Research (Cardio Vascular Thoracic Surgery)

Original Articles

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TRANSPOSITION OF GREAT ARTERIES WITH INTRAMURAL CORONARY ARTERY: EXPERIENCE WITH A MODIFIED SURGICAL TECHNIQUE
Amit Mishra; Anil Jain; Manish Hinduja; Vivek Wadhawa; Ramesh Patel; Nikunj Vaidhya; Dayesh Rodricks; Hardik Patel (Brazilian Journal of Cardio Vascular Surgery 2016;31(1):15-21)
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Objective: Transposition of the great arteries is a common<br />congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation. Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text. Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730). Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons’ armamentarium.

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PROCALCITONIN LEVEL FOR PREDICTION OF POSTOPERATIVE INFECTION IN CARDIAC SURGERY.
Pranav Sharma, Kartik Patel, Kinnaresh Baria, Ketav Lakhia, Amber Malhotra, Komal Shah and Sanjay Patel Asian Cardiovascular & Thoracic Annals 2016, Vol. 24(4) 344–349
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Background: Diagnosing infection after cardiac surgery remains difficult due to the systemic inflammatory response induced by cardiopulmonary bypass. We compared procalcitonin levels with white blood cell counts as predictors of infection after cardiac surgery. Methods: We prospectively enrolled 100 consecutive adult cardiac patients. Postoperative white blood cell counts, serum procalcitonin levels, and blood cultures were examined. Result: The sensitivity and specificity of white blood cell count and procalcitonin more than 2 ng mL1 were 60% and 100%, 58.8% and 42.5%, respectively. Procalcitonin more than 7 ng mL1 had 95% sensitivity and 80% specificity. Receiver-operating characteristic analysis showed a greater area under the curve for procalcitonin level (p less than 0.0001) compared to white blood cell count (p ¼ 0.31). Patients with positive blood cultures had significantly higher procalcitonin levels (51.97  39.62 vs. 6.67  10.73 ng mL1), Acute Physiology and Chronic Health Evaluation-II scores (16.95  3.24 vs. 13.60  2.98), and intensive care unit stay (6.35  3.42 vs. 4.6  2.2 days). Non-survivors had  significantly higher Acute Physiology and Chronic Health Evaluation-II scores (19.09  1.30 vs. 13.67  2.97) and procalcitonin levels (43.83  52.15 vs. 12.26  19.89 ng mL1) but on logistic regression analysis, only Acute Physiology and Chronic Health Evaluation-II score was an independent risk factor for mortality. Conclusion: The diagnostic accuracy of procalcitonin for bacterial infection is fairly high. Acute Physiology and Chronic Health Evaluation-II score is a better predictor of mortality and morbidity than absolute procalcitonin level. Procalcitonin more than 7 ng mL1 can prognosticate and identify the high-risk group.

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HYPOMAGNESAEMIA AND ROLE OF MAGNESIUM SUPPLEMENTATION DURING CARDIOPULMONARY BYPASS IN PEDIATRICS CARDIAC SURGERY.
Vivek Wadhawa, Manish Hinduja, Sandip Singh Rana, Anand Kumar Mishra, Sarin Mathew, Goverdhan Dutt Puri,Reema Tavar, Amit Mishra J. Evid. Based Med. Healthc. pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 3/Issue 07/Jan. 25, 2016
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BACKGROUND: Postoperative Junctional Ectopic Tachycardia (JET) remains one of the most common arrhythmias (8%-20%) after paediatric cardiac surgery. JET is associated with hemodynamic instability, longer mechanical ventilation time and longer stays in the Cardiac Intensive Care Unit (ICU). AIM: The aim of this study is to evaluate the effect of prophylactic administration of magnesium on the occurrence of postoperative arrhythmias in patients undergoing intracardiac repair for Tetralogy of Fallot and to determine the incidence of hypomagnesaemia in paediatric patients undergoing cardiac surgery who require CPB.<br />METHODS: Forty five patients with Tetralogy of Fallot undergoing intracardiac repair were enrolled to receive saline, 25mg/kg and<br />50mg/kg of Magnesium as three groups intraoperatively. Postoperative ECG monitored for JET and magnesium levels measured. RESULTS:<br />Hypomagnesaemia was present in 28% of patients. None of the patients who were administered magnesium developed hypomagnesaemia. The incidence of JET was found to be increased (53.3%) in the placebo group as compared to 13.3% and 6.7% in the groups receiving 25 and 50mg/kg of magnesium (p<0.001). Eleven patients having JET 7 (64%) had hypomagnesaemia and rest of the 4(36%) occurred in patients with normal magnesium levels (p<0.01). The mean mechanical ventilation time and the mean length of ICU stay were both prolonged those with hypomagnesaemia. The mean mechanical ventilation time and length of ICU stay were both prolonged in the patients with JET (p<.001) CONCLUSIONS: Hypomagnesemia is one of the factors responsible for JET and in turn with prolonged ICU stay and prolonged mechanical<br />ventilation.

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DIFFERENT STRATEGIES FOR SIMULTANEOUS REPAIR OF AORTIC COARCTATION AND ASSOCIATED CARDIAC DISEASES IN ADULT PATIENTS.
Jignesh Kothari, Bhavin Brahmbhatt, Kinnaresh Baria, Jigar Patel International Journal of Medical Science and Public Health | 2016 | Vol 5 | Issue 02
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Background: Coarctation of aorta and associated cardiac disease is complex medical situation. Both requires correction either simultaneous or in stages. A distinct approach is vital in order to bring down the perioperative mortality and morbidity. Objective: To study the different strategies for simultaneous repair of aortic coarctation and associated cardiac diseases in adult patients. Materials and Methods: We have operated three patients with coarctation associated with other cardiac diseases, who were treated by various surgical approaches. Developments in endovascular technology over the past decade may potentially reduce the morbidity from open surgical repair. However, some cases are unsuitable for endovascular repair, and open surgical techniques continue to play a part in the management of these patients. Coarctation and associated diseases were treated in a single stage by an ascending-to-descending bypass (n = 2). One patient underwent a two stage operation for his treatment. Result: Postoperative recovery of all the three patients was uneventful. Their ICU parameters were within acceptable limits. All the three patients showed negligible gradients of blood pressure between the upper and lower extremities and discharged within 8 to 9 days. They showed postoperative CTscan suggestive of normal functioning graft without any leak or aneurysm. Conclusion: In spite of the progress in the development and popularization of endovascular techniques, surgical intervention is becoming a more preferable option for the treatment of coarctation accompanied by cardiac diseases. Two-stage and single-stage (extra-anatomical bypass) procedures are the alternative techniques that are performed depending upon the experience of the surgeons in the center; however, we prefer the single-stage (simultaneous) ...

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INFLUENCE OF DIABETES MELLITUS ON OPERATIVE OUTCOME OF CORONARY ARTERY BYPASS GRAFT SURGERY.
Anil Kumar Jain, Chirag Doshi, Manish Hinduja, Kinnaresh Baria, Nikunj Vaidhya, Pratik Shah J of Evidence Based Med & Hlthcare, Vol. 2/Issue 57/Dec. 17, 2015 Page 8894
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BACKGROUND: Diabetes Mellitus (DM) was present in around 47% of population in India undergoing coronary artery bypass surgery for coronary<br />artery disease. Our aim of the study was to determine possible pre-operative and post-operative risk factors and mortality associated with diabetes during coronary artery bypass grafting (CABG). MATERIAL AND METHODS: We analyzed retrospective data of 224 patients at our institute operated between January 2014 to March 2014. The preoperative, intra operative and postoperative risk factors as well as the complications and 30-day mortality rates were compared between the diabetics and non-diabetics. Among the 224 patients; 132 (58.93%) were in non-diabetic group and 92(41.07%) were diabetics. RESULTS: The 30-day mortality was 11% in patients with DM and 3% in those without DM; we observed that BMI, hypertension and weight were highly significant in diabetic group compared to non-diabetic group. Prothrombin time, inotropes duration, ICU stay, hospital stay and mechanical ventilation hours were also significantly high in diabetic group compared to non-diabetic group. CONCLUSION: DM is an important risk predictor for short term mortality and morbidity among those undergoing CABG.

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COMPLEX CORONARY PATTERN AFFECTING THE SURGICAL OUTCOME OF ARTERIAL SWITCH OPERATION.
Amit Mishra, Nikunj Vaidhya, Hardik Patel, Ramesh Patel, Imelda Jain, Harshil Joshi, Komal Shah, Himani Pandya J of Evidence Based Med & Hlthcare, Vol. 2/Issue 56/Dec. 14, 2015 Page 8860
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BACKGROUND Arterial switch operation (ASO) has become the procedure of choice for the transposition of great arteries as well as for TaussigBinganomaly. Relocation of coronary arteries remains a technical problem in anatomic correction of the transposed great arteries. The present prospective study is designed to analyse the effect of coronary artery pattern on surgical outcome of arterial switch operation. METHOD: From August 2014 to November 2015, total 60 patients underwent ASO. The patients are divided in three groups. Group-A 21 patients with d-TGA with intact ventricle septum (d-TGA intact IVS), in Group-B 33 patients d-TGA with ventricular septal defect (d-TGA, VSD), and in Group C 6 Taussig Bing anomaly. The coronary pattern and outcome is analyzed. RESULTS: The overall mortality related to coronary pattern was 5%. The 2 patients died due to Intramural coronary artery leading to postoperative ventricular dysfunction, another patient with single retro pulmonary coronary artery died secondary to low coronary implant leading to kinking in coronary artery and myocardial dysfunction. On 12 monthly follow up, one of the Patients in group A had right pulmonary artery stenosis with gradient of 30 mm of Hg. Another patient in group B had supravalvular gradient of 20 mm of Hg. CONCLUSION: The ASO for TGA and Taussig-Bing anomaly has low early and late mortality. However, the mortality is still seen in the patients with Intramural coronary artery and in the patient with single coronary artery with retro pulmonary course

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PRETRANSFUSION COMPARISON OF DIALYSER BASED HEMOCONCENTRATOR WITH CELL SAVER SYSTEM FOR PERIOPERATIVE CELL SAVAGE.
Pankaj Garg, Amber Malhotra, Manan Desai, Pranav Sharma, Arvindkumar Bishnoi, Payal Tripathi, Dayesh Rodricks, Himani Pandya Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery
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Objective: Cell Saver system is the method of choice for red blood cell salvage from the surgical field; however, cost is a limiting factor. We at our institute have devised a cost-effective version of dialyser-based autotransfusion system. We performed pretransfusion comparison of our autotransfusion system with conventional cell saver system.<br />Methods: A prospective randomized observational study was performed in 104 consecutive patients with coronary artery disease undergoing by off-pump coronary artery bypass grafting. Patients were divided into two groups. In the dialyser group (53 patients), blood from surgical field was salvaged by our dialyser-based system. In the cell saver group (51 patients), blood was salvaged by cell saver. In both groups, 20-mL sample from the salvaged blood was analyzed for hemoglobin, platelets, protein, albumin, free hemoglobin, osmotic fragility, and peripheral blood smear examination.<br />Results: Total hemoglobin salvaged was comparable in both groups (85% vs 76%). On peripheral smear, red blood cells were swollen, but morphology was preserved. Moreover, normal osmotic fragility suggested absence of any lethal damage to red blood cells in either group. Dialyser-based system was more efficient in salvaging platelets (42.9% vs 6%), proteins (79.2% vs 0%), and albumin (65% vs 0%). Total free hemoglobin was three times more in dialyser group but was well below recommended limits.<br />Conclusions: Dialyser-based system is economical, is equally efficacious in salvaging red blood cells, is more effective in salvaging platelets and proteins, and does not contain significant amount of free hemoglobin. Therefore, this salvaged blood can be safely transfused.

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TECHNIQUES OF LEFT VENTRICULAR ANEURYSM REPAIR:CHALLENGES AND OUTCOME.
Jignesh Kothari, Hemang Gandhi, Bhavin Brahmbhatt, Kinnaresh Baria, Sanjay Patel,Himani Pandya J of Evidence Based Med & Hlthcare, Vol. 2/Issue 44/Nov. 02, 2015 Page 7915
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INTRODUCTION: Left ventricular aneurysm is commonly secondary to coronary artery disease. The resulting abnormal geometry after surgical treatment is most important. Many techniques have evolved over a period to restore near normal geometry of left ventricle (LV). It is mandatory to address atherosclerotic lesions which are root cause of ischemia and its sequel. METHOD AND MATERIALS: Four patients with myocardial infarction presented to our institute were investigated with 2 Dimensional Echocardiography and contrast enhanced computerized tomography (CECT) of thorax. All patients underwent left ventricle aneurysm repair and two patients also underwent Coronary Artery Bypass Grafting (CABG). We followed all of them with CECT and clinical examination. RESULT: All patients had good post-operative recovery. Their Intensive Care Unit parameters were within acceptable limits. The functional class improved to New York Heart Association class II for these patients. Post-operative CECT showed significant reduction in LV dimension and no alteration in LV geometry. CONCLUSION: The technique of Left Ventricle aneurysm repair should be determined by pre-operative evaluation and CABG must be attempted if possible

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HYPERBILURUBINEMIA AFTER CARDIAC SURGERY: AN OBSERVATIONAL STUDY.
Pranav Sharma, Chandrasekaran Ananthanarayanan,Nikunj Vaidhya, Amber Malhotra, Komal Shah and Ramanand Sharma Asian Cardiovascular & Thoracic Annals 0(0) 1–5
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Background: We aimed to assess the incidence and perioperative risk factors for hyperbilirubinemia after cardiac surgery, and determine its influence on early operative outcome. Methods: This prospective observational study was conducted on 476 patients who underwent cardiac surgical procedures from January 2014 to March 2014. Postoperative hyperbilirubinemia was defined as serum total bilirubin >2.0 mg dL1. Results: The overall incidence of postoperative hyperbilirubinemia was 25% (119 patients). Patients undergoing valve repair or replacement had the highest incidence of hyperbilirubinemia (36.2%), followed by coronary artery bypass grafting with concomitant valve surgery (34.1%), congenital heart surgery (23.1%), and coronary artery bypass alone (12.7%). Postoperative hyperbilirubinemia was associated with increased duration of inotropic support (p ¼ 0.0001), mechanical ventilation (p ¼ 0.0001), intensive care unit stay (p ¼ 0.001), hospital stay (p ¼ 0.006), and mortality (p ¼ 0.014). The perioperative factors associated with postoperative hyperbilirubinemia were increased preoperative bilirubin level (p < 0.0001), Preoperative prothrombin time (p < 0.0001), cardiopulmonary bypass time (p ¼ 0.028), aortic<br />crossclamp time (p ¼ 0.004), and blood transfusion units (p ¼ 0.0001). Conclusions: Postoperative hyperbilirubinemia is common in patients undergoing cardiopulmonary bypass and is associated with high hospital mortality. The factors associated with its occurrence are increased preoperative bilirubin<br />level, preoperative prothrombin time, cardiopulmonary bypass time, aortic crossclamp time, and blood transfusion units. Persistent hyperbilirubinemia is associated with a worse outcome than early transient hyperbilirubinemia.

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POLYMERIC SEALANT (COSEAL) IS IT WORTH IN CONGENITAL HEART SURGERY.
Amit Mishra, Hardik Patel, Komal Shah, Manish Hinduja, Vivek Wadhawa, Pratik Shah, Himani Pandya, Jigar Patel, Jigar Surti American Journal of Advanced Medical & Surgical Research, Volume 1, Issue 1, 2015, 41-43
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Our institute being a tertiary referral center in western part of India, we perform nearly 400 neonatal cardiac surgeries every year. The prospective study was designed to look for the effectiveness of the polymeric sealant (CoSeal) in controlling bleeding, and adhesion prevention, in the neonatal congenital heart diseases. From January 2013 to April 2015, 98 patients who underwent various congenital heart disease surgeries were included in the study. The sprayable polymeric matrix - Coseal surgical sealant was electively used in 57 patients (group 1) undergoing arterial switch, norwood and complex neonatal arch repairs. In group 2 no surgical sealant was used and 41 patients from surgeries apart from group 1 were enrolled. The groups were compared for demographic, preoperative, operative and post-operative characteristics. The results showed better intra- and postoperative outcome in group 1 patients as compare to group 2 patients, which was statistically significant (p less than 0.05). Amongst operative parameters, mean CPB time (162.67 ± 49.05 vs 182.29 ± 40.84 min) and aortic cross clamp time (125.72 ± 34.8 vs 147.12 ± 58.67 min) were significantly lower in patients were sealant was used. Post-operative complications namely - incidence of leaving the chest open (19.64%), greater days of ventilation (4.43 ± 2.86 days), higher ICU stay duration (10.07 ± 5.8) and hospital stay (14.02 ± 6.12 days) were more prevalent in group 2patients. The use of polymeric sealant has helped us in improving our overall results of congenital surgeries as well as in reducing post-operative morbidity, complications and the overall cost of surgery.

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ATRIAL FIBRILLATION FOLLOWING OFF-PUMP CORONARY ARTERY BYPASS GRAFT SURGERY: INFLUENCE OF SINGLE, LOW DOSE AMIODARONE.
Dr. Jignesh Kothari, Dr. Ramesh Patel, Dr. Hemang Gandhi, Dr. Ajay Chaurasia, Sanjay Patel IRPMS | VOL-1 | NO. 2 | APR-JUN | 2015
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Background: Atrial Fibrillation occurs in 20-50% of patients who undergo coronary artery bypass grafting and major cause of increased intensive care unit and hospital costs. This study, therefore assessed the safety, efficacy and benefits of low dose amiodarone in the prevention of post-operative atrial fibrillation after coronary artery bypass grafting. Materials and Methods: One hundred and twenty eight patients who underwent off pump coronary artery bypass grafting during November 2011 to January 2013 received low dose intravenous amiodarone at induction and compared to controls (N=130). A Reduction in the incidence of post-operative atrial  fibrillation, its duration and the need for other drug combinations for its control were examined. Results: Incidence of post operative atrial fibrillation in amiodarone treated patients was significantly lesser 13/121 (10.7%) patients as compared to 26/122 (21.3%) controls. The duration of atrial fibrillation, however was similar in both the groups (3.3 +/- 1.4 days in patients 3.5 +/- 1.7 days in controls Mean +/- SD). Amiodarione infusion at a dose of 700 mg for the next 24 hours in all the patients controlled the heart rate. In the average duration of reversal of atrial fibrillation to sinus rhythm was 4 to 6 hours in all these patients. Conclusion: The current study is a demonstration of significant reduction in the number of patients experiencing post operative atrial fibrillation following peri-operative single intravenous, low dose amiodarone. Further, low dose amiodarone is well tolerated and does not increase risk of intra and post operative complications in patients undergoing off pump coronary arterial bypass grafting.

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COMPARATIVE STUDY OF FRESH VERSUS OLD STORED BLOOD IN THE PRIMING OF EXTRACORPOREAL CIRCUIT IN CARDIOPULMONARY BYPASS FOR PEDIATRIC PATIENTS.
Pankaj Garg, Amber Malhotra, Pranav Sharma, Arvind Kumar Bishnoi, Atul Solanki, Nikunj Vaidya, Pratik Shah American Journal of Advanced Medical & Surgical Research, 2015;1(1):15-17.
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We aim to evaluate the metabolic effects of fresh (less than or equal to 7 days) versus old (more than 7 days) packed red blood cells (PRBCs) added to the priming solutions of pediatric patients undergoing cardiac surgery. Forty consecutive pediatric cardiac patients were divided into 2 groups. In group 1 fresh (less than or equal to 7 days old) RBCs were added to the priming solution, while in group 2 old (more than 7 days old) PRBCs were added. In each roup, blood samples were drawn from the PRBCs on arrival, after addition to the priming solution, after 10 minutes of prime circulation, after 30 minutes of beginning of cardiopulmonary bypass (CPB) and on patient’s arrival to the pediatric intensive care unit (PICU). The levels of potassium, glucose, and the acid-base balance were assessed. There was a linear increase in potassium levels in packed red lood cell samples with increasing age of PRBCs, ranging from 5.5 to 17.8 mEq/L. Significant differences in the concentrations of potassium, glucose, and the acid-base balance were found when comparing old and fresh PRBCs in samples taken during the PRBCs and early prime time. Those differences resolved after 10 minutes of reconstitution of the priming solution. The age of the PRBCs had no effect on the samples taken during bypass and those taken in the pediatric intensive care unit. The significantly higher concentration of potassium and lower pH in old stored PRBCs has a minimal effect on the final constitution of priming solution before and during cardiopulmonary bypass in children undergoing corrective cardiac surgery.

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MID-TERM OUTCOME OF SURGERY FOR CHRONIC CONSTRUCTIVE PERICARDITIS: A SINGLE CENTER EXPERIENCE.
Pankaj Garg, Amber Malhotra, Pranav Sharma, Ketav Lakhia, Komal Shah, Sanjay Patel American Journal of Advanced Medical & Surgical Research, 2015;1(1):9-14.
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We reviewed the records of 45 patients (mean age, 24.35 ± 20.46 yr; range, 21–84 yr) with a diagnosis of constrictive pericarditis who had undergone pericardiectomy from 1994 through 2006. Preoperatively, 5 of the patients (4.4%) were in New York Heart Association (NYHA) functional class I, 38 (44.4%) in class II, 39 (48.9%) in class III, and 4 (2.2%) in class IV. Pericardial calcification was detected in 14% of plain chest radiographs. Constrictive pericarditis was caused by tuberculosis in 32.6%, and chronic renal failure in 2.3%. The cause was idiopathic in 67.4% of the patients. Low-output state was the most common postoperative problem (9.8%). The mean follow-up period was 24 ± 20 months (range, 3–60 month). At three months follow up all our survived patients (n=85) were either in NYHA class I (90.6%) or in class II (9.4%). The overall mortality rate was 1.2%. One patient with tuberculosis died of sepsis early after surgery, and 1 died during follow-up probably due to arrhythmia. Our results show that pericardiectomy remains an effective procedure in the treatment of constrictive ericarditis. Tuberculosis is still an important cause of constrictive pericarditis in India, despite vaccination and use of antitubercular drugs.

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FLURESCEIN DYE-GUIDED INTRAOPERATIVE IDENTIFICATION AND CLOSURE OF MUSCULAR VENTRICULAR SEPTAL DEFECT.
Arvind Kumar Bishnoi, Pankaj Garg, Manan Desai, Pranav Sharma, Jigar Patel, Mrugesh Prajapati, and Amber Malhotra World Journal for Pediatirc and Congenital Heart Surgery, 2015 vol. 6 no. 1 59-66
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Objective : Various techniques for intraoperative identification of muscular ventricular septal defects (VSDs) are cumbersome, difficult to use in infants, and inefficient in confirming the completeness of closure. We used simple technique of intraoperative fluorescein saline injection into the left ventricle to locate the muscular VSDs and to confirm their closure. Methods : This is a prospective observational study conducted between April 2013 to December 2013, involving 22 patients with multiple VSDs either in isolated form or in association with other congenital cardiac anomalies. Following the closure of all visible VSDs, an 8F infant feeding tube was introduced into the left ventricle through the fossa ovalis and fluorescein saline was injected. Right ventricle was observed for saline leakage and VSD site tracking. Saline injection was repeated till appearance of no significant leak. Results: A total of 63 defects were closed in 22 patients. Only two patients required re-endocardialization or septal exclusion technique for Swiss cheese septum. None of them required division of moderator band or major trabeculae. Eleven patients had insignificant residual shunting found on postoperative echocardiography. There were two deaths. In the remaining 20 patients, the mean of intensive care unit (ICU) and hospital stay was 5.4 ± 3.72 and 10.2 ± 4.64 days, respectively. Comparative study between patients with and without residual VSD showed no significant difference in mean inotropic score, ICU, and hospital stay, confirming the absence of significant residual shunting. Conclusions: Intraoperative fluorescein saline injection into the left ventricle is safe, effective in precisely localizing muscular VSDs and confirming the completeness of their closure.

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OPERATIVE MANAGEMENT OF INTRACARDIAC MYXOMA: A SINGLE CENTRE EXPIRIENCE.
Amit Mishra, Mehul Shah, Pranav Sharma, Jignesh Kothari, Amber Malhotra Medical Journal Armed Forces India; Volume 70, Issue 1 , Pages 5-9, January 2014
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Background: Cardiac myxomas are the most common benign intracardiac tumors. We studied the clinical presentation of cardiac myxomas, their morbidity, mortality and recurrence rate following surgery at our institution over a period of four years. Methods: During August 2008 to November 2012, a total of 12023 cardiac surgeries were performed. Amongst these, 50 patients (12 males, 38 females) underwent complete removal of primary or recurrent intracardiac myxomas. Complete tumor excision with a cuff of interatrial septum followed copious saline irrigation of the cardiac chambers was performed in each case. Results: Forty six patients survived the surgery of which 43 are being followed up at regular intervals for development of recurrence. Myxomas constituted 0.41% of the total cardiac surgeries at our institute. Most of them were noted in the fourth decade. The commonest location was left atrium (74%) followed by right atrium (22%). Only one patient had a myxoma in the right ventricle. Forty six patients (92%) survived the surgery. Conclusions: Cardiac myxoma excision account for a very small percentage of cardiac procedures. Immediate surgical treatment is indicated in all patients. Cardiac myxomas can be excised with a low rate of mortality and morbidity.

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A SIMPLE SURGICAL TECYHNIQUE FOR CLOSURE OF APICAL MUSCULAR VENTRICULAR SEPTAL DEFECT.
Dr. Amit Mishra, Dr. Ritesh Shah, Dr. Manan Desai, Dr. Ajay Chourasiya, Dr. Hardik Patel, Dr. Nilesh Oswal, Mr. Dayesh Rodricks The Journal of Thoracic and Cardiovascular Surgery, 2014 Feb 14. pii: S0022-5223(14)00196-2
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Objective : Ventricular septal defect (VSD) is among the most common congenital heart diseases encountered in pediatric cardiac patients. Apical muscular VSD constitutes nearly 2% of defects, which may or may not be associated with other congenital heart defects. The purpose of our study is to present our innovative and simple surgical technique using custom-made low-profile polytetrafluoroethylene (PTFE) single disc device for closing multiple apical muscular and isolated apical muscular VSD. Methods : Between January 2010 and July 2013, 17 patients with isolated or multiple apical muscular VSDs with or without associated heart diseases underwent operation at our institute. The apical VSD was closed using our custom-made low-profile single disc polytetrafluoroethylene device. The operative technique and the technique used to prepare the single disc device are detailed. Results: Seventeen patients of ages ranging from 3 months to 7 years underwent operation over 3 years. One 8-month-old patient with transposition of the great arteries with multiple VSDs died after 35 days due to severe pulmonary artery hypertension and sepsis. Another newborn infant with infracardiac total anomalous pulmonary venous connection with a 4-mm apical VSD also died after 3 days because this VSD could not be identified. All other patients are doing well on follow-up. Conclusions: The technique described by us has the advantage of apical VSD closure through the left ventricle without left ventriculotomy. Our technique is simple and cost-effective.

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STUDY OF LEVOSIMENDAN DURING OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH LV DYSFUNCTION: A DOUBLE-BLIND RANDOMIZED STUDY.
B Shah, P Sharma, A Brahmbhatt, R Shah, B Rathod, Naman Shastri, J Patel, A Malhotra. Indian Journal of Pharmacology, Year:2014 | Volume:46 | Issue:1 | Page:29-34
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Objective : Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for off-pump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%). Materials and Methods : Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 μg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured. Results: The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay. Conclusions: Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay.

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IS STEEL WIRE CLOSURE OF STERNOTOMY BETTER THAN POLYESTER SUTURE CLOSING?
Amber Malhotra, Pankaj Garg, Arvind Kumar Bishnoi,Varun Pendro, Pranav Sharma, Madhav Upadhyay and Sanjay Gandhi Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(4) 409–415
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Introduction: Median sternotomy is the preferred approach for open heart surgeries. The sternotomy incision is predominantly closed with either steel wire or polyester suture. The type of material used is primarily based on the surgeon’s choice, and both materials achieve a good result. No prospective clinical study has been undertaken to evaluate differences in the incidence of wound infection and the degree of pain associated with both techniques. Patients and methods: Our randomized controlled double-blind study included 200 adults undergoing single-valve replacement. The technique of surgery, apart from the material used for sternal closure, was the same in both groups. Postoperatively, patients were analyzed for wound infection and wound pain based on the ASEPSIS score and Numeric Pain Rating Score, respectively. Results: The polyester suture group had a significantly higher mean ASEPSIS score, indicating a higher incidence of wound infection, and more late wound complications. The polyester suture group also had a significantly higher mean pain score. The steel wire group had significantly higher mediastinal drain output in the first 48 h after surgery. Conclusion: The use of polyester suture for sternal closure in adult patients results in increased wound infection,wound pain, and late wound complications, but lower mediastinal drain output.

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CORRELATION OF END TIDAL CARBON DIOXIDE WITH ARTERIAL CARBON DIOXIDE DURING CARDIOPULMONARY BYPASS.
Dr. Kothari J. V. ,Dr. Patel R. D.,Dr. Chaurasiya A,Dr. Solanki A ,Dr. Thosani R. M Indian Journal of Applied Basic Medical Science 16a(22):645-647;2014
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Introduction : Optimal blood gas management is subjected to pH- and alpha- state during hypothermia; Alpha state managed by maintaining constant total carbon dioxide stores during cardiopulmonary bypass (CPB) changes thermodynamic dissociation with change in temperature. pHremains constant during temperature changes. A correlation between end tidal carbon dioxide and arterial PCO2 known to be a non- invasive and safe procedure in patients undergoing Coronary artery bypass graft. Patients and Methods : Forty patients were maintained with normothermia and hypothermia during cardiac surgery in the current study. All patients were operated with midline sternotomy, aortic bicavalcannulation or aortic-right atrium cannulation for cardiopulmonary bypass. Arterial Blood Gas measurements (ABG) along with ETCO2 and PaCO2 monitoring were performed. Results: The patient group had undergone a variety of surgical procedures (viz. Coronary artery bypass grafting, Replacement of mitral- or aortic- valve or double valve). They were maintained on CPB with aorta cross clamp. There was no significant difference in ETCO2 and PaCO2 pressures both at normothermia as well as moderate hypothermia during CPB. Conclusions: Monitoring ETCO2 reflects accurate measurements of PaCO2. Repeated sampling for ABG therefore can be avoided as a cheap, non-invasive method to ascertain the health of the patients.

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TRANSPOSITION OF GREAT ARTERIES WITH AORTOPULMONARY WINDOW: OUR SURGICAL EXPERIENCE.
Mishra A, Gandhi H, Sharma P, Patel H, Parmar D, Sheth M, Rodricks D. Ann Thorac Surg. 2014 Jan;97(1):196-201. doi: 10.1016/j.athoracsur.2013.07.012.
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Background : Transposition of the great arteries with aortopulmonary window is a rare congenital cardiac anomaly. An arterial switch operation with repair of the aortopulmonary window is the preferred operation in this subset. As the tissue between the great arteries is missing, it is considered to be a complex operation. The purpose of this study is to present our experience of a simple yet highly effective surgical technique for the management of this rare complex cardiac defect. Methods : We detail our experience of the surgery of this complex defect in 4 patients. Standard technique of an arterial switch operation with minor modification in excision of branch pulmonary arteries is all that is needed in approaching this complex subset. The moiety of tissue resulting from the absence of an aortopulmonary window was naturally covered by the proximal and distal neo-aortic flap tissue. The operative technique used in the 4 cases and their presentations are detailed in the text. Results: Four patients of ages 28 days, 35 days, 40 days, and 6 months were successfully operated. One patient expired on postoperative day 21. In this case, advanced age of presentation, severe pulmonary artery hypertension, and sepsis possibly caused the death. The remaining 3 patients are off medication now and are being regularly followed up. Conclusions: In our experience early diagnosis and an arterial switch operation have been crucial in getting a favorable outcome in planning of this complex congenital heart disease.

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RING ANNULOPLASTY FOR ISCHEMIC MITRAL REGURGITATION: A SINGLE CENTRE EXPERIECE.
Amber Malhotra, Pranav Sharma, Pankaj Garg, Arvind Bishnoi, Jignesh Kothari and Jigisha Pujara Asian Cardiovascular and Thoracic Annals; DOI: 10.1177/0218492313513594
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Background : Ischemic mitral regurgitation associated with coronary artery disease presents a management challenge to cardiac surgeons. We report our early and midterm results of chronic ischemic mitral regurgitation treated with concomitant mitral ring annuloplasty and coronary artery bypass grafting. Methods : We performed a retrospective review of the medical records of patients who underwent coronary artery bypass grafting at our institute from January 2009 to December 2011. Data were collected in 50 patients with chronic ischemic mitral regurgitation who had mitral ring annuloplasty along with coronary artery bypass grafting. Preoperative data, echocardiographic findings, operative procedure, outcome, and perioperative hemodynamics were analyzed. Early and intermediate follow-up data were also collected and analyzed. Results: There were 3 (6%) early and 9 (18%) late deaths. Of the survivors, 38 (76%) had a significant reduction in left ventricular end-diastolic and end-systolic dimensions and improvement in New York Heart Association functional class. Conclusions: Despite a risk of residual regurgitation, mitral ring annuloplasty combined with coronary artery bypass appears to be a good treatment option in selected patients with chronic ischemic mitral regurgitation.

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PREOPERATIVE LEVOSIMENDAN IN ISCHEMIC MITRAL VALVE REPAIR.
Pranav Sharma, Amber Malhotra, Sanjay Gandhi, Pankaj Garg,Arvind Bishnoi and Hemang Gandhi Asian Cardiovascular and Thoracic Annals; DOI:10.1177/0218492313499352
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Background: Levosimendan is a new calcium sensitizing drug with vasodilatory and inotropic properties, which is used for the treatment of postoperative low cardiac output syndrome and difficult weaning from cardiopulmonary bypass. Objective: To evaluate the hemodynamic effects of levosimendan during and after coronary artery bypass grafting on cardiopulmonary bypass and mitral valve repair in patients with low left ventricular ejection fractions (<30%). Methods: 40 patients were enrolled in this double-blind prospective randomized controlled trial. They received either levosimendan or a placebo preoperatively (n¼20) for 24 h. Clinical parameters were measured before and after administration. Any adverse events during and after drug administration and postoperative complications were evaluated. Results: Patients treated with levosimendan exhibited a higher cardiac index and mean arterial pressure intraoperative and in the early postoperative period, compared to the control group. Patients treated with levosimendan required less ventilatory support (p<0.0001) and had shorter intensive care unit (p<0.0001) and hospital stay (p<0.0001). Conclusions: Preoperative treatment with levosimendan in patients undergoing coronary artery bypass grafting and mitral valve repair resulted in improved hemodynamics and a stable postoperative course.