Research (Cardio Vascular Thoracic Surgery)

Original Articles

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Lipoprotein A as an Independent Risk Factor of Coronary Artery Disease in Western Indians
Seema Sharma, Pranav Sharma, Journal of Cardiovascular Medicine and Surgery 2018 Volume 4, Issue 1, January - March 2018, Pages 40-45
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Abstract

Aims and Objective: To assess the association of lipoprotein a (Lp a) with coronary artery disease (CAD) in Western Indians. Material and methods: In this single centric, prospective and case control study 200 subjects (100 patients with CAD & 100 healthy volunteer) were enrolled. Fasting blood sample were collected from the antecubital vein of the subjects under sterile conditions. Lipid profile parameters such as total cholesterol (TC), triglyceride (TG), total lipid (TL), low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein cholesterol (VLDL), Lp (a) were measured. Results: The prevalence of cardio-metabolic risk factors was significantly higher in cases as compared to controls (p<0.05). Similarly significantly higher mean lipid levels namely total cholesterol, triglyceride, low density lipoprotein and Lp (a) was observed in CAD patients as compared to their counterparts. Lp (a) levels were well correlated with angiographic severity of the disease and overall incidence of the disease was found to be highest in the greatest quartile of Lp (a). Conclusion: Lp (a) levels are important markers of CAD in Western Indians and could be effectively used to in clinical setting.

Keywords: Lipoprotein A; Western Indians; Coronary Artery Disease; Lipid Profile. 

 

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Surgical overview of cardiac echinococcosis: a rare entity
Vivek Wadhawa, Jigar Shah, Chirag Doshi, Jaydip Ramani, Ketav Lakhia, Divyesh Rathod Reema Tavar, Jignesh Kothari, Interactive Cardiovascular And Thoracic Surgery 2018
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Abstract

OBJECTIVES

The purpose of this study was to describe our experience with the presentation and management of cardiac echinococcosis and the outcomes.

METHODS

We performed a retrospective study from January 2012 to September 2017 in 10 patients operated on for cardiac echinococcosis. There were 6 men and 4 women; the age range was 17–55 years (mean age, 35.9 ± 12.04 years). Among the 10 patients, 3 had multiple cysts and of the 7 patients with a solitary cyst, 5 cysts were in the left ventricle, 1 was in the right ventricle and 1 was in the interventricular septum. All patients were evaluated with electrocardiography, transthoracic echocardiography, computed tomography/magnetic resonance imaging of the thorax, ultrasound examinations of the abdominal organs, haemagglutination tests and histopathological examination of the cyst.

RESULTS

Nine operations were performed using cardiopulmonary bypass. One patient with a pericardial cyst was operated on with a beating heart with cystectomy and partial pericardiectomy. Preoperatively, all patients received albendazole for 2 weeks except for 1 patient who had an emergency operation. Albendazole was continued postoperatively in all patients for 12 weeks. There were no postoperative complications. No recurrences have been observed so far.

CONCLUSIONS

Cardiac echinococcosis is an infrequently encountered entity, but with clinical suspicion and early diagnosis it can be successfully managed with good outcomes.

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“RFEF” and mitral regurgitation jet direction: surrogate markers for likelihood of left ventricle reverse remodeling in patients with moderate chronic ischemic mitral regurgitation
Dr.Sumbul Siddiqui, Dr.Amber Malhotra, Dr.Komal Shah, Dr.Pankaj Garg, Dr.Pranav Sharma, Dr.Vivek Wadhawa, Dr.Kartik Patel, Dr. Anand Shukla
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Purpose

Surgical management of moderate chronic ischemic mitral regurgitation (CIMR) is controversial. We propose a simplified classification of moderate CIMR based on regurgitant fraction (RF), ejection fraction (EF), and jet direction (central/eccentric) to predict left ventricle (LV) remodeling and identify patient subsets which need mitral valve (MV) repair along with coronary artery bypass grafting (CABG).

Methods

In this prospective controlled study (n = 210), patients with moderate CIMR were randomized. Group I (n = 106) underwent off-pump CABG alone while group II (n = 104) underwent CABG + MV repair. The product of regurgitation fraction and ejection fraction (“RFEF”) was taken as a surrogate for myocardial reserve. The cut-off defined was 0.12; patients with RFEF ≤ 0.12 were categorized as the “bad” and those with RFEF > 0.12 as the “good” subset. The patients were further subdivided on the basis of their mitral regurgitation (MR) jet direction (central/eccentric). The percentage improvement in left ventricular end-systolic volume index (LVESVI) and MR grade were recorded 6 monthly.

Results

Analysis of the continuous variable “RFEF” in conjunction with jet direction was performed. At 12 months, the patient in good subset with central direction of jet showed improvement in LVESVI % in both groups (p = 0.428), while the patients in bad subset with eccentric direction of jet showed significantly higher improvement in LVESVI %, group II as compared to group I (p = 0.004).

Conclusion

This study thus identifies “RFEF” as a surrogate for reverse remodeling capacity. In association with MR jet direction, predicts the subset of moderate CIMR patients most likely to have maximum LVESVI and MR grade reduction.

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‘CLAS’ score: an objective tool to standardize and predict mitral valve repairability
Amber Malhotra, Sumbul Siddiqui, Vivek Wadhawa Himani Pandya, Kartik Patel Komal Shah, Hemang Gandhi Pankaj Garg, Kamal Sharma
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Perpose

Carpentier’s classification has been used to classify both stenotic and regurgitant lesions. However, given the extreme variability of lesions, a universal nomenclature suggestive of the complexity and the prognosis of the repair procedure for the entire spectrum of the mitral valve disease still remains elusive. We present the predictors of mitral valve repairability with the help of a four-level-based ‘CLAS’ scoring system.

Methods

A total of 394 patients undergoing mitral valve procedure were prospectively studied. The valvular apparatus was divided into four sub-units, namely Commissures (C), Leaflet (L), Annulus (A), and Subvalvular apparatus (S), and the components were scored individually and the summation scores were calculated. Based on our results, three CLAS groups were formulated.

Results

A total of 376 (n = 394) patients underwent successful MVRep (95.43%; on-table failure in 18 patients). A total of 276 were rheumatic, 51 degenerative, 28 congenital, and 16 had infective endocarditis. Thirty-day mortality was 14 (3.72%) while delayed re-intervention rate was 8 (2.12%). The mean follow-up period was 30 months. One hundred percent patients with a CLAS score ≤ 8 had a successful repair as compared to 93.33 and 69.69%, respectively, for patients with scores between 9 and 12 and > 12, respectively. The cardio pulmonary bypass time, aortic-cross-clamp time, and ICU stay also showed a significant correlation with the patient’s ‘CLAS’ groups.

Conclusion

The CLAS score is highly predictive of a successful repair. We thus propose that, in the patients with a score of ≤ 8, repair should always be attempted irrespective of the pathology. The patients expected to be scored > 8 should be referred to a repair reference center.

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Direct Femoral Cannulation in Minimal Invasive Pediatric Cardiac Surgery: Our Experience with Midterm Result
Vivek Wadhawa, Kartik Patel Chirag Doshi, Jigar Shah Jaydip Ramani, Pankaj Garg, Sudhir Adalti, Yashpal Rana, Himani Pandya, Vijay Gupta
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Objective 

One of the major challenges faced in minimally invasive pediatric cardiac surgery is cannulation strategy for cardiopulmonary bypass. Central aortic cannulation through the same incision has been the usual strategy, but it has the disadvantage of cluttering of the operative field. We hereby present the results of femoral cannulation in minimally invasive pediatric cardiac surgery in terms of adequacy and safety.

Methods 

From January 2013 to June 2016, 200 children (122 males) with mean ± SD age of 9.2 ± 4.51 years (median = 6 years, range = 3–18 years) and weight of 19.22 ± 8.49 kg (median = 15 kg, range = 8–45 kg) were operated for congenital cardiac defects through anterolateral thoracotomy. The most common diagnosis was atrial septal defect (144 patients). In all the patients, femoral artery and femoral vein were cannulated along with direct superior vena cava cannulation for institution of cardiopulmonary bypass.

Results

There were no deaths or any major complications related to femoral cannulation. Femoral artery cannulation provided adequate arterial inflow, whereas femoral vein with direct superior vena cava cannulation provided adequate venous return in all the patients. No patient required vacuum-assisted venous drainage. No patient required conversion to sternotomy or developed vascular, neurological complications. At discharge and at 1-year follow-up, both femoral artery and vein were patent without a significant stenosis on color Doppler ultrasonography in all the patients. At mean ± SD follow-up period of 30.63 ± 10.09 months, all the patients were doing well without any wound-related, neurological, or vascular complications.

Conclusions 

Femoral arterial and venous cannulation is a feasible, reliable, and efficient method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

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Ebstein's Anomaly: "The One and a Half Ventricle Heart"
Amber Malhotra ,Vishal Agrawal, Kartik Patel ,Mausam Shah, Kamal Sharma, Pranav Sharma, Sumbul Siddiqui, Nilesh Oswal, Himani Pandya
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Abstract
 
Objective

Ebstein's anomaly remains a relatively ignored disease. Lying in the 'No Man's land' between congenital and valve surgeons, it largely remains inadequately studied. We report our short-term results of treating it as a 'one and a half ventricle heart' and propose that the true tricuspid annulus (TTA) 'Z' score be used as an objective criterion for estimation of 'functional' right ventricle (RV).

Methods

22 consecutive patients undergoing surgery for Ebstein's anomaly were studied. Echocardiography was performed to assess the type and severity of the disease, tricuspid annular dimension and its 'Z' score. Patients were operated by a modification of the cone repair, with addition of annuloplasty, bidirectional cavopulmonary shunt (BCPS) and right reduction atrioplasty to provide a comprehensive repair. TTA 'Z' score was correlated later with postplication indexed residual RV volume.

Results

There was one (4.5%) early and no late postoperative death. There was a significant reduction in tricuspid regurgitation grading (3.40±0.65 to 1.22±0.42, P<0.001). Residual RV volume reduced to 71.96±3.8% of the expected volume and there was a significant negative correlation (rho −0.83) between TTA 'Z' score and indexed residual RV volume. During the follow-up of 20.54±7.62 months, the functional class improved from 2.59±0.7 to 1.34±0.52 (P<0.001).

Conclusion

In Ebstein's anomaly, a higher TTA 'Z' score correlates with a lower postplication indexed residual RV volume. Hence, a complete trileaflet repair with offloading of RV by BCPS (when the TTA 'Z' score is >2) is recommended. The short-term outcomes of our technique are promising.

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Transverse Split Sternotomy for Repair of Tetralogy of Fallot: Mid Term Results
Kartik Patel, Chandrasekaran Ananthanarayanan, Pankaj Garg, Vaibhav Jain, Parth Solanki, Ketav Lakhia, Vijay Gupta, Sanjay Patel
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Abstract

Background: Mini-invasive pediatric cardiac surgery has been slow to gain pace due to limited surgical exposure and long learning curveWe started performing transverse sternal split (TSS) to improve surgical exposure with advantage of mini incision in tetralogy of Fallot (TOF) and here we have reviewed our short and mid -term results. Methods: Retrospectivereview of patientsof TOF (n=23) operated using TSS (Group 1) from January-2015 to Dec- 2016 was performed. Patients were compared with matched patients operated using midline sternotomy (Group 2). Further,TSS group wasdivided into two sub-groups: Group 1A-patients operated in 2015 (n=11) & Group 1B-patients operated in 2016(n=12). Pre-operative, intraoperative and post-operative datawere collected and analyzed. Results: There was no significant difference in mortality, residual defects and morbidity between TSS and sternotomy group. Mean preparation (p<0.001), cross clamp (p=0.001), CPB (p<0.001), and surgery time (p<0.001) were significantly higher in TSS group than sternotomy group. However, mean duration of ventilation, ICU and hospital stay were significantly lower (p<0.05) in TSS group. Whileanalyzing TSS sub-groups, mean preparation, cross clamp, CPB and surgery time were significantly lower (p<0.05) in group 1B as compared to group 1A, however all remained higher than sternotomy group. Cosmetic result was satisfactory without sterna dehiscence in TSS group and all were in NYHA-Iat mean follow-up of 17.6±7.4 months. Conclusions: The TSS is good alternative to a midlinesternotomy for TOF repair in selected patients with satisfactory cosmetic results without compromising the surgical exposure or quality of repair. With increase in expertise, operative duration can be decreased although it remains higher than midline sternotomy.

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A Normokalemic, non depolarising, long Acting Blood Cardioplegia
Vivek Wadhawa ,Amber Malhotra, Jaydip Ramani, Pankaj Garg, Pranav Sharma , Himani Pandya, Dayesh Rodricks, Asian Cardiovascular Thoracic Annals. 2017 Sep-Oct;25(7-8):495-501
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Abstract
Objective: Blood cardioplegia, the gold-standard cardioprotective strategy, requires frequent dosing, resulting in
hyperkalemia-induced myocardial edema. The aim of our study was to compare the efficacy and safety of a longacting
blood-based cardioplegia with physiological potassium levels versus the well-established cold blood St. Thomas’
Hospital no. 1 cardioplegia solution in multivalve surgeries.
Methods: One hundred patients undergoing simultaneous elective aortic and mitral valve replacementtricuspid valve
repair were randomized in two groups. In group 1, adenosine 12 mg was given via the aortic root after crossclamping,
followed by a single dose of long-acting solution at 14C (30 mLkg1); in group 2, an initial 30 mLkg1 of St. Thomas’
cardioplegia at 14Cwas administered, followed by 15 mLkg1 every 20 min. Duration of cardiopulmonary bypass, inotropic
score, arrhythmias, ventilation time, and the levels of interleukin-6, creatinine kinase-MB, and troponin I were compared.
Results: Mean cardiopulmonary bypass and crossclamp times were 134.0436.12 vs. 154.3434.26 (p¼0.004) and
110.3724.80 vs. 132.4831.68 min (p¼0.002), respectively, in the long-acting and St. Thomas’ groups. Cardiac index,
creatinine kinase-MB and troponin I levels were comparable. Interleukin-6 levels post-bypass were 61.7215.33 and
75.4431.78 pgmL1 (p¼0.007) in the long-acting and St. Thomas’ cardioplegia groups, respectively.
Conclusions: Single-dose long-acting cardioplegia gives a cardioprotective effect comparable to repeated doses of the
well-established St. Thomas’ Hospital no. 1 cold blood cardioplegia.

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Off Pump CABG and Stroke: Incidence and Mechanisms: A Single Center Experience
Dr. Sudhir Adalti, Dr. K N Bhosale , Dr. Vijay Gupta, Ms. Himani Pandya, Journal of Cardiovascular Medicine and Surgery Volume 3 Number 2, July - December 2017
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Abstract

Background: Perioperative stroke is a distressing complication and it can lead to severe debilitation and excess mortality [14]. Perioperative strokes are mostly ischemic and the occurrence of perioperative stroke was different in the existing studies and ranges from 0.5 to 4.5% [57]. OPCAB has been conveyed to propose an inferior risk of stroke [89]. However, there is unavailability of adequate information on the timing and mechanisms of perioperative stroke in the setting of OPCAB. The aim of the study was to assess the incidence and mechanisms of perioperative stroke after OPCAB. Methods and Materials: We designed a retrospective, observational study and enrolled 2375 patients operated for isolated OPCAB between January 2014 and December 2016. Perioperative stroke is distinct as a neurologic deficit of abrupt onset affected by a disturbance in cerebral blood supply (ischemic or hemorrhagic) that did not resolve within 24 hours after CABG and continued for more than 72 hours [10]. Perioperative stroke does not include the neurologic deficits of confusion, delirium, and (or) encephalopathic (anoxic or metabolic) events. Result: The incidence of stroke in our study was 1.01% (24 patients out of total 2375 patients suffered stroke). There were fifteen men and nine women with the median age of 64 years (range, 60 to 68 years).Fourteen patients had a history of stroke prior to surgery. All the patients had impaired left ventricular ejection fraction. Three fourths of our patients were diabetic and two thirds hypertensive. Almost half of our patients were in atrial fibrillation and had previous myocardial infarction and coexistent peripheral vascular disease. Conclusion: Stroke rate in present study is on lower side of the reported range of stroke incidence as reported in various studies. Risk factors that we identified in the present study are similar to other studies as well but owing to its observational nature, results cannot be generalized.

Keywords: OPCAB; Stroke; CABG. 

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Coarctation and Its Surgical Repair: Mid to Long Term Follow Up in Children and Adults
Sudhir Adalti, Vivek wadhawa, Vijay Gupta , Sanjay Patel, Journal of Cardiovascular Medicine and Surgery 2017 Volume 3 Number 2, July - December 2017
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Abstract

Introduction: Coarctation of the aorta is a common defect that accounts for 58% of all congenital heart defects. Various surgical techniques are described in the literature. We hereby present our experience about surgical management of CoA and their long term outcome. Materials and Methods: This is a retrospective analysis of 70 patients operated for the aortic coarctation. Their age ranged from 641 years with mean age of 19.4 years. Demographic and clinical data was recorded for all the cases. All cases underwent surgical repair by various techniques like, Patch aortoplasty, Resection with end to end anastomosis and resection with interposition grafting. All patients were followed up for a period spanning from 4 to 12 years. Results: There were two early mortalities. Most common complication was recurrent laryngeal nerve injury and postoperative bleeding. Mean follow up was 7.8 years. 84.3% came for follow up. There was no late mortality. Thirty (43%) patients continued to be hypertensive. There was no recurrence in Coarctation. One patient who was operated with Dacron patch aortoplasty developed an aneurysm at the repair site. Conclusion: Asymptomatic patients with uncontrolled or refractory hypertension is the presenting symptoms of Coarctation. End to end anastomosis after complete excision of the coarcted segment in younger patients is the best approach and for older patients resection with interposition grafting is the preferred choice. Persistent postoperative hypertension is a concern and needs further analysis and evaluation. Postoperative CT /MRI is helpful in diagnosing complications of repair.

Keywords: Coarctation of the Aorta; Ventricular Septal Defect; Congenital Anomalies.

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OPCABG for Moderate CIMR in Elderly Patients: a Superior Option?
Amber Malhotra, Chandrasekaran Ananthanarayanan , Vivek Wadhawa, Sumbul Siddiqui , Pranav Sharma , Kartik Patel, Komal Shah, Pratik Shah, Brazilian Journal of Cardiovascular Surgery 2017
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Abstract

Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation.

Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied.  They were subdivided according to presence or absence of high operative risk. Peri-operative variables and   early   operative   outcomes   were   retrospectively   studied.  Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed.

Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction

(P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intra-aortic balloon pump usage, arrhythmias, renal dysfunction, liver  dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting.  Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs.54.5%)

Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Keywords: Mitral Valve Insufficiency/surgery. Mitral Valve Annuloplasty. Mitral Valve/surgery. Coronary Artery Bypass. Coronary Artery Bypass, Off-Pump

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Techniques, Timing & Prognosis of Post Infarct Ventricular Septal Repair: a Re-look at Old Dogmas
Amber Malhotra , Kartik Patel, Pranav Sharma , Vivek Wadhawa ,Tarun Madan , Jagdish Khandeparkar, Komal Shah ., Sanjay Patel, Brazilian Journal of Cardiovascular Surgery 2017; Volume 32(3): 147–155.
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Abstract

Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management.

Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed.

 Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II.

Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery – Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with “Optimal Delay” and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes. 

Keywords: Myocardial Infarction. Heart Septal Defects, Ventricular. Cardiac Surgical Procedures. Prognosis.

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Single-Dose Lignocaine-Based Blood Cardioplegia in Single Valve Replacement Patients
Jaydip Ramani, Amber Malhotra, Vivek Wadhwa, Pranav Sharma, Pankaj Garg, Malkesh Tarsaria, Himani Pandya, Brazilian Journal of Cardiovascular Surgery 2017 Volume;32 Issue (2): pp 90-95
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Abstract

Objective: Myocardial protection is the most important in cardiac surgery. We compared our modified single-dose long-acting lignocaine-based blood cardioplegia with short-acting St Thomas 1 blood cardioplegia in patients undergoing single valve replacement.

Methods: A total of 110 patients who underwent single (aortic or mitral) valve replacement surgery were enrolled. Patients were divided in two groups based on the cardioplegia solution used. In group 1 (56 patients), long-acting lignocaine based-blood cardioplegia solution was administered as a single dose while in group 2 (54 patients), standard St Thomas IB (short-acting bloodbased cardioplegia solution) was administered and repeated every 20 minutes. All the patients were compared for preoperative baseline parameters, intraoperative and all the postoperative parameters.

Results: We did not find any statistically significant difference in preoperative baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and 76.4±16.9 minutes (P=0.43) and cross clamp time were 58.9±10.3 and 66.3±11.2 minutes (P=0.23) in group 1 and group 2, respectively. Mean of maximum inotrope score was 6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and group 2, respectively. We also did not find any statistically significant difference in creatine-phosphokinase- MB (CPK-MB), Troponin-I levels, lactate level and cardiac functions postoperatively.

Conclusion: This study proves the safety and efficacy of longacting lignocaine-based single-dose blood cardioplegia compared to the standard short-acting multi-dose blood cardioplegia in patients requiring the single valve replacement. Further studies need to be undertaken to establish this non-inferiority in situations of complex cardiac procedures especially in compromised patients.

Keywords: Cardiopulmonary Bypass. Cardioplegic Solutions. Lidocaine. Heart Valves/Surgery. Aortic Valve/Surgery. Mitral Valve/ sSurgery.

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Outcome of Bioprosthetic Aorticvalvular Replacement: A Single Centre Experience
Parth Solanki, Journal of Cardiovascular Medicine and Surgery Volume 3 Number 2, July - December 2017
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Abstract

Context: Use of bioprosthetic valves instead of mechanical valves is increasing even in young patients apparently because of its advantages. Aims: We aimed to report a single centre experience of bioprosthetic valvular replacement and the complications in Western Indians. Settings & Design: Prospective, observational. Methods & Material: We have enrolled 54 patients undergoingAVR using biological valve implantation from May 2012 to April 2016 in a Medical college at Ahmedabad, Gujarat. Demographic, clinical and operative details of the patients were collected. Statistical Analysis Used: The statistical calculations were performed using SPSS software v 20.0 (Chicago, IL, USA) Quantitative data was expressed as mean±SD whereas qualitative data was expressed as percentage. Kaplan Meier was performed to assess survival of the population. Results: Overall 22.22% mortality was observed in the study cohort. The probability of freedom from a survival event at 5 years was 77.8% for patients with mitral valve bio prosthetic replacement. Postoperative complications observed were tachyarrhythmia 4 (7.4%), reexploration 4 (7.4%), hemolysis 1 (1.85%) congenital cardiac failure 4 (7.4%), structural valve degeneration 8 (14.8%) and thromboembolism 4 (7.4%) in postoperative complication. Conclusions: In the present report, AVR with bioprosthetic valve for patients <70 years old was associated with a low reoperation rate, postoperative complications and higher survival.

Keywords: BioProsthetic Valve; Aortic Valve Replacement; Reoperation; Survival. 

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Study of Video Assisted Thoracoscopic Surgery
Parth Solanki, Journal of Cardiovascular Medicine and Surgery Volume 3 Number 2, July - December 2017
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Abstract

Background: Video assisted thoracoscopic surgery (VATS) is a well established method for diagnostics and therapeutics. Many thoracic procedures are performed minimal invasively and our aim of the study is to check the results of video assisted thoracic surgery in all thoracic diseases and find out the complications due to video assisted thoracic surgery. Method: This is a retrospective study of video assisted thoracic surgery in management of various thoracic diseases carried out in V.S. General Hospital, Ahmadabad with 60 patients on an indoor patient department basis during the period of November 2012 and June 2014. Proper routine workup preoperatively was done and proper postoperative care was given to the patients. Regular initial follow-ups were taken into account. Result: Out of 60 patients 4 patients were required postoperative ventilator support. 2 patients in which lobectomy right upper and another left lower lobectomy was performed required ventilator support and both were extubated in the postoperative ward after 6 hours. Similarly 1 patient of hydatid cyst with multiple cysts involving left lung required ventilator support and was extubated after 4 hours. 1 patient in which thymectomy was done required ventilator support post operatively for 2 hours. Conclusion: Video assisted thoracic surgery is a strong pillar of modern day surgery and future trends will see its ever growing role.

Keywords: Video Assisted Thoracoscopic Surgery; DoubleLumen Endobronchial Tube. 

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Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure & ASD Device Retrieval
Vivek Wadhawa , Chirag Doshi , Manish Hinduja, Pankaj Garg , Kartik Patel , Amit Mishra, Pratik Shah, Brazilian Journal of Cardiovascular Surgery 2017;32(4):270-5
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Abstract

Objective: Midline sternotomy is the preferred approach for device migration following transcatheter device closure of  stium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect.

Methods: Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy.

 Results: Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic crossclamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication.

Conclusion: Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.

Keywords: Heart Septal Defects, Atrial/Surgery. Sternotomy. Minimally Invasive Surgical Procedures.

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A SINGLE CENTRE EXPERIENCE WITH CORONARY ENDARTERECTOMY IN PATIENTS UNDERGOING OFF-PUMP CORONARY ARTERY BYPASS GRAFTING
Dr.Chirag Doshi, Dr.Manish Hinduja, Dr.Vivek Wadhawa Dr. Gaurag Shah, Dr. Malkesh Tarsaria, Dr.Bhavin Brahmbhatt, Dr. Shaival Majumdar, Dr. Sumbul Siddiqui, Journal of Evidence Based Medicine And Healthcare. 2017; Volume4 (11), pp 578-583.
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A SINGLE CENTRE EXPERIENCE WITH CORONARY ENDARTERECTOMY IN PATIEN...: Ingenta Connect

Abstract:
 
BACKGROUND Coronary Artery Bypass Grafting (CABG) is one of the most frequently done cardiac surgical procedures. However, with the advancements in catheter-based interventional procedures, the category of patients taken up for CABG is gradually being restricted to more high-risk group. Additional surgical procedures like Coronary Endarterectomy (CE) are needed for treating such high-risk coronary artery disease to achieve complete revascularisation. Off-pump coronary endarterectomy can be performed safely with morbidity and mortality comparable with those of conventional coronary endarterectomy. MATERIALS AND METHODS This is a single institutional retrospective study with 480 patients underwent concomitant off-pump CE and CABG. Average number of coronary bypass grafts were 2.4±0.8. There were 321 cases of LAD endarterectomy with 246 receiving LIMA as the arterial graft. 2.9% patients were converted to on-pump surgery intraoperatively because of intraoperative hypotension. RESULTS The incidence of postoperative MI was 0.8%. The 30-day mortality was 0.8% from complications of bowel ischaemia and three patients with septicaemia associated with prolonged intubation. The mean operating time was 118±22 minutes. CONCLUSION We have shown that the effect of OPCABG with CE appears to be safe and early outcomes are encouraging. Hence, diffuse disease requiring endarterectomy should not be considered a contraindication to OPCABG. Surgical skills and the suitability criteria of the patients are very important in this regard.

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TECHNIQUES AND EARLY RESULTS OF MINI LEFT THORACOTOMY APPROACH FOR REPAIR OF TETRALOGY OF FALLOT
Dr.Chirag Doshi, Dr.Vivek Wadhawa, Dr.Manish Hinduja Dr. Pankaj Garg, Dr. Nikunj Vaidhya ,Dr. Jaydip Ramani, Dr. Vaibhav Jain, Dr. Mausam Shah, Journal of Evidence Based Medicine And Healthcare. 2017; Volume 32(3): 147–155.
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ABSTRACT


BACKGROUND
Right minithoracotomy and lower partial sternotomy are usual approaches for mini-invasive repair of congenital cardiac defects with a better cosmetic outcome. These approaches have been inadequate for repair of TOF due to limited exposure of the Right Ventricular Outflow Tract (RVOT) and pulmonary artery. Mini-left thoracotomy approach is sternal sparing and has the advantages of a cosmetic mini incision for surgical correction of patients with Tetralogy of Fallot (TOF).

MATERIALS AND METHODS
From December 2013 and January 2015, 27 paediatric patients (15 females) with mean age 13.2 years and mean weight 26.7 kg underwent intracardiac repair for TOF. A mini-left thoracotomy in third intercostal space involving a 3-5cm skin incision was used in all the patients. In 12 patients, pulmonary annulus was preserved and infundibular muscle resection was performed through RVOT. Fifteen patients received transannular patch. Ventricular Septal Defect (VSD) was closed through right ventriculotomy in all the patients.

RESULTS
There was no mortality or significant morbidity in the postoperative period or during follow up. Mean cross-clamp time was 48.33 minutes and mean cardiopulmonary bypass time was 83.66 minutes. All patients were weaned off mechanical ventilation within 14 hours of surgery. There was no residual defect in any patient. All patients were in NYHA class I during follow-up. During follow-up, one patient (preserved annulus) had residual gradient of 40 mmHg across right ventricular outflow tract without symptoms.

CONCLUSION
The left minithoracotomy is a safe and effective alternative to a classical median sternotomy in selected group of patients for surgical repair of TOF with satisfactory results and better cosmesis.

KEYWORDS
Tetralogy of Fallot, Right Ventricular Outflow Tract, Ventricular Septal Defect.

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Dialyzer-based cell salvage system: a superior alternative to conventional cell salvage in off-pump coronary artery bypass grafting
Amber Malhotra, Pankaj Garg, Arvind Kumar Bishnoi, Pranav Sharma, Vivek Wadhawa, Komal Shah, Sanjay Patel, Umesh Kumar Ahirwar, Dayesh Rodricks, Himani Pandya, Interactive Cardiovascular And Thoracic Surgery 2017; 1–9 doi:10.1093/icvts/ivw371
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Abstract

OBJECTIVES: Our goal was to test the hypothesis that the use of a dialyzer-based cell salvage system during off-pump coronary artery bypass grafting (OPCABG) reduces requirements for homologous blood transfusions (HBT) and improves postoperative haemtochemical parameters.

METHODS: Data were prospectively collected for 222 patients who had OPCABG using 3 different cell salvage techniques: (1) dialyzer-based cell salvage (DBCS) (n = 75), (2) conventional cell salvage (CCS) (n = 73) and (3) without cell salvage (WCS) (n = 74). Salvaged blood was transfused at the end of the operation. The primary outcome of the study was the amount of homologous blood transfused. Secondary outcomes were changes in haemtochemical parameters, postoperative bleeding, need for non-invasive ventilation (NIV), postoperative complications, renal dysfunction, clotting derangement, duration of intensive care unit (ICU) and hospital stay and mortality rates.

RESULTS: There were no deaths. In patients with >1000 ml blood loss, there was a significant reduction in HBT in the DBCS group (300 ± 161 ml) compared with the WCS group (550 ± 85 ml) (P < 0.0001). Postoperative changes in haemtochemical parameters were significantly fewer in the DBCS group compared with the other 2 groups. The incidence of NIV (P = 0.002), renal dysfunction (P = 0.009) and postoperative complications (P = 0.003) was least in the DBCS group and highest in the WCS group. Mean ICU stays were comparable (P = 0.208); however, the mean hospital stay was significantly shorter in the DBCS group (6.08 ± 3.12 days) compared with the WCS group (7.54 ± 4.46 days) (P = 0.022). There was no significant increase in coagulopathy in any group as suggested by comparable chest tube drainage (P = 0.285) and comparable prothrombin time.

CONCLUSIONS: The use of the DBCS system in OPCABG resulted in a significant reduction in HBT, improvement in postoperative levels of haemoglobin, platelets and albumin and reduction in complications without increased risk of coagulopathy.

Keywords: Off-pump coronary artery bypass grafting, Dialyzer-based cell salvage system, Conventional cell salvage

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Transverse Split Sternotomy: A Safe Mini-Invasive Approach for Repair of Congenital Cardiac Defects.
Pankaj Garg, Arvind Kumar Bishnoi , Kartik Patel , Chandrashekaran Annanthnarayan, Jigar Patel , Malkesh Talsariya , Komal Shah, Sanjay Patel, Innovation Technology And Techniques of Cardiovascular And Thoracic Surgery 2017;32(3):184-90
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Abstract

OBJECTIVE: In this article, we aim to review our mini-invasive technique of transverse sternal split (TSS) with or without cervical cannulation for cardiopulmonary bypass (CPB), its usefulness, and efficiency for repair of congenital cardiac defects.

METHODS: Between January 2013 and June 2015, 34 infants and small children were operated through TSS in third or fourth intercostal space [Tetralogy of Fallot 11, perventricular ventricular septal defect (VSD) device closure 23]. Cardiopulmonary bypass was established through cervical (common carotid artery [CCA] and internal juglar vein [IJV]) and inferior vena cava cannulation. In patients operated on CPB, near-infrared spectroscopy was monitored during surgery for cerebral oxygenation and Doppler ultrasonography was performed postoperatively for patency of CCA and IJV. Patients were followed up after discharge with physical examination and transthoracic echocardiography (TTE).

RESULTS: Surgical site exposure through TSS was adequate in all patients. There was no significant morbidity, postoperatively or during follow-up except three patients with VSD device closure who required prolonged mechanical ventilation. Cervical cannulation was sufficient for arterial inflow in all patients operated on CPB. There was one mortality and three procedure failures in VSD device closure group. There was no incidence of neurological complication. Both CCA and IJV were patent in all patients operated on CPB. No significant residual defect was found in either group on postoperative transthoracic echocardiography.

CONCLUSIONS: Transverse sternal split with or without cervical cannulation is a feasible technique for repair of tetralogy of Fallot and perventricular device closure in selected group of infants and small children without compromising the exposure or quality of repair.

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Effect of Prime Blood Storage Duration On Clinical Outcome AfterPediatric Cardiac Surgery
Arvind Kumar Bishnoi, Pankaj Garg, Kartik Patel, Parth Solanki, Jigar Surti, Atul Solanki, Komal Shah, And Sanjay Patel, World Journal For Pediatric And Congenital Heart Surgery 2017; Volume 8(2):166-173.
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Abstract
Background: In this study, we tested the hypothesis that in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) with blood prime, the storage duration of the packed red blood cells (PRBCs) used in prime led to differences in postoperative complications and metabolic profiles of the patients. Methods: For this prospective observational study we included 400 pediatric patients undergoing cardiac operations using CPB and requiring PRBCs prime. To study the effect of storage duration of PRBCs on postoperative morbidity, mortality, and metabolic profile, patients were divided into four groups (based on storage duration of PRBCs used in prime). Group 1: 7 days, group 2: 8 to 14 days, group 3: 15 to 21 days, and group 4: >21 days. Results: On univariate analysis, patients transfused with PRBCs stored >14 days had significantly higher incidence of postoperative complications, for example, liver dysfunction, hematological complications, sepsis, and multiorgan failure. However, after regression analysis and adjusting for the other confounder’s effects, no significant association was found between storage duration of PRBCs and postoperative complications and mortality. Metabolic profile of PRBCs was observed to become deranged with increasing duration of storage. This, however, improved to near physiological range early after the initiation of CPB and remained normal one hour after weaning from CPB, irrespective of the storage duration. Conclusion: Storage duration of PRBCs used for priming the pediatric CPB circuit neither affects the metabolic profile of the patients on CPB or early after surgery, nor it has any association with postoperative complications and mortality.

Keywords
pediatrics, cardiopulmonary bypass, red blood cells, prime, metabolite.

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Transverse Sternal Split: a Safe Mini-invasive Approach for Perventricular Device Closure of Ventricular Septal Defect
Pankaj Garg, Arvind Kumar Bishnoi , Ketav Lakhia, Jigar Surti , Sumbul Siddiqui , Parth Solanki , Himani Pandya, Brazilian Journal of Cardiovascular Surgery 2017; Volume 32(3):184-190
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Abstract

Objective: Perventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique.

Methods: Thirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality.

Results: Procedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography.

Conclusion: Transverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Keywords: Prosthesis Implantation. Heart Septal Defects, Ventricular. Cardiopulmonary Bypass.

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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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COMPARISON OF PREOPERATIVE NONINVASIVE AND INTRAOPERATIVE MEASUREMENTS OF AORTIC ANNULUS
Manish Hinduja, Vivek Wadhawa, Sandip Singh Rana, Harkant Singh, Parminder Singh, Manphool Singhal, Chirag Doshi, Amber Malhotra, Journal of Evidence Based Medicine And Healthcare. 2016; Volume 3(80), pp 4310-4317
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COMPARISON OF PREOPERATIVE NONINVASIVE AND INTRAOPERATIVE MEASURE...: Ingenta Connect

Abstract
 
BACKGROUND Precise preoperative assessment of aortic annulus diameter is essential for sizing of aortic valve especially in patients planned for transcatheter aortic valve replacement. Computed Tomographic (CT) and echocardiographic measurements of the aortic annulus vary because of elliptical shape of aortic annulus. This study was undertaken to compare the measurement of aortic annulus intraoperatively with preoperative noninvasive methods in patients undergoing aortic valve replacement. MATERIALS AND METHODS Aortic annulus diameter was measured with cardiac CT and Transesophageal Echocardiography (TEE) prior to open aortic valve replacement in 30 patients with aortic valve stenosis. In CT, aortic annulus dimensions were measured in coronal plane, sagittal oblique plane and by planimetry. Both 2-dimensional and 3-dimensional TEE were used. These were compared with intraoperative measurements done by valve sizers and Hegar dilators. Pearson analysis was applied to test for degree of correlation. RESULTS CT in coronal and sagittal oblique plane tends to overestimate the diameter of aortic annulus when compared with intraoperative measurements (coefficient of relation, r &61; 0.798 and 0.749, respectively). CT measurements in single oblique plane showed a weaker correlation with intraoperative measurements than 3D TEE and 2D TEE (r &61; 0.917 and 0.898, respectively). However, CT measurements by planimetry method were most correlating with the intraoperative measurements (r &61; 0.951). CONCLUSION Noninvasive investigations with 3-dimensional views (CT-based measurement employing calculated average diameter assessment by planimetry and 3-dimensional TEE) showed better correlation with intraoperative measurement of aortic annulus. CT-based aortic annulus measurement by planimetry seems to provide adequate dimensions most similar to operative measurements.

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Hemodiafiltration—A Technique For Physiological Correction of Priming Solution In Pediatric Cardiac Surgery: An In Vitro Study
Pankaj Garg, Arvind Kumar Bishnoi, Kartik Patel, Vivek Wadhawa, Jigar Surti, Atul Solanki, Komal Shah, And Sanjay Patel, Artificial Organs 2016. Volume 41(8):773-778
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Abstract: Pediatric cardiopulmonary bypass (CPB) circuit invariably requires priming with packed red blood cells (PRBCs). Metabolic composition of stored PRBCs is unphysiological and becomes worse with increasing duration of storage. It is recommended to correct these abnormalities before initiation of CPB. We tested the hypothesis that hemodiafiltration of the prime with 0.45% saline is sufficient for reducing the metabolic load and reaching a physiologic state. In an in vitro study, 100 mL of blood each from 45 units of PRBCs stored for 3–20 days were used for priming the 45 neonatal CPB circuits. Based upon the method used for removal of excess crystalloid from the prime, circuits were divide d into three groups. Group 1: Direct removal through manifold line. Group 2: Ultrafiltration of prime. Group 3: Hemodiafiltration of the prime. Blood gas analyses were obtained from the PRBCs an d from the prime before and after removal of crystalloid. Both direct removal o f crystalloid and ultrafiltration resulted in significantreduction in biochemical and metabolic load of blood ( P < 0.001). However, the final composition of the prime was far from being physiological. Hemodiafiltration resulted in improvement of metabolic parameters to near physiological range (lactate: 33.8 6 4.44 vs. 14 6 2.53 mg/dL, pH: 7.05 6 0.15 vs. 7.34 6 0.06, bicarbonates: 4.83 6 0.59 vs. 27.6 6 2.94 meq/L; P < 0.001). Similarly, sodium (147.76 6 12.73 vs. 144.6 6 5.96 meq/L) and potassium (9.6 6 2.83 vs. 4.23 6 0.37 meq/L) also changed significantly (P < 0.001) to near physiologic range. Hemodiafiltraion of final prime is a simple, efficients and rapid method of correcting the biochemical parameters and reducing the metabolic load of stored PRBCs towards the physiological range before initiating the CPB. Key Words: Cardiopulmonary bypass—Hemodiafiltration—Ultrafiltration—Pediatrics.

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Redo Mitral Valve Replacement For Prosthetic Valve Thrombosis: Single Center Experience
Jignesh Kothari, Kartik Patel,Bhavin Brahmbhatt,Kinnaresh Baria, Malkesh Tarsaria,Sanjay Patel, Sandeep Tailor, Journal of Clinical And Diagnostic Research 2016; 10(11):PC01-PC03. doi: 10.7860/JCDR/2016/20209.8913
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ABSTRACT

Introduction: Prosthetic Valve Thrombosis (PVT) remains a significant cause of morbidity and mortality after valve replacement. Although surgical treatment is usually preferred as life-saving in cases of obstructive PVT, optimal treatment is yet to be decided.

Aim: To evaluate risk factors and outcome of the patients undergoing redo mitral valve surgery for acute PVT.

Materials and Methods: Between January 2012 and February 2015, 65 patients underwent redo surgery for obstructive PVT of mitral valve in Department of Cardiothoracic Surgery, UN Mehta Institute of Cardiology & Research Centre. Patients having acute PVT of aortic valve or combined aortic and mitral valve were excluded. Pre-operative, intra-operative and post-operative factors affecting the outcome as well as follow-up data were measured.

Results: There were total 65 patients, 17 males and 48 females. Most common presenting symptom was dyspnea (100%), followed by palpitation (57.88%) and fatigue (29.45%). Total mortality was 29.2% (19/65). Mortality rate was significantly higher (16/35, 46%) in patients with direct surgery (Group-2) as compared to those with failed thrombolysis (3/30, 10%) (Group-1).

Mortality was also significantly higher in patients presented with New York Heart Association (NYHA) III/IV class as compared to those presented with NYHA I/II class (p=0.02). All survived patients are NYHA Class I-II in follow-up with mean follow-up period was 24 ± 9 months.

Conclusion: PVT still remains a challenging problem in a post-operative patient with a high mortality independent of treatment modality. Though life-saving, the surgical management of this condition still carries a high risk in haemodynamically unstable and in NYHA class III/IV patients.

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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.