient utilisation of operating theatre time, staff and equipment is possible. Nursing care of infants after arterial and atrial switch operation 314 Shaji P, Rohini Paul, Mary Jyosmin K, Jeena PJ, Raghunath CN, S Sivasubramanian, Amit Varma, Devi Prasad Shetty Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Objectives: Infants who undergo arterial or atrial switch (Senning) operation for transposition of great arteries (TGA) pose a nursing challenge. The margin of safety is small and hence precise and accurate institution of therapy is vital. skilled nursing care is essential to the Standard precautions in a cardiac speciality hospital Jojimol Varghese, Mini George, C Janesh, Prem Anand, successful outcome. This paper analyses our experience with the post- 316 K Muralidhar, Devi Prasad Shetty operative nursing care of these children. Narayana Hrudayalaya Institute of Medical Sciences, Bangalore Patients and Methods: We analysed our nursing protocol for 60 patients undergoing arterial (n=36) or atrial (n=24) switch operations Introduction: Standard safety precautions are important in the for TGA between May 2001 and September 2002. Patients were future of a patient care facility in order to prevent nosocomial infection warmed in a F/P warmer bed. Mean arterial pressure of 45 mmHg as well as prevention of transmission of infections to health care was maintained. Use of inotropes like milrinone, dopamine and workers. dobutamine was initiated if necessary. Elective ventilation with FiO2 Methods: Over the period of 18 months, we operated upon 3461 of 60% to 90% was continued for varying periods until the child was patients for various cardiac ailments. In the pre-operative screening, fit for extubation. Sedation and paralysis with Fentanyl and 22 patients (0.6%) were found to be positive for Hepatitis B, surface Vecuronium was given as needed. Urine output was maintained at antigen (HbsAg), 3 of whom showed acute infectivity (HbeAg 0.5 to 1 ml/kg/hr. Haematocrit was maintained between 35% and positivity). 5 patients (0.14%) had antibodies against Hepatitis C virus 40% by transfusion of packed red cells. Antibiotic prophylaxis was (HCV). 3 patients tested positive for VDRL, all of them had aortic initiated as per our unit protocol. aneurysms which were later operated. 16 patients underwent open Results: Hospital stay ranged from 9 to 98 days (median=24 days). heart surgery. There were 9 early deaths in hospital (mortality rate-15%). Other Results: We had no incidents of cross-infection or contamination complications included need for peritoneal dialysis, sepsis in 3 cases resulting in the transmission of infection to other patients or to and tracheostomies in 4 cases. operating room or intensive care unit staff. Conclusion: In management of patients after switch operations Conclusion: The use of standard precautions, employee for TGA, the nursing care is aimed at the maintenance of all immunization programme and safe disposal of sharp have been physiological parameters within specified normal range. Outcome is instrumental in preventing occupational infections in health care related to the understanding of neonatal patho-physiology underlying workers. Importance of hand washing and reporting of needle stick complex cardiac surgery. injury is important.

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Efficacy of non-invasive blood pressure Results: Mean weight of the patients was 7.4 kg and mean age monitoring in comparison to invasive 317 57 months. At the time of initiation of peritoneal dialysis, all patients blood pressure monitoring achieved negative balance (mean 380 ml/day) in the haemodynamic CN Raghunath, Usha Rani, Amit Varma group, mean screatinine decreased from 1.3 to 0.9 while S potassium Narayana Hrudayalaya Institute of Medical Sciences, Bangalore decreased from 3.7 to 2.9. In the renal failure group, a similar decrease Background: Surgical repair for congenital heart disease in the was noticed, S ceatinine 2.3 to 1.2 and S potassium 4.2 to 3.6. neonatal period and infancy is becoming the norm procedures being Complications of PD were transitory and to minimal clinical performed at an increasingly lower age. There is always a desire to significance. In both groups, fluid balance was similar inspite of the wean the patient from invasive lines due to the attendant infection cardiac function and variable need for inotropic support. All patients risks. Occasionally, long-term sustainability of these arterial lines is in the haemodynamic group (9/9) died while 1/5 expired in the also an important issue. renal failure group. Aim: To gauge the efficacy of Non-Invasive Blood Pressure (NIBP) Conclusions: Peritoneal dialysis is an effective and safe method monitoring in comparison to Invasive Blood Pressure (IBP) lines in for the treatment of Acute Renal Failure (ARF) after open-heart children <10 kg. operations. Morality and complications are low in this group. When Methods: 50 consecutive infants <10 kg who underwent cardiac it is initiated in the haemodynamic group as an adjuvant to treat surgery were studied and blood pressure readings were documented low cardiac output, in spite of achieving negative fluid balance and both by traditional and correct size NIBP cuff techniques at the same normalized electroyte parameters, mortality tends to remain high. time. Current protocol regimes were standardized and adhered to for Thus usage of the PD catheter shows unquestionable benefit in ARF. all study subjects. Four readings of blood pressure were done at fixed However we found no improvement in outcome in the low cardiac six hourly intervals on the 1st postoperative day. The age of the patients output state. ranged between 2 days to 3 years, of these 22 were below 5 kg. Results: NIBP systolic values versus ABP systolic values showed no significant difference at 6 am, 12 pm, 6 pm, and 12 mid nights respectively, (6 am P value 0.1907, 12 pm P value 0.4211, 6 pm P value 0.4648 and 12 mid night P value 0.4846 respectively). Similarly, there was no statistical difference at any time period in the diastolic values. This was seen regardless of the age, sex or weight of the patient. Emerging drug resistance in bacterial isolates Conclusions: Non-invasive blood pressure monitoring is a safe from a specialty cardiac surgery unit among 319 and efficacious tool with high accuracy to measure blood pressure pediatric cases after high-risk surgery. This would suggest that aggressive delining Amit Varma, Prem Anand Nagaraja, Hannah Satish can be practiced in such units to decrease the incidence of infections, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore decrease ICU stay and enable a reduction in costs after such Background: Pediatric patients with congenital cardiac defects are procedures. predisposed to infections, which require hospitalization and therapy before surgery. These patients are also at a higher risk of acquiring hospital infections. Emerging antibiotic resistant strains have added another dimension to the issue. Methods: A total of 982 young patients with cardiac defects requiring surgical intervention were treated in the hospital over a period of 15 months. A total of 385 samples were received from pre- operative cases and 818 samples from post-operative cases. Peritoneal dialysis after paediatric cardiac surgery – Results: The culture positivity rate was 16% and 15.5% respectively. Does it affect outcome? 318 E. coli (29.7%) was the commonest isolate in pre-op cases while S. CN Raghunath, Colin John, Rajesh Sharma, Amit Varma aureus (18.7%) followed. Post op patients showed a higher rate of S. Narayana Hrudayalaya Institute of Medical Sciences, Bangalore aureus isolates (25.1%) while E. coli was 25.9% among all isolates. Overall, gram-negative isolates formed 75% and 63.7% of all isolates Background: Peritoneal dialysis (PD) is used fairly frequently in in the pre and post op patients respectively. Gram negative isolates pediatric cardiac centers. Indications cited are usually in low cardiac from pre-op cases showed higher rates of sensitivity to output states to improve haemodynamic parameters and in renal failure. aminoglycosides (94.7% vs 60%), cephalosporins (53% vs 14%), Recently some centers have advocated its usage prophylactically quinolones (63% vs 31%). S. aureus isolates from post-op cases showed especially in cases which have undergone prolonged bypass times and higher resistance (compared to pre-op isolates) to semi-synthetic volume overload is an issue. Other studies have cited poor outcome in penicillins (61% vs 100%), quinotones (41% vs 90%), oxacillin (56% vs patients who have had a PD catheter placed. The aim of this study was 100%), glycopeptides (96% vs 100%) and cephalosporins (41% vs to demarcate indications, utility and outcome parameters in all patients 100%). Resistance profiles of gram negative isolates showed 36% who underwent a PD catheter placement. higher rate post-op cases. Pseudomonas and S. aureus isolates showed Methods: 900 patients <18 years underwent pediatric cardiac 44% and 34% higher rate in resistance profiles among post-op isolates. surgery at our institution between May 2001 to September 2002. Out Resistance to newer antibiotics like Cefuroxime-Sulbactam, Ticarcillin- of those 14 (1.5%) had a PD placed, 9 (64%) for haemodynamic Clavulanate, Piperacillin-Tazobactam, Cefpirome and Meropenem has considerations and 5 (36%) for renal failure post surgery. Of the 14, 13 also been documented in post-op gram-negative isolates. were <10 kg and one over 10 kg. All had Peritocat® (B Braun Linezolidone, a new antibiotic has been useful in combating post-op Melsungen AG, Germany) placed by a paediatric cardiac surgeon in infections caused by S. aureus, with no resistance being encountered the operating room or ICU under standard aseptic precautions. The so far. remaining ICU protocols were maintained with same. We recorded Conclusions: The importance of monitoring emergence of drug intake/output, S. Creatinine, electrolytes and haemodynamic data in resistance bacteria and antibiotic policy implementation in hospital all patients’ pre and post PD insertion. is reiterated.

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Midterm evaluation of aortic valve replacement Surgical results in mitral valve replacement, an with autogenics valve 320 analysis of 100 patients 321 Sanjay kumar, XY Jin, Ravi Pillai Madhu Andrew Philip, Roy Thankachen, Bhawna Parihar, Oxford Heart Centre, The John Radcliffe Hospital, Oxford, UK Vinayak Shukla, Roy John Korula Department of Cardiothoracic Surgery, Christian Medical College, Background: This study assesses early and midterm results of Vellore autologous pericardium tissue cardiac valve (APTV) at the aortic location. Background: Valvular heart disease in developing countries Methods: The glutaraldehyde tanned autologus pericardium, resulting from rheumatic fever is disabling and if untreated leads to harvested at the time of operation, is mounted on a stent requring no congestive heart failure and death. Mitral valve replacement has suturing. APTV was implanted in the aortic position between June remained the procedure of choice for advanced mitral valve disease. 1996 and October 1996 in 5 patients, 3/2 M/F and aged 73±6 years. Methods: During 2000 & 2001, 100 patients underwent mitral valve One patient presented with aortic stenosis and 4 had mixed lesion. replacement. The mean age was 42.52 (5–65 years). Due to the Additional coronary artery bypass was done in one. Aortic cross clamp favourable earlier experience, the Starr Edwards ball valve prosthesis and cardiopulmonary bypass times were 48± and 56±7 min. Follow- was used in the large majority of our subjects. The follow-up was up was performed clinically and by colour Doppler echocardiography 6-10 months after surgery, 21 (21%) patients had significant MS, 25 at 3 months and yearly thereafter. Follow-up was 100% complete at 6 (25%) patients had significant MR, 54 (54%) patients had significant years. combined lesions. Results: Overall survival was 100 and 80% at 5 years and 6 years Results: The 30 day hosptial death rate was 2% and death occurred respectively. One death after 5 years was not valve related. All four in 3 (3%). A low intensity anticoagulation regimen was followed to suriving patients have been followed up to a period of 6 years now maintain the INR at 2.5 to 3.5. 15 patients were lost to follow-up. Nearly (mean 70 months). Freedom from reoperation has been 100% at 6 years all the patients improved in their NYHA class with 76 in class I, 8 in follow-up. Predischarge echocardiogram demonstrated excellent Class II, 1 remained in class III. Complications were few- haemodynamics, with a mean gradient of 6 mmHg and trival aortic thromboembolism occurred in 6 (7.05%) patients, minor haemorrhagic insufficiency in one patient. At first follow-up 4 patients were in NYHA complications in 8 (9.41%) and others occuring in the immediate post class I and one patient was in class II. Echocardiograph showed no op period was 16 (18.32). evidence of valve failure or degeneration in the patients studied up Conclusions: Mitral valve replacement should still be reserved to the end fifth and sixth postoperative year. The valve leaflet was for those patients with moderate to severe disability and should not free of generalized calcification in all instances. be delayed until severe pulmonary vascular changes and myocardial Conclusions: The intraoperative fabrication of a geometrically damage pose a major deterrent. In view of the acknowledged perfect trileaflet APTV fulfills the concept of a nonantigenic, advantage of superior durability, increase thrombo resistance in our noncalcifying, more durable bioprosthesis. The mid-term results of patient population and its cost effectiveness, the Starr Edwards ball this small series are encouraging. valve is the mechanical prosthesis of choice. The low intensity anticoagulant regimen has offered sufficient protection against thromboembolim as well as haemorrhage.

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