Use of Nitroglycerin and Verapamil Solution by OrganBath Technique in Preparation of Left InternalThoracic Artery for Coronary Artery Bypass SurgeryChandan Kumar Ray Mohapatra, Prashant Mishra,Jayant V KhandekarDepartment of Cardiovascular Thoracic Surgery, LTM Medical College&Hospital, Sion, Mumbai

Introduction & Objective: The aim of this prospective study was tocompare the effect of application of nitroglycerin with verapamil solution(GV) by organ bath technique with other methods of applications such as,papaverine solution by organ bath technique, topical GV solution andtopical papaverine solution on the free blood flow in the left internalthoracic artery (LITA) prepared for coronary artery bypass grafting(CABG).Methods: One hundred twenty consecutive ischemic patients posted forCABG were randomly assigned to four groups: group I (n _ 32, GVsolution by organ bath technique), group II (n _ 30, papaverine solutionby organ bath technique), group III (n _ 29, topical GV solution) orgroup IV (n_29, topical papaverine solution). In each patient, pedicledLITA was harvested; thereafter applied with the randomized differentmethods and solutions. The free flow from the distal cut end of theLITAwas measured under controlled hemodynamic conditions after har-vesting (Flow 1). Just before the anastomosis, the flows of the LITAweremeasured again (Flow 2). The flow rate before and after applications ofsolution were compared among the entire group and analyzed.Result: The mean blood flow in the LITA was 56.2±5.0 ml/min beforeapplication of solutions. After application, the mean blood flow in group Iwas 102.3±7.0 ml/min (p<0.0001), in group II, it was 92.7±3.4 ml/min,and in group III, it was 88.6±2.2ml/min) and in group IV, it was 81.4±2.1.Proportional increases in blood flow observed in group I (82.6%) >groupII (65.1%) > group III (57.6) > group IV (44.8%) (p<0.0001).Conclusions: Nitroglycerin with verapamil solution and papaverine areable to treat the spasm and increase the flow of the LITA, when they areused by organ bath technique compare to topical application. The GVsolution by organ bath technique is effective and superior in compare toothers.

Atrial Septal Defect Device Complications- SurgicalManagement - A Case SeriesSantosh Kumar DangetiMeenakshi Mission Hospital and Research Centre

Introduction: Atrial septal defect is a common congenital cardiac anom-aly. Although surgical closure has been the traditional and gold standardtreatment of choice, percutaneous device closure is gaining popularity inrecent times because of the very short duration of stay, cosmetic advan-tage and relative avoidance of morbidity associated with surgery, never-theless they are associated with some unavoidable complications makingsurgeons intervention mandatory.Material and methods: Between may 2014 to June 2016, 6 patients hasbeen referred to our centre after percutaneous closure of atrial septaldefects. Of them, 3 patients referred for device migration within 24hrsand 1 patient with device migration and Right atrium puncture producingpericardial collection and cardiac tamponade. 1 patient referred with en-docarditis of device done 6 months back and 1 patient with device done 1year back eroding the aorta producing Aorto- RA fistula.

Results: The 3 patients with device migration underwent surgery andretrieval of device and pericardial patch closure of defect and 1 patientwith device migration and RA perforation underwent emergencysternotomy with device retrieval and patch closure of defect. 1 patientwith endocarditis of device underwent elective surgery with device re-trieval, mitral valve replacement and pericardial patch closure of the de-fect. 1 patient with Aorto-RA fistula underwent device removal, closureof fistula with Dacron patch and pericardial patch closure of the defect.All patients are discharged with normal convalescence.Conclusion: Although the complications for Atrial septal defect devicesare minor, some times they can be very disastrous leading to high mor-tality in a rapid transit of time, making surgeons intervention mandatoryand emergency surgery with device retrieval and for the correction oforiginal defect and other device related complications.

Surgical Management of Chronic ThromboembolicPulmonary Hypertension- A Single Centre Experience.Ashwin Uday Phadke, G. Ramasubrahmanyam, T.VamshidharCARE Hospitals, Banjara Hills, Hyderabad.

Introduction: and Objectives Cardiopulmonary function in patients withchronic thromboembolic pulmonary hypertension (CTEPH) can almostbe normalised by pulmonary endarterectomy, mortality of which is re-ported from 4-24% in various literature. The procedure involves the re-moval of organised and incorporated fibrous obstructive tissue from thepulmonary arteries (endarterectomy rather than embolectomy). We reportour results in series of 11 patients with CTEPH that underwent surgery atour centre.Materials and Methods: From 2011 onwards, 11 patients (9 males, 2 fe-males)withage range26 to46yearsunderwentpulmonaryendartectomyatourcentre.3ofthepatientshadapositivehistoryofDVTandallwereinNYHAclassIIIorIV.AllpatientsreceivedanIVCfilterpre-operatively.Pre-operativemedianPulmonary Arterial (PA) systolic pressure was 75 mmHg (Std. Deviation 18)andmedian PAmean pressure was 46mmHg (Std. Deviation 11). PulmonaryVascular resistance ranged from 650-950 dynes/cm. Midline Sternotomy, car-diopulmonary bypass and deep hypothermic circulatory arrestwas essential forall patients.Results:Average total operating time was 380 minutes with mean bypasstime of 190 minutes and median circulatory arrest time of 45 minutes.Post-operative PA pressures reduced significantly (systolic PA 46mmHgand mean PA 28.7 mm Hg). There were two early deaths (18%) (one dueto sepsis and the other due to sudden fibrillation). There were no latedeaths. Re-perfusion pulmonary edema developed in 1 patient ( 8.1%)which later subsided. Average ICU stay was 5 days and average hospitalstay was 11 days.Conclusions: Pulmonary endarterectomy is the gold standard for thetreatment of CTEPH. However, it requires careful patient selection, sur-gical expertise and highly meticulous post operative care.

Hybrid Cardiac Surgery- A single Centre ExperienceSwapnil Deshpande,P.K. Deshpande, S.K. Deshpande,D.V. Gupta, Jyoti Panhekar, M.K. Deshpande,PrajaktaKayarkar, V. Bisne, Prabhakar Deshpande, Anil Modak,Shrikant Kothekar, D.R. BahekarDr. K.G. Deshpande Memorial Centre

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Indian J Thorac Cardiovasc Surg (January–March 2017) 33(1):74–101DOI 10.1007/s12055-017-0489-y

Introduction: Hybrid Cardiac Surgery is a novel method of treatingpatients with combination of diseases and giving them complete cure inone admission itself.Material and Methods: we present our data of 28 patients who haveundergone Hybrid cardiac surgery at our centre from September 2010 tillOctober 2016 8 patients underwent one stage OPCAB Plus Renal ArteryStenting. 1 patient underwent One Stage OPCAB Plus Bilateral RenalArtery Stenting plus Ascending aorta to Bi Femoral Bypass using TubeGraft. 1 patient underwent pulmonary thrombectomy followed by com-pletion angiogram, 1 pulmonary artery thrombectomy plus trans RightAtrial IVC filter placement. 17 patient underwent CABG to Left sidedCoronary Arteries via Left Thoracotomy plus Stenting to Right Coronaryartery. all the patients were operated inHybrid Cardiac Surgery Theatre sodid not require any shifting from CathLab to Operation theatre or ViceVersa.Results: All patient are doing well and did not require any additionalhospitalisation for any of the medical issues. the Treatment given to allthe patients was complete and was done in same sitting and same admis-sion without any complication and significantly reduced thehospitalisation days, cost and morbidity of additional procedure. TheOperative time was not very prolonged. also there was no significantincrease in the ICU stay or any additional morbidity. There was noMortality in any of the patientsConclusion:Hybrid Cardiac Surgery is an Attractive, Complete and LessExpensive way of treating patients having multiple problems under oneadmission. The availability of Hybrid Cardiac Operation theatre reducesthe pain of repeated admissions. Proper Teamwork and planning is a mustfor proper therapeutic result and outcome.

Septo superior vs left atrial approach in redo mitralvalve surgeriesG Praveen Prabu, Saravana Krushna RajaMMC,RGGGH,Chennai

Introduction: To analyse the surgical techniques in superior septal andleft atrial approach and to evaluate the best of the two incisions for redomitral valve replacement and record the post operative events in the studygroups.Materials and methods: Inclusion Criteria: All adult patients whounderwent closed mitral commissurotomy, mitral valve repair &replacement admitted with mitral valve pathology. ExclusionCriteria: Patients who underwent mitral valve procedures alongwith coronary artery bypass grafting, aortic valve replacement,tricuspid valve repair or replacement. Two groups were dividedwith one group of patients undergo superior septal approach andthe other group of patients with conventional left atriotomy inci-sion in redo mitral valve replacement. Electrocardiographic andechocardiographic findings were compared between the studygroups.Results: In our study group females 64% and 36%weremales. Themajorindication for redo MVR in our study groups was mitral restenosis fol-lowing previous closed mitral commissurotomy (94%). The average prebypass time in superior septal approach group was 49.6 minutes, crossclamp time was 74 minutes, total CPB time on an average was 112minutes. where as in patients who underwent in left atriotomy was 77.8minutes, 76 minutes, 126 minutes respectively. In our study groups, 3patients in superior septal approach needs temporary pacemaker and 4patients in left atriotomy needs it.Conclusion: Our study results conveyed that superior septal approachappeared to be good alternative to conventional left atriotomy incisionin redo mitral valve replacement. Pre bypass time and total cardiopulmo-nary bypass time were less in superior septal approach compared to theleft atriotomy approach. No statistically significant increase in newrhythm disturbances and the need for temporary pacemakers among thestudy groups.

Coronary artery bypass grafting with Mitral ValveReplacement for Acute Severe Mitral regurgitation– Our ExperienceKrishna Kishor S, GracyRoyalcare Superspeciality Hospital

Introduction: Ischemic mitral regurgitation is a well-documented com-plication following myocardial infarction (MI) with increased mortalityand morbidity. Following MI 50 % of patients develop mitral regurgita-tion (MR). Adding mitral valve surgery to coronary artery bypassgrafting( CABG )has shown increased survival and better long termresults.Methods: Between 2013 and 2016, 38 patients underwent CABG +MVR of which 8( 22%) patients had acute severe MR (within 6hrs ofMI) and 30 (78%) patients had recent MI (within a week) and presentedwith severe MR. The male to female ratio was 30: 8. Intra aortic balloonpump (IABP) was inserted preoperatively in 4 patients and 34 patientsneeded IABP during weaning off from cardiopulmonary bypass.Intraoperative findings revealed that 22 patients had papillary musclerupture and 16 patients had multiple chordal rupture. None of the patientshad signs of chronic MR. All patients underwent CABGwith MVR.Internal mammary artery and saphenous veins were used as conduitsand grafting was done on bypass. Mitral valve was replaced using me-chanical prosthesis and interrupted pledgeted sutures. The native valvewas plicated preserving the chordal apparatus. All patients weredischarged on 6th post op day.Results: All patients had uneventful post-operative period with nil mor-tality. 37 patients are in regular follow up and 1 patient lost to follow-upover past 6 months. Follow up echocardiogram shows normal functioningmitral prosthesis with improved ventricular function by 10-15 % and noparavalvular leak or gradient across the prosthesis. All our patients re-ported a good quality of life.Conclusion: CABG with MVR in acute severe MR was found to yieldbetter outcomes in terms of mortality and morbidity. We prefer replace-ment over repair for negating the need of second surgery in future.

RandomizedComparativeProspectiveStudyOfEffectOfPapaverineOnLIMAFlowAfterIntraluminalInstillationandTopicalApplicationArun GargSri Jayadeva Institute of Cardiovascular Sciences and Research

Introduction&Objectives: Left internal mammary artery (LIMA) is oneof the most commonly used conduits in coronary artery bypass grafting(CABG) but it has the tendency for spasm during harvesting. Papaverinehas been used by many surgeons to relieve spasm and to increase theLIMA flow before grafting mostly by topical use. In this study we havecompared the effects of intraluminal versus topical application of papav-erine on LIMA flow.Material & method: This was prospective randomized study of 60 pa-tients. They were divided into two groups: group 1 (n=30; intraluminalpapaverine application) and group 2 (n=30; topical papaverine applica-tion). The blood flow from the LIMA from distal cut end was measuredunder controlled hemodynamics, before papaverine application and 5minafter papaverine application.Results: The mean blood flow in group 1 measured was 61.07±3.1 ml/min before papaverine application and 119.6±3.72 ml/min after papaver-ine intraluminal instillation (p value <0.0001). In group 2, it was 60.4±2.24 ml/min before and 72.13±2.56 ml/min after papaverine topicalapplication. The increase in blood flow observed in group 1 was95.84% versus 19.42% in group 2.Conclusion: In this study we observed that rate of increase ofblood flow after papaverine application was significantly higherin patients with intraluminal instillation than in patients with top-ical application.

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Heart Transplantation outcomes after Mechanicalsupport with Heart Ware Ventricular Assist Device:Single Centre ExperienceHassiba Smail, Pankaj Saxena, DavidMc Giffin, SylvanaF MarascoCardiothoracic Surgery, The Alfred hospital, Melbourne, Australia

Background / Study Objective: The safety and efficacy of the HeartWare Ventricular Assist Device (HVAD) as bridging therapy to transplanthas been proved . The outcomes of heart transplant remain less describedafter HVAD supportWe report our single institutional experience with thepost-operative and long-term outcome of heart transplantation afterHVAD support Patients 44 patients received HVAD, 33 left ( LVAD), 9biventricular (BiVAD), 2 right (RVAD) . 4 (10%) recovered, 2 (5%)remain on support and 29 (65%) patients underwent heart transplant .From the transplanted patient, the mean age was 46± 16 years, 20 (69% ) male, dilated cardiomyopathy in 23 (80%). Mean duration ofsupport before heart transplant was 373 ± 258 days range (36-970 days)Methods: From September 2011 to April 2016, 29(65%) patients re-ceived a heart transplant after HVAD we retrospectively evaluated theearly post operative outcome after heart transplant, global survival andsurvival without rejection or allograft vasculopathy.Results: Mean duration of ICU and hospital stay was 15±10 , 39± 41days, re-explorations for bleeding 8 (27%), dialysis for kidney injury 5(17%), primary graft failure in 10 (34%) patients, requiring ECMO sup-port in 4 and Intra aortic balloon pump in 3. 30 days post-operativemortality was Nil. Mean duration of follow up was 1.6± 1.1 years; 2patients suffered from humoral chronic graft rejection, no coronary allo-graft vasculopathy Actuarial survival after heart transplantation at 1, 2, 3years was respectively 89% ±5%, 83% ±7%, 83% ±7%.Conclusion:We report high rate of transplant after HVAD support withexcellent early and long-term post transplant survival. These findingssupport the efficiency and safety of the HVAD used as single orbiventricular support as bridge to transplant.

Magnetic Resonance Imaging in Follow-up after TironeDavid I Procedure: Single Centre ExperienceHassiba Smail, Jean-Nicolas Dacher, FrançoisBouchart, Fabien DoguetDepartment of Thoracic and Cardiovascular Surgery, University HospitalCharles Nicolle, Rouen, France.

Background: We analysed the outcome after Tirone David I procedureand assessed the aortic valve function, the left ventricular remodelling andthe size of the remaining thoracic aorta using cardiac MRI.Methods: 121 patients underwent Tirone David I; the mean agewas 55 ± 15 years. Marfan syndrome was diagnosed in 12% (n =15), bicuspid aortic valve in 15% (n = 18) and aortic dissectionin 20% (n = 26). During surgery, 30% (n = 40) had an aorticvalve repair. The clinical and echocardiography follow-up in-volved 92 patients, followed by cardiac MRI in 65 patients forduration of 4.2 ± 2.3 years.Results: Hospital mortality was 4.9% (n = 6). The TTE revealed an AR≥grade II in 19% (n = 18) patients. The cardiac MRI revealed an AR ≥II in27% (n=18), left ventricular ejection fraction <50% in 9 patients, a leftventricular mass of 72 ± 18 g/m2, no aortic dilatation or aortic dissectionhas occurred in the remaining thoracic aorta. Freedom from aortic valvereplacement at 1, 5, and 10 years was 96% ± 1.4, 91% ±3.5, 91% ±3.5.The overall survival was 93% ±2 at 1 year, 87% ±3 at 5 years and 75%±9 at 10 years.Conclusions: The Tirone David I technique is a safe, reproducibleprocedure. Cardiac MRI could be a new tool for a homogenousfollow up to assess of the aortic valve function, the left ventric-ular remodelling, the size of the aortic annulus and the remainingthoracic aorta.

Standardising the Pulmonary artery banding CouldLAST (Left Anterior Small Thoracotomy) be theanswer?B R Jagannath, Ashish M AgrawalSTAR Hospital

Introduction & objectives: Pulmonary artery band has always been asso-ciated with high morbidity, mortality and unpredictable outcomes.Approach, parameters to consider while banding is still undefined.Trusslers formula defines only the band length for two different situationsi.e. single ventricle pathway or two ventricle pathway. In an attempt to definethe parameters and standardize the protocol for PA band, we conducted aretrospective analysis of all our PA bands over the last 5 years. The paperoutlines our management protocol and decision making algorithms.Materials and Method: All patients who underwent a PA band betweenApril 2010 till Dec 2015 ( N=49) were studied retrospectively. The initialapproach was towards a full median sternotomy (n = 26) but of late thetrend is towards performing a small left anterior thoracotomy in the 2nd or3rd intercostal space (n = 23). Pre marked Mersilene Tape based onTrusslers formula is used.Results: No significant differences were seen in demography of patientsbut Sternotomy was associated with higher in hospital mortality (15.3 %)vs. LAST (4.3%), lower conversion to second stage (23%) vs. LAST (52%), longer duration of ventilation and ICU stay. Also follow up mortalitywere higher in sternotomy group (18 %) vs. LAST (13 %) even thoughthere was no significant differences in the band gradients at time of hos-pital discharge.Conclusion: PA banding still has a significant mortality. Trusslers esti-mate still is the gold standard, but additional parameters are taken intoconsideration.We present our standardised protocol for PA banding in thesetting of increased pulmonary blood flow, as part of preparation foreither single ventricle pathway or bi-ventricular repair. We advocate theLAST as it is simple, safe, effective, easily reproducible and the re-entryin the second stage becomes easy.

Timing is crucial in surgery for endocarditis; lessonsfrom a case seriesVasudev B Pai, Sambhram Shetty, Nikhil Nandineni, SGanesh KamathKasturba Medical College, Manipal University, Manipal

Introduction & Objectives: Despite all diagnostic and therapeutic ad-vances, surgery for infective endocarditis, is still related to a high risk ofmorbidity and mortality. Patients initially managed in community hospi-tals with basic facilities are frequently referred to specialized centres in analready advanced stage of the disease. Appropriate antibiotic treatmentaccording to culture sensitivity; good heart failure management; closemonitoring and timely surgery is needed in these patients.Materials &Methods:All patients who underwent surgery for endocar-ditis from 2013 to 2016 were studied. Their cultures, antibiotics as well asoperative details are summarized.Results: 7 patient underwent surgical treatment for infective endocarditis.Their ages ranged from 20 to 68 years (mean of 40.6) and all were males.Blood cultures were positive in all patients. All the patients were elec-tively taken up for valve replacement. 3 patient had embolic stroke pre-operatively. 5 patients underwent double valve replacement and 2underwent aortic valve replacement. Average bypass time was 198 mi-nutes with a cross clamp time of 116mins. Valve culture report and serol-ogy revealed 2 patients with brucellosis, 4 patients with streptococcus and1 patient with staph aureus. Post operatively antibiotics were continuedfor 6-8 weeks after consultation with the infectious diseases team.Average ICU stay was 3 days and postoperative stay was 8 days.Waiting for a few days until antibiotic treatment reduced the systemicbacterial load thus helping to prevent profound refractory hypotensionwhen cardiopulmonary bypass was instituted.

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Conclusion: After appropriate diagnosis antibiotics according to cultureis essential. Timing of surgery is crucial especially in patients with stroke.Three of the patients presented with strokes and were operated after ap-propriate intervals to achieve optimal results. Operating these patients tooearly could have resulted in poor postoperative recovery since they wouldhave been unable to mobilise after surgery.

A comparative Study between Video AssistedInsertion of InterCostal Drain and conventional tech-nique of Insertion.Shaik Gouse Khaja Arif, Subrata Dey, Rajarshi Basu,Bhaskar DasR.G Kar Medical College and Hospital

Introduction: Intercostal chest drain (ICD) is the commonest interven-tional procedure performed electively and in emergency settings for re-moval of collections in the pleural space. And like any invasive procedurethe conventional ICD have various complications such as injury to un-derlying structures and inadequate drainage. A method to counter this haslong been sought Objective:- To evaluate outcomes and safety of VideoAssisted ICD insertion in Comparison with conventional ICD insertion.Material & Methods: A total of 75 patients were included in the study.The Video Assisted technique was attempted in 35 (46.6%) cases, andcompared with 40 (53.3%) cases of conventional technique.outcomescompared were procedure time, intra operative complications, reposi-tioning requirement, post procedure thoracotomy requirement, mean hos-pital stay & achievement of complete lung expansionResults: Technical success was obtained in 94% for the Video Assistedtechnique as compared to 92% of conventional technique. The proceduretime for the video and the conventional techniques was approximately25+/-15 and 15+/-10 minutes, respectively. Iatrogenic Complications oc-curred in 2.5% for video group versus 10% for conventional.Repositioning requirement was 6% in video group as compared to 42%in conventional group. Formal Thoracotomy Procedure requirement was11.4% in video assisted group as compared 35% in conventional group.Mean hospital stay was 7+/-2 days in video group as compared to 18+/-4days in conventional group. Complete lung expansion was achieved in94% in Video group as compared to 85% in conventional groupConclusion: Video assisted ICD is a safe and effective procedure It wassufficient to achieve complete lung expansion in 33 out of 35 cases.Meanhospital stays was also lesser. Avoidance of formal thoracotomy proce-dure was higher and Intra op complications were lower. It also aided indiagnosis in 3 cases.

Impact of Retrograde Autologous Priming of theCardiopulmonary bypass circuit on post operative he-modilution and blood transfusion requirementsRemananda Krishnanand Pai, MuruganMS, MurugesanPR, Imran K, Biradar P, Ganeshan C, Mathew APSG Institute of Medical Sciences & Research, Coimbatore,Tamilnadu,India

Introduction: Approximately 60% of patients undergoing cardiac sur-geries on cardiopulmonary bypass (CPB) require blood / products trans-fusion. Blood transfusion is associated with increased risk of WoundInfection, Renal Impairment, mediastinitis, and poor long term survivaland coronary artery bypass graft patency. RetrogradeAutologous Priming(RAP) of the CPB circuit has the potential to be part of an effective bloodconservation strategy.Materials & Methods: In a prospective, randomized single blindedstudy, on first time CABG patients, we compared the degree of hemodi-lution and transfusion requirement in patients in whom RAP was used(Group A)[60 patients] with those in whom RAP was not used (Group B)[60 patients] intraoperatively during first-time CABG. Primary end-point

studied were intraoperative and postoperative haematocrit and secondaryoutcomes measured included total blood loss, blood products transfused,inotropic requirement, need for re-exploration, hospital stay and majoroutcomes / postoperative complications.Results: The two groups were evenly matched in terms of patient riskprofile and investigative parameters. We were able to achieve an averageof 387.95ml ± 21.47ml RAP volume. This resulted in a significantlybetter hematocrit on bypass in RAP group at 40 minutes [GroupA=24.34 vs Group B=23.90, p<0.04] and 60 minutes[[Group A=24.41vs Group B=24.03, p<0.01]. There was no difference however in thehematocrit coming of CPB, the blood transfusion requirement or postoperative outcomes.Conclusion:Removal of asanguinous prime volume and replacing it withpatients blood can be achieved safely and with good outcomes. A Rapvolume of 390 ml [average] did not show any statistical improvement inoutcomes compared to group of patients not having RAP. A higherthreshold of RAP may be required to show statistically obvious benefitson transfusion outcomes.

Surgica l Management of Femoral ArteryPseudoaneurysms: our seriesSoumik Pal, Subhash Kumar Kadim, Parvez,,MayuriS.,Vikas SR,Sathyanarayan J, Syed, Shio Priye,Durgaprasad Reddy BVydehi Institute of Medical Sciences and Research Centre

Introduction: Femoral artery pseudoaneurysms are a vascular complica-tion that are increasingly occurring due to the increased number of per-cutaneous interventions. We report our case series of patients with femo-ral pseudoaneurysms.Materials andMethods:The study was conducted from January 2007 toJanuary 2015. The study included all the patients who developedpseudoaneurysm of the femoral artery following percutaneous interven-tions, which were not amenable to conservative management. There werea total of 15 patients in which 12 were male and 3 were female. All thepatients were subjected to routine blood investigations, Doppler ultra-sound, CT angiogram. These patients underwent surgery resection ofthe pseudoaneurysm and primary repair of the artery.Results: 13 patients recovered uneventfully in the post operative periodand got discharged in the first week. 2 patients developed skin necrosisand required debridement and dressing. All the patients came for followup after 3 months and 1 year and had no complaints.Conclusion:When conservative methods fail, open surgical repair is thegold standard in treatment of pseudoaneurysms. It is usually used as a lastresort. Absolute indications for open surgical repair include shock orcardiovascular instability, greater than 100% increase in size of thepseudoaneurysm on duplex US, imminent rupture, and evidence of vas-cular compromise. The disadvantages associated with open repair includepotential for bleeding, infection, nerve injury, and lymphatic leaks.

Surgery in Grown up Adults with Congenital HeartDiseases (GUCH) – a single centre 11 year ExperienceAkhilesh Arumalla, RV Kumar, Vijay Kumar, T RamaKrishna DevNizam's Institute of Medical SciencesOutcomes data for adults undergoing congenital heart surgery are limited.The overview of our 11 years experience (2005 – 2015) with more than924 operations of adults with CHD at our department gives a basis forcontemplation and planning the special requirements needed in surgicalcare for this very specific group.

AIM & OBJECTIVES: To identify demographic characteristics ofAdults with Congenital Heart Diseases presenting to our centre NIMSfor cardiac surgery. To asses presenting Complaints, clinical presentations

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and to asses Surgical Complications faced and their management includ-ing postoperative immediate complications.Material & Methods: The study subjects were consecutive GUCH pa-tients who underwent cardiac surgery (CPB) at the age of 15 years orolder at NIMS Hospital over the period from January 1, 2005 toDecember 31, 2015. Medical charts, anaesthetic records, and operativerecords were retrospectively reviewed.Results: The median age of our 924 patients is 28.76±12.09,with nearlyequal sex ratio. CPB time (90min±53) andAortic cross clamp time(45min±33). Most common Acyanotic Lesion is ASD( 57.9%n=535) followedby VSD( 8.23%,n=76). Most Common Cyanotic Lesion is TOF. Thepredominant number of patients presenting for surgery belong to 15-20years 313(33.87%).60% of Complex Lesions,40% lesions with moderatecomplexity present before 20 yrs of age. 49.8% (n=460) patients are inNYHA Class1, 40.8% (n=377) are in class 2, 8.7% (n=80) are in class3,and 0.8%(n=7) are in class 4.78 cases (8.44%) of series had previoussurgeries 96.75% (n=872) had complete repair, 2.60% (n=24) hadreoperations, 3.03% (n=28) had palliative surgeries. Postoperative com-plication rate in our study is 21.86%. TheMean ICU Stay varied from lessthan a week to 18days.The Mortality is 1.5% (n=14).Conclusion: Despite the long term deleterious effects of CHD in adultpatients, surgical correction can be achieved with low mortality and ac-ceptable morbidity. Key Words: adults, heart defects, congenital,surgeryoutcome assessment, GUCH.

Outcome of Ischemic Mitral Regurgitation in Patientundergoing Coronary revascularizationNitin Kumar GuptaG. K. N. M Hospital

Aims andObjectives:IschemicMR has been a well known complicationof coronary artery disease and revascularization procedures are known tobe insufficient to reduce mitral regurgitation. The aim of this study is toevaluate the patient of coronary artery disease with significant ischemicMR who are undergoing CABG, to compare clinical outcome and echo-cardiographic results of patients who underwent CABG with or withoutconcomitant Mitral valve intervention.Materials and Methods: The study was a prospective non randomisedstudy conducted from May 2013 to June 2015. It included patients withcoronary artery disease associated with ischemic MR,who underwentCABG with or without Mitral valve intervention in the form of eithermitral valve repair with reduction annuloplasty ring or mitral valve re-placement. They were divided into three groups: group I - CABG +MVR, group II - CABG + MV Repair, group III - CABG alone. Thedecision on repair or replacement was purely based on discretion of sur-geons and on table TEE assessment of Mitral valve pathology. All pa-tients were followed up during the 1 year interval.Results: 90 patients were recruited with moderate or more ischemic MRassociated with coronary artery disease , who underwent elective CABGwithmitral valve intervention for the first time. The study groupwas dividedinto 3 groups, Group I had 36 patients (CABG+MVR ), group II had 43patients (CABG+MV Repair ) and group 3 had 11 patients (CABG). Theaetiology ofMRwas similar in all groups. There was significant reduction inmean MR grade in group 1 (1.09 ± 2.07) and group II (2.50 ± 2.43) com-pared to Group III (6.84 ± 3.18) .There was significant reduction in leftventricular dimensions LVID (s) and LVID (d) in group II compared withgroup I and group III with P value - 0.05. The mean NYHA class inpreoperative period was 2.85 ± 0.93 in group I , 2.71 ± 0.92 in group IIand 3.44 ± 0.71 in group III. In one year follow up NYHA class wassignificantly reduced to 1.21 ± 0.41 in group I, 1.17 ± 0.44 in group II,and 1.56 ± 0.76 in group III. The survival rate was highest in group II(95.3%) and group I (91.7%) compared to group I (81.8%) which favoursthe concomitant addressing of IMR with coronary revascularization.Conclusion: Patients with ischemic MR who are undergoing CABGachieve superior midterm outcome with mitral valve intervention than

isolated coronary revascularization. The patients who underwent CABGwith concomitant MV repair have superior outcome than CABG withMV replacement.

Which variables predict mortality in mitral valvereoperations? A 20-year single surgeon experienceDaniel Almeida, Filipe Almeida, Rui M S AlmeidaAssis Gurgacz University Foundation

Objectives: Mitral valve diseases are one of the most prevalent heartvalve diseases in developed and nondeveloped countries. As we still havenot achieved an ideal valve substitute, the great majority of patients willhave their prostheses replaced once or more times, during their lifetime.The authors evaluated a consecutive series of mitral valve reoperations,performed by the same surgeon, and identify as primary objective thevariables, predicting mitral valve mortality and as secondary all othervariables, using multivariate analysis.Methods: A retrospective analysis, February 1993 to January 2015, of107 patients, undergoing mitral valve reoperation was performed. Thedemographics included pre-operative clinical and ecochardiografic data,trans and post-operative variables, and they were analyzed in a multivar-iate analysis frame, to target, which would predict hospital mortality. Thepatients were divided according to the logistic EuroScore into two groups(0-9,9% and 10% and above).Results: The mean age was 48,00 ± 15,18 (8-76 years), being 71,96%females. In 70,09% biological valves were used and in the other cases thevalve was replaced by a mechanical one (23,36%) or repair was per-formed (6,54%). Associated procedures were performed concomitantlyin 9,35%, being concomitant aortic valve replacement performed in 50%and CABG in 30%. The left atrial appendage was closed in all cases wereatrial fibrillation was the basic rhythm (56,07%). The mean logisticEuroScore was 8,10%. The mean length of stay in ITU was 3,00 ± 6,15and in hospital 7,00 ± 10,43 days. The overall mortality was 14,02%,mainly on the high EuroScore group, and on those patients with morethan one reoperation.Conclusion: The statistical analysis identified age, NYHA class and pul-monary hypertension as preoperative primary predictors for mortality.The authors conclude that the reoperation can be performed safely onthe technical point and the result depends on the patient pre-operativeconditions.

Single Stage CABG and Peripheral Arterial Bypassfor Combined Coronary and Peripheral ArterialDiseaseDivya Arora, Ashok Chahal, Kuldeep Laller, ShamsherSingh LohchabPt B D Sharma PGIMS Rohtak

Introduction: Peripheral arterial disease and Coronary artery diseaseoften coexist and former is an indicator of systemic atherosclerosis.Patients undergoing surgery for PAD alone in presence of significantCAD are at high risk of perioperative major adverse events hence weadopted the strategy of single stage CABG and peripheral arterial bypassfor combined disease.Methods: From January 2014 to August 2016 36 patients all males meanage 62 ± 7 years range 45 to 73 years underwent concomitant off pumpCABG and peripheral arteria bypass for combined CAD and PAD. Thesepatients presented with severe lower limb ischemia and lower extremityCT angiography demonstrated infra renal aortoiliac disease in 9(25%)patients, isolated external iliac occlusion in 12 (33%), and superficialfemoral artery occlusion in 15 (42%). Significant double vessel coronaryocclusion was found in 12(33%) and triple coronary disease in 24 (67%)on coronary angiography. LV dysfunction was there in 24 (50%). Therewere 9(25%) diabetic patients. The strategy adopted for aortoiliac disease

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was single stage abdominal aortobifemoral bypass grafting first followedby off pump CABG keeping in view the need for IABP. For iliac arterydisease and superficial femoral artery, the peripheral bypass was doneafter completion of CABG.Results: The operative mortality observed was in 2/36 (5.5%) related tolimb ischemia and renal failure. Postoperative complications observedwere acute limb ischemia in 1/36 (2.7%). Renal failure 2/36 (5.5%).Two patients required IABP support and in one patient the catheter wasput through the one limb of aortobifemoral femoral graft. 30/34 (88%)patients were asymptomatic at maximum follow up of 32 months range(3-32).Conclusion: Single stage off pump CABG and peripheral artery bypasscan be performed safely and obviates the major cardiovascular events inpatients presenting with severe lower extremity ischemia.

Coronary Endarterectomy: It is not a DevilSunil Agrawal, Geevarghese Mathew,ChandrasekharVarma,Rakhi K.R., Nikhil George,K.M.CherianSt. Gregorios Cardiovascular Centre, Parumala, Kerala

Background: To achieve complete revascularization in patients withdiffusely diseased coronary arteries, endarterectomy is the only option.There are concerns about increased risk of arrhythmias, and early graftocclusion in these patients Aim: The aim of this study is to discuss theresults of our endarterectomy and the tips and protocol we follow afterendarterectomy.Material and Methods: From January 2007 –October 2016, 2107 pa-tients underwent CABG, of which 376, patients had endarterectomies(17.8%). Isolated RCA/PDA endarterectomy was the most common(286 patients). 109 patients hadmultiple endarterectomies including tripleendarterectomies. In all cases it was ensured that the endarterectomy iscomplete, with extensive arteriotomies and patch plasty if needed. In thecase of RCA, attention was paid to complete endarterectomy in both PDAand PLB. Amiodarone (150mg) was electively added to the pump afterendarterectomy. It was then continued as infusion for 24-48 hours beforeswitching over to oral doses. Antiplatelets (Clopidogrel 75mg+Aspirin75mg) was given once drainage settled (as early as 4 hours post surgery).Unfractioned heparin infusion was started once the drainage settled withthe ACTmaintained between 175-200.This was changed to subcutaneousheparin till the 4th POD.Warfarin was used in few patients with extensivearteriotomies and vein patch plasty in the beginning but since 2012 westopped warfarinaltogether and continuing only with dual anti-platelets.Results: We had 3 hospital deaths. All three patients had severe LV dys-function prior to surgery. The incidence of post op arrhythmias was low. Theincidence of AF was 10%. Life threatening arrhythmias were not observedin any patient. There were no peri-operative infarctions. We do the TMTroutinely at 3 months and 12 months after the surgery in all the patients. Sofar only 2 patients needed repeat interventions due to recurrence of angina.

Outcome analysis after surgical management of ven-tricular septal defect complicating acute myocardialinfarction in a tertiary referral Government HospitalKallol Dasbaksi, Plaban Mukherjee, Suranjan Haldar,Mohammad Zahid Hossain, Tinni MitraDepartment of CTVS, Medical College, Kolkata, 88, College Street,Kolkata-700073

Introduction:Although the present incidence of Post myocardial infarctionventricular septal defect ( PI-VSD) is .20%, the outcome of PI-VSD remainspoor even in the era of reperfusion therapy. We reviewed our experiencewith surgical repair of 6 cases of PI-VSD during the last 3 years and ana-lyzed outcomes with an objective to identify prognostic factors.Methods: From March 2014 to April 2016, data from 6 consecutivepatients of PI VSD who underwent surgical repair at our institute were

retrospectively reviewed. Referral was after echocardiographic diagnosisof post MI VSD from Cardiology Department. 4 Patients had coronaryangiography (CAG) done after the diagnosis of Myocardial infarction(MI) and before the VSD developed. Whereas no CAG was done in 2patients. Out of the 6, 4 patients could be stabilised with conservativemanagement (3 anterior VSD,1 posterior VSD) but 2 patients being inrefractory “shock” needed emergency surgery (1 anterior and 1 posteriorVSD). The 4 patients who could be stabilised were operated upon 14 to18 days later. Out of the 6 patients 4 had anterior VSD and 2 had posteriorVSD. All were repaired with bovine pericardium using cardiopulmonarybypass under moderate hypothermia. In all the 4 patents, who had CAG,the obstructed coronary arteries were bypassed.Results: There were two deaths, one each from emergency surgery groupand one from the conservatively managed with delayed surgery group.Post operative analysis revealed that the survivors had higher preopera-tive left ventricular ejection fractions (LVEF) compared to those who died(40 ± 3.7% vs. 25± 2.4%, respectively;). Failure of improvement of he-modynamic status to resuscitative measures including IABP and conse-quent earlier surgical intervention, the extent of MI including right ven-tricular infarction, have been found to be associated with poor prognosisin our study. We did not find any relation of the length of total period ofcardioplegic arrest toward mortality.Conclusion: Inadequate response to resuscitative measures and need foremergency surgery are predictors of increased mortality. Low LVEF andextent of myocardial damage also determine final outcome.

Acute kidney injury after OPCAB surgery: incidenceand outcomes.Swadesh Ranjan Sarker, Siddhartta Shankar Howlader,Shahriar Moinuddin, Sabrina Sharmeen Husain, Md.Kamrul HasanNational Institute of Cardiovascular Diseases, Dhaka, Bangladesh.

Background:Acute kidney injury (AKI) is a common complication aftercoronary artery bypass grafting (CABG), and is associated with adverseoutcomes. Still, the incidence and outcomes of AKI vary according to itsdefinition. Our monocentric study comparatively investigates the yield ofRIFLE definition, which is based on the elevation of serum creatininelevels (SCr) or the reduction of urine output (UO), taking into accountonly one or both criteria.Methods: All adult patients undergoing OPCAB between January 2014and May 2015 were included. Clinical, biological and surgical featureswere recorded. Baseline serum creatinine was determined as its value onday 7 before surgery. Post-operative AKI was diagnosed and scoredbased upon the highest serum creatinine and/or the lowest urine output.Results: 121 patients (Male/Female ratio, 2.3; median age, 53y) wereincluded, with 56 (46.3 %) developing postoperative AKI. Elevated se-rum creatinine (AKISCr) and oliguria (AKIUO) was observed in 9.2 %and 37.1%, respectively. AKI patients had a significantly higher BMI andbaseline SCr. In comparison to AKIUO, AKISCr mostly occurred inpatients with co-morbidities, and was associated with an increased mor-tality at 1-year post surgery.Conclusions: The use of standard RIFLE definition of AKI in 121 pa-tients undergoing OPCAB surgery resulted in an incidence reaching 46%. Still, significant discrepancies were found between AKISCr andAKIUO regarding the incidence and outcomes. In line with previousreports, our data questions the utility of urine output as a criterion forAKI diagnosis and management after cardiac surgery.

Impact of Renal Insufficiency on In-hospitalOutcomes after Off-pump Coronary Artery BypassSurgerySonjoy Biswas, Syed Al-NahianUnited Hospital Limited, Dhaka, Bangladesh

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Introduction and Objectives: Chronic kidney disease (CKD) is a pre-dictor of increased morbidity and mortality in patients undergoing off-pump coronary artery bypass surgery (OPCAB). To evaluate the charac-teristics and predictors of increased morbidity and mortality in the CKDpopulation submitted to OPCAB. To compare in-hospital outcomes be-tween patients with and without CKD, and with andwithout developmentof acute kidney injury (AKI).Materials and Methods: A prospective analysis of all isolated OPCABperformed at United Hospital Limited from January, 2015 to October,2016. CKD was considered when e-GFR < 90 ml/min/1.73m2. Clinicalcharacteristics, mortality and post-operative complications were evaluat-ed according to renal function and stages of CKD.Results: Out of 1463 patients, 169 (11.6%) had CKD. This populationwas older, presented greater prevalence of hypertension, left ventriculardysfunction, prior stroke, peripheral vascular disease and triple vesseldisease, hence, higher EuroSCORE. In-hospital outcomes revealed great-er incidence of stroke (4.4% vs 1.6%), atrial fibrillation (12% vs 6%), lowcardiac output syndrome (12% vs 7.2%), longer stay in intensive care unit(4.84 vs 2.83 days), and greater mortality (8.4% vs 2.4%). Female gender,smoking, diabetes and peripheral vascular disease were associated withhigher in-hospital post-operative complications and mortality within theCKD group. Patients who did not develop post-operative AKI presented2.4% mortality; non-dialytic AKI: 16.7%; dialytic AKI: 33.3% mortality.Mortality was directly related to the stages of CKD.Conclusions: CKD patients submitted to OPCAB represent a high riskpopulation, with increased incidence of complications and mortality.Post-operative AKI is a strong in-hospital mortality predictor.

Study between ring anuloplasty and sutureannuloplasty in Tricuspid valve diseasesMenander M, Uday Jadhav, D V Kulkarni, Kamlesh JainSeth G. S. Medical College and KEM Hospital

Objective: Tricuspid regurgitation (TR) may be primary or secondary toleft sided heart diseases. Residual tricuspid regurgitation is seen after bothring and suture annuloplasty. A study was conducted in to validate thelong term benefits of tricuspid ring annuloplasty over suture annuloplasty(TVA).Materials and methods: 80 patients undergoing mitral valve replacement(MVR) with TVA were studied. Of these patients 50 patients underwentMVR with ring annuloplasty and 30 underwent MVR with DeVegasannuloplasty. Criteria studied were ionotropic support required, length ofdecongestive treatment, reduction in pulmonary hypertension.Echocardiography was done pre operatively and post operatively at 24hours, 7 days, 1 month and at 1 year to determine PASP (pulmonary arterysystolic pressure), Grade of Tricuspid regurgitation, TAPSE (TricuspidAnnular Plane Systolic Excursion) and tricuspid annular dimension.Results: Ionotropic support, decongestive treatment and reduction in pul-monary hypertension were comparable in both groups at 1 month. 82% ofpatients of ring annuloplasty group had reduction in PASP at 1 monthcompared to 56% in DeVegas annuloplasty group. Grade of regurgitationimproved from moderately severe TR to mild TR in 86 in ringannuloplasty group compared to 53% in DeVegas annuloplasty group atone year. 68% of patients of ring annuloplasty had improvement inTAPSE at one year compared to 46% of patients in DeVegas annuloplastygroup. Mean tricuspid annulus showed reduction from pre op annulussize of 37.72 to 27.5 in ring annuloplasty group to 37.9 to 32.13 inDeVegas annuloplasty group.Conclusion: Tricuspid ring annuloplasty is a durable repair compared tosuture annuloplasty for secondary tricuspid regurgitation in the long run.Though DeVegas annuloplasty is comparable to Ring annuloplasty in theimmediate post operative period, tricuspid regurgitation worsens overtime. Aggressive management of secondary tricuspid regurgitation withring annuloplasty could decrease the occurrence of late tricuspid regurgi-tation following mitral valve surgery.

IMMEDIATE ANDMID TERM RESULTS AFTERCABG WITH MITRAL VALVE REPAIR INPATIENTS WITH ISCHAEMIC MITRALREGURGITATIONVinitha V Nair, TK JayakumarGovernment Medical College , Kottayam, Kerala

Background: Ischemicmitral regurgitation (MR) result from left ventric-ular remodelling in ischemic heart disease despite structurally normalvalves. The presence of ischemic MR itself is associated with excessmortality. Patients with moderate or severe regurgitation require concur-rent mitral valve intervention as repair or replacement.Material and methods: 34 patients with ischemic regurgitationunderwent coronary artery bypass grafting with mitral valve repair atour centre over a period of 3 years (2013-2015). M: F was 25:9 with amean age of 56 years (range 41-73 years). 17 patients had moderate and17 had severe regurgitation. The left ventricular function was normal in16, dysfunction mild in 7, moderate in 9 and severe in 2. All patientsunderwent revascularisation and annuloplasty with rigid ring. Additionalprocedures were required in 3 patients (P3 neochordae, quadrangularresection PML and PML cleft closure ).Results:There were no in-hospital deaths. Themean hospital stay was 6.8days (range 4-15 days). At discharge, 17 patients had no mitral regurgi-tation, 14 had trivial to mild regurgitation and 3 had moderate mitralregurgitation. 4 patients expired during follow up at 2,2,10 and 21monthsrespectively. 3 of them had severe mitral regurgitation preoperatively.Follow up was complete for 28 patients (2 were lost to follow up). Theminimum follow up was 6 months. (Median: 18 months, range: 6-38months). 2 patients progressed from mild to low moderate regurgitationduring follow up at the end of 36 and 23 months respectively. 2 patientswith moderate regurgitation had low moderate regurgitation at 12 and 8months follow up. All the other patients maintained good mitral valvecompetence during follow up.Conclusion:Mitral valve repair along with revascularisation in ischemicmitral regurgitation has good midterm results and the patients remainedgood valve competence.

Difference in pain,mobilization and incentive spirom-etry compliance between extra-pleural and open in-ternal mammary artery harvesting in off-pump coro-nary artery bypass (OPCABG) patientsNeeraj Aravind Kamat, Neeraj Kamat, Shruti Sonar, John Thomas,Sandeep Sinha,UpendraBhalerao, Ashish Gaur, Satish Jawali, AnvayMulayFortis Hospital, Mulund, Mumbai

Introduction: Pleurotomy during IMA harvesting impairs respiratoryfunction during the postoperative period. Hikmet iyem et al found thatpreservation of pleural integrity during IMA harvesting decreases post-operative bleeding, pleural effusion and atelectasis. Many studies report-ed that pleural effusion, atelectasis, blood loss, the need for secondarythoracotomy, pain and intercostal neuralgia are far less encountered whodid not receive IMAs. Hence the aim of the study was to compare thepatients capacity to do incentive spirometry, pain and mobilisation statuspostoperatively in extrapleural versus open IMA harvesting methods.Materials and Methods: It’s a single centre, single surgeon, retrospec-tive observational study. It includes patients operated for off pump coro-nary artery bypass surgery by either extra-pleural (closed) or open tech-nique of harvesting IMA at Fortis hospital from September 2015-February 2016. A total of 145 patients undergone OPCABG out of which60 patients were done with open technique of harvesting IMA and theremaining 85 patients had closed or extrapleural harvesting of IMA.Results: The demographic characteristics in terms of age and gen-der and preoperative variables were comparable in both groups.Results were grouped in 3 categories 1. Incentive Spirometry

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Open and closed pleurotomy patients were subjected to incentivespirometry exercise preoperatively and postoperatively and it wasobserved that the closed pleurotomy patients were able to dospirometry better as compared to patients with open pleurotomyas compared to their respective preoperative spirometry levels.Closed pleurotomy patients were able to generate an excess of360ml on spirometer on an average as compared to patients withopen pleurotomy who were able to generate only 225ml in excessof their preoperative spirometric values 2. Pain scale There wasno significant difference in pain in both groups. 3. Mobilisation&discharge Patients with closed pleurotomy were mobilised earli-er i.e. 4 days as compared to 6 days in patients with open pleuraand hence patients with closed pleura were discharged two daysprior as compared to patients with open pleura. 4. only 1 patientof open pleurotomy required re-intervention for postoperativepleural effusion as compared to 3 patients with closed pleurotomy.5. IMA was injured in 2 patients with closed pleurotomy as com-pared to only 1 injury in patients with open pleurotomy.Conclusions:Definitely the advantages of leaving the pleura intact whileharvesting the IMA in the postoperative recovery far outweigh but utmostcare needs to be taken to avoid injuring the IMA and a very low thresholdfor opening the pleura need to be kept if any doubt of injuring the IMA.

Our experience with Prosthetic valve Sparing AorticRoot ReplacementA Mohammed Idhrees, VVBashi, Mukesh, Niranjan, AjuJacobInstitute of Cardiac and Advanced Aortic Disorders (ICAAD), SIMSHospital, Chennai, India -600 026

Objective: Reoperation on the aortic root is challenging because of highhospital morbidity and mortality. In prosthesis valve sparing aortic rootreplacement the well-functioning prosthetic aortic valve is preserved dur-ing reoperation. This is done to avoid passing sutures through the weak-ened aortic annulus if the initial prosthesis is removed. The aim of thepresent study was to assess short- and mid-term outcomes of patients whounderwent such procedures.Methods: Between June 2002 and March 2014, twenty-one patientsunderwent re-operative prosthesis valve sparing aortic root operations(mean age: 51.24 + 10.30 years; male: 85.71%). Nineteen of the pre-served aortic prosthesis were mechanical valves. The mean time fromprevious aortic surgery was 10.86 + 5.67 years. Eleven patients(52.38%) patients presented with type A aortic dissection, 38.09%(n=8) had ascending aortic aneurysm and one patient had rupture of sinusof valsalva and yet another had a LCA aneurysm.Results: Isolated prosthesis valve sparing aortic root replacement wasperformed in 13 patients while it was associated with aortic arch repairin 8 patients. The mean cardiopulmonary bypass time was 227.86 +/-51.09 minutes and aortic cross clamp time was 159.86 + 26.09 min.71.43% (n=15) had aortopathy includingMarfans syndrome and bicuspidaortic valve. We had one in-hospital mortality. All the patients werefollowed up for a minimum of 2 years and maximum of 12 years.There were 2 late deaths due to non-cardiac cause [Road traffic accident(after 1 yr.) / Liver carcinoma (after 2 yrs.)].Conclusion: Our favourable short- and mid-term results indicate that theprosthesis-sparing operation is a valid treatment option in re-operative aorticroot procedures. In selected patients bioprosthetic valve sparing is also aviable option. This can be done with acceptable morbidity and mortality.

Hybrid Aortic Arch Replacement: Outcome analysisA Mohammed Idhrees, VVBashi, Mukesh, A BGopalamurugan, Aju JacobInstitute of Cardiac and Advanced Aortic Disorders(ICAAD), SIMS Hospital, Chennai, India -600 026

Purpose: Hybrid aortic arch replacement is emerging as a safe treatmentalternative for arch aneurysms. We assessed our experience with all thetypes of arch hybrid procedures.Method: From 2007 to May 2016 we have performed 112 endovascularaortic repairs (EVAR), of which 53 underwent hybrid aortic arch repair.The hybrid repair entailed aortic arch vessel debranching andconcomitant/delayed antegrade ± retrograde EVAR stent grafting of thearch. For Type I and II hybrid procedures, debranching of the arch vesselswere done without circulatory arrest and EVAR was performed on thefollowing day. In Type III hybrid procedures, antegrade EVAR of thethoracic aorta and arch reconstruction with four-branch Gelweave™Plexus graft was performed in single stage.Results: Of the 53 patients, 15 patients had Type I repair, 32 had Type IIrepair, and 6 had Type III repair. Mean age was 57.25 years with maleconstituting 79.24% (n=42). Aortic dissection was the primary pathologyin 54.71% (n=27) patients followed by aneurysm in 43.39 % (n=23)patient. Marfans syndrome was present in 30.18% patients (n=16).Redo-sternotomy was performed in 7 patients (13.20%). Incidence ofstroke was 5.66% (n=3) and there was no patients with renal dysfunctionrequiring hemodialysis. There was one retrograde aortic dissection in typeI group. There were two endoleaks, both in type I patients.Mean length ofhospital stay was 13.2 + 9 days. 30 days in-hospital mortality was 5.66%(2 in type I and 1 in type II). The data is presented in table 1. Consideringour own experience, recently we performmore of type II hybrid than typeI hybrid.Conclusion: Hybrid aortic arch replacement can be performed with lowincidence of stroke and renal dysfunction. Type II hybrid is better thantype I hybrid in our experience in spite of the non-availability of frozenelephant.

Management of coarctation of aorta with ascendingaortic aneurysm.Shiv Kumar Choudhary, Amol Bhoje, ShivaparasadM B,Sachin Talwar, Parag Gharde, Manoj Sahu, LissyPavulose, Sanjeev Kumar, Lokender Kumar, Velayoudam Devagourou,Balram AiranAll India Institute of Medical Sciences, New Delhi

Introduction: Coarctation of aorta with ascending aortic aneurysm(AAA) is a rare entity. The ideal approach in such patients is stilluncertain. Debate exists not only on the lesion to be correctedfirst but also on the timing of surgery. Surgery can be one stagedor two staged. Hybrid techniques have also influenced the deci-sion-making. We review our experience of 15 years for this com-plex entity.Methods and materials: A single surgical team managed 17 patientswith coarctation and AAA between 2001 and 2016. The coarctation mor-phology decided themanagement strategy. In 12 patients, coarctation wasmanaged first using endovascular techniques (n=7), interposition graft(n=4), and left subclavian-aortic bypass (n=1). Five patients underwentsingle stage correction at the time ofAAAmanagement: patch aortoplastyusing a ‘T’ sternotomy in two, and ventral aorta repair in three. Variousprocedures for AAA included Bentall’s in 15, aortic root remodeling inone, and Wheat procedure in another.Results:All patients survived operation. One patient, who underwentconcomitant Bentall’s and patch aortoplasty, required tracheostomy andprolonged ventilation. Median ICU stay was 3 days. Follow-up ragedfrom 1 to 12 years. One patient required balloon dilatation forrecoarctation. Another patient developed type B aortic dissection and isbeing followed. Twelve patients continued to receive anti-hypertensivetherapy.Conclusion: This disease combination can be managed with one or twostaged procedure. However hybrid procedure hasminimized surgical risk.The selection of procedure should be based on proper case selection,surgeons experience and institutional protocols.

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Study of Circle of Willis in Indian populationShiv Kumar Choudhary, Sumit Agasti, Arun V, PradeepR, Sachin Talwar, Manoj Sahu, Parag Gharde,Velayoudam Devagourou, Balram AiranAll India Institute of Medical Sciences, New Delhi

Introduction: During aortic arch or carotid interventions, completenessof Circle of Willis (COW) is an important determinant of cerebral pro-tection strategy. Studies performed in different ethnic groups report dif-ferent patency rates of COW. We performed this pilot study aim is toassess the anatomy and variations of COW in Indian population bymeansof magnetic resonance angiography (MRA).Patients and methods:MRA data from 200 consecutive patients withoutabnormalities of the main feeding vessels of the COW were analyzed. Ageranged from 21 years to 72 years. 130 were males. Most common indica-tions for MRAwere cerebrovascular accident (55.0%), AV malformations(10%), visual loss (8.0%) and transient ischemic attacks (4.0%).Results: 62 patients (31.0%) had incomplete COW and males and fe-males were equally affected. Out of these, only one patient had a trulyincomplete COWas both the ipsilateral anterior communicating and pos-terior communicating arteries were absent. 38 patients had deficient pos-terior COW (25 on the right side, 12 on the left side and one patient hadboth the posterior communicating arteries absent). 24 patients had defi-cient anterior COW (15 on the right and 9 on the left side).Conclusion: The COW was anatomically incomplete in 31% cases in arandomly chosen set of patients for whomMRAwas performed for a varietyof reasons including cerebro-vascular lesions. Further studies involving alarger cohort of patients need to be planned before these results can beextrapolated to the general Indian population. Also, the functional signifi-cance of these anatomically deficient COW needs to be investigated.

Aortic Valve Replacement (AVR) with Zero PatientProsthesis Mismatch (PPM): An integrated approachShiv Kumar Choudhary, Amol Bhoje, Anupam Das, ParagGharde,Manoj Sahu, Lissy Pavulose, Rajesh Yadav, SachinTalwar, Velayoudam Devagourou, Milind Hote, Balram AiranAll India Institute of Medical Sciences, New Delhi

Introduction:PPM has been associated with higher early and late mor-tality after aortic valve replacement. Prosthetic valve Indexed EffectiveOrifice Area (EOAI) < 0.85cm2/m2 has been considered significantPPM. We review our strategy to prevent PPM in patients undergoingAVR with either a mechanical valve or bioprosthesis.Patients and method: A single surgical team performed 634 isolat-ed AVR over the period of 15 years from January 2001. Ageranged from 6 years to 82 years, and 482 were males. Bodysurface area (BSA) ranged from 0.93 m2 to 2.34 m2. Aorticstenosis was the predominant lesion in 386 patients. Choice ofmechanical valve or bioprosthesis depended upon age, comorbid-ities, expected survival, life style, and socio-economic factors. Anintegrated approach was used in selection of prosthesis and tech-nique of insertion to achieve prosthetic valve EOAI > 0.85cm2/m2. If it was not possible to insert the desired prosthesis in thenative annulus, posterior root enlargement was performed.Results: All patients survived the operation. It was possible toinsert a valve prosthesis with EOAI > 0.85cm2/m2 in all patients.Only 28 (4.4%) patients required aortic root enlargement. In pe-diatric patients, irrespective of BSA, minimum EOA > 1.4cm2was ensured to accommodate future growth. Intra-operativetrans-esophageal echocardiography was performed in later half ofexperience in 267 patients. Mean transvalvular aortic gradientsranged from 4 to 26 mm Hg. Two patients had significantparavalvular leak and needed re-intervention. There was no oper-ative mortality and 16 patients required re-operation for excessmediastinal drainage.

Conclusion:With careful selection of prosthesis and insertion technique,it is possible to achieve zero PPM in patients undergoing AVR. Aorticroot enlargement is required infrequently in <5% patients.

Acute Type A Dissection complicated by Stroke:Optimum Strategy ?Shiv Kumar Choudhary, Amol Bhoje, Anupam Das,Parag Gharde, Manoj Sahu, Manjumol Biju, SudhaLama, Rajesh Yadav, Sachin Talwar, Velayoudam Devagourou, BalramAiranAll India Institute of Medical Sciences, New Delhi

Introduction: Management of acute type A aortic dissection (AAAD)complicated by stroke remains controversial. The urgency of immediaterepair is tempered by the concern about cerebral reperfusion and hemor-rhagic conversion. The purpose of this study was to analyze our resultswith AAAD complicated by new onset stroke.Patients and Methods: During the period of 15 years (2001-2016), asingle surgical team managed 7 patients of AAAD complicated withstroke. Patients presented after 6 hours to 120 hours of chest pain. Sixpatients presented with left hemiplegia/hemiparesis with innominate ar-tery with or without right common carotid artery (CCA) involvement.One patient presented in coma (intubated, onmechanical ventilation) withinnominate and left CCA involvement. Six patients were operated onurgent basis using different cannulation strategies. One patient with mas-sive infarct and significantmidline shift but without aortic regurgitation ortamponade, underwent decompression craniotomy first. This patient wasclosely followed and dissection repair was performed after 3 months.Results: There was no episode of hemorrhagic conversion of the infarct.Among patients who were operated early, the patient with coma deterio-rated and expired on 5th day. She had extensive bilateral infarcts and nosalvage neurosurgical procedure was attempted. In two patients, neuro-logical status deteriorated in post-operative period and required decom-pression craniotomy. One patient who presented at 6 hours, recoveredcompletely. Other two patients who presented late showed slight neuro-logical improvement only. The patient operated late showed marked neu-rological improvement. Follow-up raged from 3 months to 12 years. All,except one, are able to lead an independent life.Conclusion: Stroke in AAAD is not a contra-indication for dissectionrepair. A close coordination with neurologist and neurosurgeons is re-quired to achieve optimum results.

Renal cell carcinoma (RCC) with intracardiac exten-sion: Radical excision under moderate hypothermiaShiv Kumar Choudhary, Amlesh Seth, Amol Bhoje,Parag Gharde, Manoj Sahu, Lissy Pavulose, Parul,Rajesh Yadav, Sachin Talwar, Velayoudam Devagourou, Balram AiranAll India Institute of Medical Sciences, New Delhi

Introduction: RCC, rarely, can grow till right atrium (RA) via renal veinand inferior vena cava (IVC). We have developed a technique of radicalnephrectomy and intracardiac thrombus removal under cardiopulmonarybypass (CPB) and moderate hypothermia.Patients and Methods: 32 patients with RCC without metastaticdisease but with tumor thrombus extending in the supra-hepaticIVC or right atrium were operated upon between Jan 2001 andJuly 2016. Mean age was 50.2 years (range 14-72 years), male:female ratio was 24:8, and 27 tumors were located in right kid-ney. All patients were operated via midline sterno-laprotomy. CPBwas established after radical nephrectomy with aortic, superiorvena cava, and infra-renal IVC cannulation. Under moderate hy-pothermia, cardioplegic arrest, and with supraceliac abdominalaortic occlusion, suprarenal vena cava and right atrium wasopened and tumor thrombus was removed.

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Results: There were three early deaths (excessive bleeding and its atten-dant complications in two, and post-operative renal failure in one).Additional complications included wound infection in 3, pleural effusionneeding inter-costal drainage in 2 and acute psychosis in one patient.Lower body ischemia time ranged from 15 to 24 minutes. Cardiac arresttime ranged 21 to 26 minutes, and CPB time ranged from 38 to 64.Transfusion requirements ranged from 2 to 14 units (median 4). Medianventilation time was 10 hours (6-21 hours) and average ICU stay was 3.2days. Mean follow-up was 38.4 months (range 2-78 months). Mediansurvival in operative survivors was 62 months.Conclusion: Aggressive surgical management in patients of renal tumorwith intracardiac thrombus provides good long-term prognosis with ac-ceptable mortality and morbidity.

Trans-aortic mitral valve repair for functional MR inpatients undergoing aortic root / valve procedure: Afeasibility studyShiv Kumar Choudhary, Atul Abraham, Amol Bhoje,Parag Gharde, Manoj Sahu, Mary Thomas, Ligimol Liju, Parul,Yogesh Solanki, Sachin Talwar, Balram AiranAll India Institute of Medical Sciences, New Delhi

Introduction:There are no clear guidelines for management of functionalmitral regurgitation (MR) in patients undergoing aortic valve interven-tions. The risks of additional mitral intervention often outweighs thebenefits of abolition of MR. Trans-aortic edge-to-edge mitral repairemerges as a quick and technically simple procedure in this setting. Thepresent study evaluates feasibility, safety, and efficacy of this procedure.Patients andMethod:Between Jan 2012 and Nov 2016, sixteen patients( age 24-76 years) underwent trans-aortic edge-to-edgemitral valve repairfor moderate/severe functional MR. All patients were primarily operatedfor severe aortic regurgitation ± aortic root lesions. LVIDes ranged from35 to 69 mm, LVIDed ranged from 54 to 85 mm, and ejection fractionranged from 20 to 60%. MR was 2+ in 8, 3+ in 6, and 4+ in two. Primarysurgical procedure included Bentall’s ± hemiarch replacement in 10, aor-tic valve replacement in 5, and non-coronary sinus replacement withaortic valve repair in one.Results: Intra-operative TEE showed diminished severity of MR in all.There was trivial or no MR in 13, mild (1+) in two, and moderate (2+) inone. There were no gradients across mitral valve in 9, less than 4 mm Hgin 6, and 9 mm Hg in one. There was no operative mortality. Follow-upranged from 2 weeks to 54 months. Follow-up echocardiography showedtrivial or no MR in 12, mild in 2, and moderate in two. None of thepatients had significant mitral stenosis. LVEDed ranged from 42 to 74mm, and LVIDes ranged from 28 to 64mm. Ejection fraction also im-proved mildly (22-65%).Conclusion:Trans-aortic edge-to-edge mitral valve repair is a safe andeffective technique to abolish functional MR. However, its impact onoverall survival needs to be studied.

Analysis of the Extent of Degenerative changes inIntra-pericardial Aorta of patients with BicuspidAortic Valve (BAV)Shiv Kumar Choudhary, Pradeep R, Ruma Ray, SudheerKumar Arava, ParagGharde, Manoj Sahu, Sudha Lama,Manjumol Biju,Palleti Rajshekar, Balram AiranAll India Institute of Medical Sciences, New Delhi

Objectives: To study the extent of degenerative changes in intra-pericardialaorta of patients with BAV presenting with aortic valvular lesion.Methods: Patients with BAV, who were undergoing aortic valve inter-vention with or without ascending aortic replacement, from January 2010till March 2016 were included. Biopsies taken from aortic sinus, midascending aorta and distal ascending aorta, were analyzed for

degenerative histopathologic changes using modified Schlatmann andBecker criteria and a composite histopathological examination (HPE)score was calculated. Preoperatively, patients were evaluated clinically,echocardiographically, and by computerised tomographic angiogram.Results:112 (94 male) patients were included. The mean age was 39.3±15.6 years (range11-78 years). Aortic stenosis was the predominant lesionin 64 (57%) patients. The mean diameter of the aorta was 39.5 ±10.06mm (range 23-108mm) at sinus level, 45.1 ± 11.49mm (range 18-85mm) at mid ascending aortic level and 36.3 ± 6.93mm (range 22-60mm) at distal ascending aortic level. The mean total HPE compositescore was 6.25 at aortic sinus level, 5.75 at mid ascending aortic level and4.75 at distal ascending aortic level. There were significant degenerativechanges even with aortic diameter less than 4.5cm at all the three levels.Statistically significant correlation between aortic diameter and histopath-ologic degenerative changes was present at all three levels: aortic sinus(R= 0.3, p = 0.001),mid ascending aorta (R= 0.26, p =0.009) and distalascending aorta (R= 0.23, p = 0.01).Conclusion: There is significant correlation between the severity of de-generative histopathologic changes and the ascending aortic diameter atall levels. Maximum correlation was found at the aortic sinus level. Thedegenerative changes were not only present in the dilated segments ofaorta; significant changes were also present in non-dilated segmentsthroughout the ascending aorta.

A Study on Efficacy of Video Assisted ThoracoscopicSurgery ( VATS) Biopsy as a Diagnostic toolAshith Shetty, KR Balasubramoniam, Praveen K VarmaAmrita Institute of Medical Science, Kochi

Introduction: Numerous medical conditions remain diagnostic dilemmaseven after extensive investigative modalities. Video Assisted ThoracoscopicSurgery (VATS)biopsyoffers anminimally invasive surgical option to attaina definitive histopathological diagnosis withminimal morbidity and nomor-tality. In our study we report a series of patients with various thoracic pathol-ogies whowere evaluated and not yielded final histopathological diagnosis.Materials and Methods: Our study consisted of 30 patients with clini-cally and radiologically apparent thoracic pathology who were undiag-nosed despite investigations like PET scan, CT, bronchoscopic or EBUSguided biopsy who then underwent VATS biopsy for a definitive histo-pathological diagnosis. They were assessed based on variables like age,sex, histopathological diagnosis, length of hospital stay,complications,pain scale and diagnostic efficacy. VATS biopsy was per-formed under General anaesthesia with Double lumen endotracheal tube.Results:Oursurgicalcohort(n=30)consistedof17maleand13femalepatients.Mean age was 47.37 years. VATS Biopsy included lung biopsy in 11 patients,lymph node biopsy in 11, mediastinal mass biopsy in 5, lung and lymph nodebiopsy in 2, lung and pleural biopsy in 1.Mean length of hospital stay was 4.8days. Definitive histopathological diagnosis was obtained in all 30 patients(100%). Mean pain scale was 3.2 out of 10. Only complication was persistentair leak for > 7 days which was present in 2 patients (6.6%). No mortalityreported.Conclusion:VATS Biopsy is a new weapon in the physicians armamentar-ium which promises a high rate of diagnostic efficacy with minimal mor-bidity and no mortality to the patient. It should be considered as the safe andreliable investigative modality of choice for thoracic mass lesions and med-ical conditions presenting with mediastinal lymphadenopathy.

Immediate and early cardiovascular functional alter-ations after off-pump and on-pump coronary arterybypass grafting: A comparative analytical studySayar Kumar Munshi, Pares Bandyopadhyay, KrishnenduChakrabartiNilratan SircarMedical College and Hospital (NRSMCH), Kolkata,WestBengal

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Introduction & Objectives: The purpose of the study is to evaluate andcompare the effect of off-pump and on-pump coronary artery bypassgrafting (CABG) on the cardiovascular functioning in the immediateand early post-operative period and to compare it with the preoperativestatus.Materials & Methods: The study population included a total of 106patients who were operated for CABG from January 2015 toJune 2016. The patients with age <40 or >80 years, with ejection fraction<30%, with serum creatinine level >2 mg/dl or patients undergoing redooperation were eliminated from the study. Among the total number ofpatients studied, 75 patients were operated for off-pump CABG and restwere operated under cardiopulmonary bypass. Hemodynamic parametersincluding heart-rate, cardiac output, cardiac index, stroke volume, sys-temic vascular resistance index and left ventricular stroke work indexwere measured before surgery as well as 1, 4 and 20 hours after surgery.Troponin-T and creatine kinase-MB were also measured in blood sampleat the same interval.Results: There was no significant difference in age, sex, ejection fractionand number of grafts between the groups. Cardiac output, cardiac index,stroke volume and left ventricular stroke work index were higher after 1and 4 hours of surgery in off-pump group than on-pump group. Systemicvascular resistance index was lower after 1 hour of surgery in off-pumppatients. Troponin-T and creatine kinase-MB were significantly lower inoff-pump group after 1 and 4 hours of surgery than on-pump group.Conclusions: Immediately after surgery there is better cardiovascularfunction and less release of markers of myocardial damage after off-pump CABG compared to the on-pump CABG group. Time-dependentincrease of hemodynamic parameters were also significantly higher inoff-pump group than on-pump patients in this period. At 20 hours almostall differences were eliminated.

Aortic Valve cuspal replacement with glutaraldehydetreated autologous pericardiumVikas Kumar Keshri, Aandrei J JhaThe Mission Hospital, Durgapur, (WB), India.

Background: Severe aortic valve pathology at young age presents thesurgeon with options such as replacement of the valve with a mechanicalprosthesis or a pulmonary autograft. Both these options have certainlimitations. We present a third option of aortic valve repair by cuspalreplacement with glutaraldehyde treated autologous pericardium.Materials and methods: From January 2013 to Dec 2015, 25 pa-tients (14 female, 11 male) underwent aortic valve repair. Themean age was 8 yrs (range, 7-20 yrs). 20 patients were inNYHA class III & IV and 5 in class II but with dilated ventricles.12 patients had definite history of rheumatic fever, the otherswere also presumed to be of rheumatic origin. At surgery thediseased cusps were excised and neo aortic cusps were fashionedfrom glutaraldehyde treated autologous pericardium and stitchedonto the true annulus. All three cusps were replaced in 22 pa-tients, two cusps in 1 patient and only one cusp in 2 patients.Warfarin was prescribed for 6 months to maintain INR of 1.5 to2.0. Patients were followed up with serial echocardiogram at one,six and twelve months.Results: Intraoperative TEE showed no aortic stenosis (AS) or regurgi-tation (AR) in 18 patients and trivial to mild AR in 7 patients. Mean peaksystolic gradient (PSG) across aortic valve was 12 mm Hg (range, 8-20 mm Hg). There was no in-hospital mortality. Two patients were lostto follow up. Mean follow up was 12 months (range, 3-20 months). 74%patients were in NYHA class I, 22% in class II. Increase in PSG wasnoted in 3 patients with mean PSG of 26 mm Hg. 4 patients had lowmoderate AR (mean vena contracta 0.4).Conclusion:Aortic valve cuspal replacement with glutaraldehyde treatedautologous pericardium is a viable alternative to aortic valve replacementin younger patients.

Mitral valve repair in children and young patientswith rheumatic heart disease - A series of 270 casesfrom rural eastern IndiaAandrei J Jha, Vikas Kumar KeshriThe Mission Hospital, Durgapur, (WB), India.

Background: Mitral valve (MV) repair has always been the preferredchoice over MVreplacement as it gives the patient a better lifestyle and ismore physiological. However the operation in rheumatic heart disease(RHD) has its challenges.Materials andMethods: From January 2012 andDec 2015, 270 patients(116 male, 154 female) underwent MV repair. Mean age at presentationwas 12 yrs (range, 5-25 yrs). 88 % of the patients presented in NYHAclass III & IVand 12% in class II. Underlying aetiology was RHD in 98%patients and infective endocarditis in 2%. 21% patients had pure mitralregurgitation (MR), 24% had pure mitral stenosis (MS) and 55% hadmixed lesions. Reparative methods used were ring annuloplasty 89 %,sub-valvular release and fenestration 90% , PML augmentation 21% ,commisurotomy 75%, cuspal thinning 35%, chordal shortening 20%,AML augmentation 10% , quadrangular resection 15%, chordal transfer10%, neo-chordae construction 2%. Patients were followed up with serialechocardiogram at one, six and twelve months.Results: Intraoperative TEE showed noMR in 62%, trivial tomildMR in35%, low moderate MR in 3% patients. The gradient across the MVfollowing repair was 3-7 mm Hg. 30 days mortality was 2%. Out of the5 deaths two were secondary to complications of infective endocarditis,one due to refractory heart failure and two due to sepsis. Mean follow upwas 14 months (range, 3-30 months). 68% patients were in NYHA classI, 28% were in class II and 3% patients had class III and IV symptoms. 6patients required repeat surgical intervention of which one was success-fully repaired with chordal transfer and other 5 required MVreplacements.Conclusion:With the concern of poor patient compliance in rural popu-lation mitral valve repair is practical, feasible and reproducible with ac-ceptable results.

Carotid Aneurysm after stenting: a dreadful situation& its managementAsit Baran Adhikary, Saha H, Ranjan R, Bhandari S,Saha SK, Adhikary N, Adhikary SBangabandhu Sheikh Mujib Medical University (BSMMU)

Introduction: Carotid artery dissection followed by aneurysm formationis a rare but important complication of Carotid stenting. In this study 7patients with carotid Aneurysm after stenting were treated surgically.Materials and Methods: The study period was from January 2014 toSeptember 2016. A total of 7 consecutive patients were selected for surgicalmanagement. All these 7 patients were suffered from huge swelling &severe pain over neck, vertigo, headache, signs of facial palsy such as devi-ation of angle of mouth, unable to close the affected side’s eyelid, slurredspeech etc. All patient developed this aneurysm within the period of 6months of carotid stenting. Carotid angiogramwas done routinely to confirmthe diagnosis and to see the extent of the lesion. Surgical procedure: UnderGAneckwas opened. Both end of aneurysmwas identified, heparinized andthen after 5 minutes’ vascular clamps were applied. Aneurysmal sac wasopened and occluded stent with atheroma was removed. Then a 5-mminterposition PTFE graft was anastomosed end to end with 6-0 prolene. Inall the 7 cases, proximal anastomosis was done in common carotid artery outof which in right side 2 distal anastomoseswere in internal carotid artery&2just before the bifurcation, in left sided case distal anastomosis were incommon carotid artery just before the bifurcation. All Patients weredischarged from hospital on 5th POD.Results: Post-operatively all the pre-operative symptoms were im-proved. Carotid duplex was done on 4th POD & after 3 monthsin every patient which showed excellent flow through graft. No

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Major complication or death was recorder during the follow-upperiod.Conclusion: Surgical correction of carotid aneurysm after stenting is asafe and effective modality of treatment but prompt decision and metic-ulous dissection with proper stitching is needed for good result.

Total anomalous systemic venous drainage –Management and Outcome in Six Patients.Chinna swamy ReddyNarayana Institute of Cardiac Sciences

Introduction: Total anomalous systemic venous return is a very rare anom-aly,wheresuperiorvenouscava,inferiorvenacavaandcoronarysinusdrainitsleft atrium. This condition requires the presence of a left – to – right shunt forsurvival. Atrial septal defect, patent ductus arteriosus or ventricular septaldefect to allow the systemicvenous return to reach the pulmonary circulation.Methods: Six patients were operated between November 2012 to August2016. Diagnosis was made by echo / CT angio / MRI / Cath studies. Theyoungest patient was 5years and oldest was 18 years. Four were femalesand two was male, five patients underwent re-routing of TASVC to rightatrium with small 4mm fenestration in the intra atrial baffle and onepatient had BD Glenn shunt.Results: There was no in hospital mortality. All patients recovered wellexcept for the need for increased duration of inotrophic support. Oneoldest patient had supraventricular tachycardia and treated withantiarrythmic drugs and same patient was readmitted a year later forcomplete heart block requiring permanent pacemaker implantation.Mean follow up of 28months. All patient were in NYHA class I exceptone patient who had BDG who was in NYHA class II symptoms. Echoevaluation showed good biventricular function with goodRV size. Patientwith Ebstein anomaly had moderate TR and small RV cavity.Conclusion: Total anomalous systemic venous drainage is a infrequentcondition and can exist in multiple different forms. Although it remainsan uncommon form of cyanotic CHD is should he considered in thedifferential diagnosis of hypoxemia. Total anomalous systemic venousdrainage has been reported in all age ranges from neonates to adults,Review of literature revealed a total of approximately twenty supportedcases with diagnosis attained from a combination of contrast Echo cardi-ography and angiography. Surgical interventions is guided by associatedcardiacmorphology. In the presence of isolated Total anomalous systemicvenous drainage atrial septation with appropriate routing of veins orifice.In the presence of associated extreme ventricular imbalance, auniventricular pathway may need to the resorted to.

ROSS Procedure- Our ExperienceCinnaswamy ReddyNarayana Institute Of Cardiac Sciences

Introduction: ROSS procedure has become established as on appropriatemethod for aortic valve replacement in children and young adults. In1967, Donald ROSS developed native pulmonary valve autograft foraortic valve replacement in turn replacing the pulmonary valve with ahomograft. Pulmonary autograft uses live tissue from the patient’s ownpulmonary valve. This means the valve grows as the patient grows andcan function indefinitely. More over patient do not need permanentanticoagulation. Pulmonary autograft permits central seminal flow andimproves hemodynamics performance so that previous dilation and ven-tricular hypertrophy recede in most patients.Methods: Over 5 years period from June 2011 to August 2016, 24 pa-tients underwent the ROSS procedure. The medium age was 12.2 years(1-22years) of which 15were males and 9 were females. The main indi-cations were: Aortic regurgitation in 13 patients; aortic stenosis in 7patients and mixed aortic valve disease in 4 patients. Fourteen patientshad previously undergone balloon dilatation of aortic valve.

Results: There have been no deaths reported in this series. Over a medianfollow up period of 28 months there have been no re-operations for repairof autograft leak. All patients were in NYHA functional class I except twopatients were in NYHA class II. One of the patient had severe neo aorticregurgitationwith moderateMRwho underwentMVRepair andAVR( StJudes Bi leaflet prosthetic valve). The other patient had severe obstructionof homograft in pulmonary position due to dense calcification requiringre-operation.Conclusion: The ROSS procedure is a complex aortic valve replacementused with great success in patients with congenital and acquired etiolo-gies. Among possible complications found at follow up was autograft insufficiency and progressive homograft stenosis. Young children can beexpected to out grow their homograft. Re-operation to replace the pulmo-nary homograft is a relatively un complicated procedure and can be ac-complished with low mortality. Despite the increased technical complex-ity, the ROSS procedure can be performed safely in both paediatric andadult population with satisfactory mid term results of the ROSS proce-dure.

30 day Readmission Post Cardiac SurgeryVinay Malhotra, OP Yadava, Vikas Ahlawat, AnirbanKundu, Amita Yadav, Vinod SharmaNational Heart Institute

Objective: To identify causes of readmission post cardiac surgery and itsimpact on outcomes.Methods: A retrospective analysis of 30 day readmission over the last 5years.Results: 50 out of 2653 patients were readmitted within 1 month ofdischarge (1.8%) (off pump coronary artery bypass grafting-40/1852-2.15% ; valvular-8/525-1.52%; congenital- 2/276-0.72%). The presentingcomplaints (cardiac -23/50; non cardiac 27/50) were breathing difficulty(34%), sternal wound related complications (24%), gastroenteritis (14%)and chest pain (12%). In these patients the average hospital stay duringthe first hospitalisation was 9 days (range 6-22) compared to 6 days inregular patients. The average hospital stay during readmission phase was6.5 days (range 1-36) with 60% readmitted within first week. Out of 12patients who were readmitted with sternal wound related complications, 7patients presented within first week with 3 requiring omentoplasty(42.8%) as against 3 out of 5 requiring omentoplasty (60%) who present-ed after 1 week of discharge. This suggests early presentation requires lessinvasive procedures for management. Among 17 patients readmitted forbreathing difficulty, 9 were admitted in first week. Pleural effusion wasdetected in 3 of them (33.3%) and their mean hospital stay was 2.5 days.Compared to this, 8 patients were readmitted more than 1 week afterdischarge. Pleural effusion was detected in 3 (37.5%) and 2 patients(25%) diagnosed as tamponade. The average stay was 4.5 days. Overall5 patients (10%) had rhythm abnormalities with atrial fibrillation among 4of them. There was no mortality reported during readmission phase at ourinstitute.Conclusion: Cardiopulmonary bypass does not increase readmissionrate. Prolonged first hospitalisation predisposes to readmission. Earlyreadmission with prompt intervention leads to better prognosis.

Changing trends in reoperative coronary artery by-pass grafting: a 18 year studySudhanshu Singh, Lokeswara Rao Sajja , GopichandMannam, Satyendranath PaturiStar Hopsitals, Road No.10, Banjara Hills, Hyderabad- 500034

Introduction & Objectives: Currently a fewer patients undergo re-operative coronary artery bypass grafting (CABG) for recurrent coronaryartery disease (CAD). The present study was proposed to analyze theprevalence of redo CABG and prior percutaneous coronary interventions

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(PCI) in patients with recurrent CAD and the early outcomes of redoCABG.Patients & Methods: Data on demographics, preoperative risk factorsand early postoperative outcomes were collected from the institutionaldatabase for 222 consecutive patients undergoing redo CABG fromJanuary 1998 through July 2016. Patients were divided into two groupsbased on the period of performance of redo CABG. Group 1: January1998 through December 2004 (n=114) and group 2: January 2005through July 2016 (n= 108). Redo CABG was performed using on-pump technique in 163 patients (group 1:107 patients and group 2:56patients) and off-technique in 59 patients (group 1:7 patients and group2: 52 patients). We have analyzed the trends and early outcomes of redoCABG.Results: Prevalence of redo CABG decreased from 4.6% in group 1 to1.24% in group 2 (P= 0.000). A significant increase in the prevalence ofPCI prior to redo CABGwas observed (10.5% in group 1 to 33.3% in group2 p= 0.000). Internal thoracic artery graft used was more in group 1 than ingroup 2 (71.9% vs 53.35% p=0.035). The number of patients with advancedage, left ventricular dysfunction and renal insufficiencywere higher in group2. There is no statistically significant difference in the hospital mortalitybetween the two groups (6 patients vs 2 patients p= 0.281 ).Conclusions: There is a declining trend in the number of patients under-going redo coronary artery bypass graft surgery. In spite of high incidenceof co-morbidities in the latter part of the study (group 2) no increase in theoperative mortality was observed.

Obstruction of Mechanical heart valve prostheses:Our experienceNikhil PachpandeNational Heart Institute

Introduction: Prosthetic valve obstruction (PVO) is a life-threateningcomplication. We reviewed our experience regarding incidence, risk fac-tors and treatment strategies of this complication.Methods: The data of 14 patients who presented with PVOwas analysedretrospectively from Oct 2010- Oct 2016.Results: Of these 6 were operated in our institute and 8 at other centres.Mitral valve was obstructed in 9 and 5 involved Aortic valve. The meantime interval from implantation to obstruction was 118 months (MV-90,AV-152). Onset of symptoms was acute in 50% (n-7; MV-6, AV-1), sub-acute in 35% (n-5; MV-3, AV-2) and chronic in 14% (n-2; MV-1, AV-1).The most frequent presentation was severe CHF in 42% (n-6), 14% hadoliguria (n-2) and 14% had multiorgan failure (n-2). On presentation, PT-INR was <2.5 in 84% (n-12). All had mechanical disc type prosthesis.92% had bileaflet prosthesis (n-13; MV-8, AV-5) and 7% single leaflet(AV-1). On ECHO, single leaflet obstruction was found in 42% (MV-5,AV-1) and bileaflet in 58% (MV-4, AV-4). Pannus formation was seen in4, 1 diagnosed preoperatively (operated) and 3 intraoperatively. In MV,Chordal preservation was done in 44% at primary surgery (Partial AMLand full PML-22%, basal Chordae-22%). Before thrombolysis, peakTransvalvular gradient ranged from 22-58 mm Hg for MV and 70-108for AV, which decreased to 6-32 and 48-77 mm Hg respectively.Reoperation was done in 28% (MV-3, AV-1). Mean ICU stay was 4.14days while total hospital stay was 6.5 days. Total in-hospital mortalitywas 21% (n-3). 2 died due to multiorgan failure and 1 sudden deathpresumably due to total obstruction of AV.Conclusion: Inadequate anticoagulation is the most important factor forpathogenesis of prosthetic valve PVO. They respond well to thromboly-sis. Obstruction due to pannus requires reoperation.

Minimal invasive approach for intracardiac repair ofTetralogy of fallotChirag Doshi, Manish Hinduja, Vivek WadhawaU N Mehta Institute of Cardiology and Research Centre

Introduction and Objective:Median sternotomy has been the standardapproach for intracardiac repair of patients with tetralogy of fallot. In theera ofminimal invasive surgery, left anterior thoracotomywas assessed asan alternative approach for the same procedure.Materials and Methods: From January 2014 to October 2016, 26 pa-tients with tetralogy of fallot underwent intracardiac repair via a shortincision left anterior thoracotomy and minimal invasive cannulation. 16patients were children and 10 were adult. The average age was 7.4 +/- 2.8years (2 - 32 years). The average weight was 18.6 +/- 4.6 kg(10 - 67 kg).Patients were selected based on their favourable surgical anatomy andpatients with associated cardiac lesions were excluded. Skin incisionswere as long as 5 cm. Intraoperative and post operative parameters werestudied.Results: Mean CPB time was 88 min (70-134 min). 10 patients wereextubated within 2 hours of surgery. Cosmetic results were very good.There was one mortality due to intractable ventricular arrhythmia. Postoperative hemodynamics, need for inotropic support, drain output andICU stay were similar to patients routinely operated via mediansternotomy.Conclusion: Intracardiac repair for tetralogy of fallot through left anteriorthoracotomy is a safe, effective and cosmetically better alternative tosame surgery via median sternotomy.

Influence of Diabetes Mellitus in women undergoingCABGShylesh Kunnanattil, Sweta R, Madhu Sankar N,Kulasekharan M, Cherian KMFrontier Life Line Hospital, Chennai

Background: Female gender has been considered as a risk factor forCABG. This single centre study aim at evaluating the influence of diabe-tes mellitus as a peri-operative risk factor in women undergoing CABG.Material and Methods: Retrospective study including all women pa-tients undergoing CABG during the period January 2014 to December2015. The patients were divided two groups. 78 patients were diabetic(Group I) and 82 patients were non diabetic (Group II). The parametersanalysed include presence of risk factors like hypertension, renal disease,no of vessels affected, previous PTCA, Ejection Fraction, presence ofRWMA, menopausal status, use of LIMA, re-exploration, units of bloodtransfused, use of IABP, mean ICU stay, mean hospital stay, post opera-tive renal dysfunction, post operative cerebrovascular event and hospitalmortality. Patients with previous cardiac surgery or concomitant cardiacprocedure have been excluded from the study. Patients with critical pre-operative state, has been excluded. The outcome in diabetic group wascompared to non diabetic group.Result: A total of 160 patients fulfilling the inclusion criteria of this studyunderwent isolated CABG during the study period. Mean age was 58.77 +/-7.8years (Range41-81years).13patientshadpreviousPTCA.2patientsdiedin thehospital (1 in eachgroup).Therewasno latemortality.The incidenceofpost operative renal dysfunction ismarginally higher inDiabetic patients.Conclusion:Diabetic women undergoing CABG in the modern era havesimilar outcomes compared to non diabetic women in the study group.

Total arterial multivessel MIDCABManish Hinduja, Chirag Doshi, Vivek WadhawaU N Mehta Institute of Cardiology and Research Centre

Objective: In current era of cardiac surgery, minimal invasive coronaryartery bypass (MIDCAB) plays an important and challenging role. AlsoMIDCABwith bilateral internal thoracic conduits or total arterial grafts isthe best option for patients with coronary artery disease who are high riskfor sternotomy. We evaluated 108 such selected patients who underwentminimally invasive multivessel total arterial off pump anaortic CABGthrough left anterolateral thoracotomy.

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Material &Methods: The procedure was performed using 4-8 cm leftanterolateral thoracotomy incision. LIMA harvested in every patient,RIMA or radial artery used as second conduit. LIMA RIMA Y, orLIMA -RADIAL Y was made to accomplish multivessel total arterialbypass grafting. All intraoperative (hemodynamics and requirement ofinotropic support, perioperative blood transfusion ) and post-operativedata (bleeding, wound infection, pain score, ICU stay, duration of me-chanical ventilation, arrhythmias, perioperativeMI, pleural effusion, needfor IABP support, and post operative patient satisfaction index) werecollected and evaluated. Post-operative graft patency was checked inevery patient by CT coronary angiography before discharge.Results:Multivessel total arterial CABG was accomplished in all select-ed individuals. There was no mortality or wound infection. Re-exploration was done in one patient for bleeding. In two patients saphe-nous vein was used to graft LAD and LIMA used to graft diagonal asLIMA length was not adequate to graft distal LAD. In one individualconversion to sternotomy and CPB was required due to unstable hemo-dynamics. Muscle healing of anterolateral thoracotomy was faster ascompared to bone healing of conventional sternotomy incision.Conclusion: With conventional immobilization techniques and instru-ments multivessel, total arterial MIDCAB can be accomplished safelyin selected individuals. RIMA can be harvested in long standing diabeticpatients with no concern for sternal wound healing. Muscle healing ofanterolateral thoracotomy is faster as compared to bone healing of con-ventional sternotomy and patients are back to normal life earlier.

Aortic dissection repair – good results are possiblewith attention to detail- a case seriesVasudev B Pai, Nikhil Nandineni, S Ganesh KamathKasturba Medical College, Manipal University, Manipal

Introduction & Objectives: Type A dissection repair still carries a highmortality even in the best of centres. Recommendations for emergencyrepair have been described with deep hypothermia and circulatory arrest ifneeded. We describe our series and the lessons we have learnt from them.Materials & Methods: All patients who underwent surgery for type Adissection repair from 2013 to 2016 were studied. Their operative detailsand postoperative course are summarised.Results: 7 patients underwent surgical treatment for aortic dissection.Their ages ranged from 35 to 68 years and 4 were females and 3 weremales. All the patients were taken up for emergency dissection repair. 2patients underwent aortic root replacement and 2 underwent aortic valvereplacement with interposition grafting of the aorta and 3 patients neededonly aortic interposition grafting. Average bypass time was 328 minuteswith a cross clamp time of 192 mins. 2 patients did not need circulatoryarrest and the average circulatory arrest time for the 5 patients was 46minutes. All the patients had Teflon sandwich patch repair of the aorta.One patient had previous heart surgery of mitral valve repair a few yearsback; one patient had a recent PCI and one patient was detected with sidebiting clamp injury during beating heart surgery. All the patients werehypertensive. Average ICU staywas 7 days and postoperative stay was 17days. One patient developed a stroke postoperatively and one developednon dialysis dependant renal failure postoperatively.Conclusion:Repair for aortic dissection has high mortality as the surgeryis long and demanding on very poor quality tissues. Attention to detailduring the operation and good postoperative care are crucial to achievinggood results.

Successful Submitral Left Ventricular AneurysmRepair – A Case SeriesAshish Rayate, G Ramasubrahmanyam, G NagasainaRao, CR VijayaMohan, Himani Shrivastava, TogitiSushanth, T VamshidharCARE Hospitals, Banjara Hills, Hyderabad

Introduction &Objectives: Submitral aneurysm is a rare cardiac pathol-ogy seen mainly in African population, with less incidence in Indianpopulation. Etiology can be congenital defect in fibrous annulus of pos-terior mitral leaflet and/or inflammatory conditions like tubercular peri-carditis, takayasu arteritis etc. Here we present a case series of five pa-tients who underwent Submitral aneurysm repair with mitral valve re-placement with excellent results.Materials & Methods: From April 2007 to September 2016, we treated 5patients (3 males, 2 females) of Submitral left ventricular aneurysm, whosemean age was 34 years. One patient had moderate mitral regurgitation, 4patients had severe mitral regurgitation. Three patients had aneurysms withmultiple necks; two of them had extension of aneurysm into left atrium.Posterior annulus of mitral valve was found to be distorted in all the patients.Diagnosis was made by echocardiography. Coronary angiography was nor-mal for all the patients. In all cases, aneurysm was excised and mouth of thesac closed with treated autologous pericardial patch. Mitral valve was re-placedwithmechanical valve in all the patients. Regular follow-upwas donewith periodic echocardiography evaluation.Results: Hospital stay for all the patients was uneventful with no early or latemortality. All the patients were discharged in a stable condition. There was noresidualMRor residual aneurysmal sac for anypatient on follow-upevaluation.Conclusions: Submitral aneurysm is a rare condition. Offering an aneu-rysm repair along with Mitral Valve Replacement is a good strategy incase of distorted annulus for long term benefits as the predisposing etiol-ogies can lead to recurrence. Understanding the relations of aneurysm,identification of additional aneurysm necks, adequate closure of aneu-rysm and addressing the mitral regurgitation is the key to successfulsurgical repair.

Post MI VSD-Early Surgery is the keyA Kapoor, O P Yadava, A Kundu, VAhlawat, A Yadav, APrakash, V SharmaNational Heart Institute

Objective: Institutional experience of post MI VSD repair with or with-out CABG (2010-2016).Methods: Retrospective analysis of clinical data was done. 16patients including 5 females were analysed. Mean age was67.06 years. 10 patients presented with anterior & 6 with poste-rior VSD. 12 patients were in cardiogenic shock. Intraaortic bal-loon pump was inserted in 12 patients preoperatively. 7 patientswere diabetic, 8 patients had prior history of coronary artery dis-ease, 5 were hypertensive, 6 were smokers, 2 were thrombolysed.Coronary angiography was done in all patients, of which 8 hadSVD, 5 DVD and 3 TVD. 8 underwent concomitant CABG (2diagonal, 2 distal RCA, 2 PDA, 2 LAD). Operative approach wasmedian sternotomy, bicaval cannulation, cold blood cardioplegia,VSD closure with Dacron patch using pledgetted prolene sutures& ventriculotomy closure with 3-0 prolene over Teflon strips. 1patient underwent LV aneurysmectomy.Results: 2 patients died in hospital both of which had anteriorVSD. Of these 1 patient underwent concomitant CABG. Therewere no intraoperative deaths. 4 patients had residual shunt.Mean ACC time with CABG was 86.75 minutes and withoutCABG, 64.37 minutes. Mean ICU and hospital stay was 7 and15 days, respectively. IABP was removed after average of 48hours. Early era and late era mean period between MI & VSDdetection was 5.2 days and 4.9 days; & from VSD detection tosurgery, 45.6 hours and 19.5 hours, respectively. Postoperatively 1patient who underwent CABG had renal failure and sepsis. 1patient died of coagulopathy on POD zero, another succumbedto ventricular arrhythmias on POD 9.Conclusion: In the current era, viewing abysmal result of medicalmanagement patient to be taken early for surgery including pos-terior VSD.

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Size of Patent Ductus Arteriosus - A determining fac-tor for the modality of surgical treatmentMenander M, Uday Jadhav, D V Kulkarni, Kamlesh JainSeth G S Medical College and KEM Hospital

Objective: Patent Ductus Arteriosus (PDA) is one of the commonestacyanotic congenital heart disease. Surgical closure is done when medicalmanagement fails. Simple ligation of PDA has been shown to have highrecurrence rate. Operative technique either direct ligation or modifieddivision and suturing technique was based on the size of PDA at pulmo-nary end. A study was conducted to assess the type of surgical techniqueto be followed.Materials and methods: 30 cases of PDA were studied from 2012– 2015. All patients were operated with limited thoracotomy. Ofwhich, 10 were taken for division and suturing and 20 underwentligation. Size of PDA at pulmonary artery end was the determi-nant in deciding the type of technique. 5 or more than 5 mm wasconsidered for division and suturing. Less than 5 mm was con-sidered for ligation. 40% of the patients were females. The agesranged from 12 days to 14 months with youngest weighing 650grams.Results: Therewere no immediate or late postoperative deaths. Therewere nointra-operative or post-operative complications. The mean hospital stay was 3days.RepeatECHOafter 3months did not show recanalization in either group.Conclusion: Surgical closure of PDA is a safe and effective technique.Division and suturing of PDA can be done safely for PDA more than 5mm. However, larger, long follow up and a multi centric study is requiredto set up a definitive guideline.

Midterm outcomes of superior septal approach formitral valve repair/replacementBharath Kumar M, Ejaz Ahmed Sheriff, Rajan S,Sivakumar Pandian, Karthik Raman, Sumit Rawal, AnjitPrakash, Arun Singh, Swaminathan, Naga Sai LakshmiThe Madras Medical Mission Hospital

Introduction and Objectives: Good exposure of the mitral apparatus ismandatory for mitral valve (MV) procedure. The aim of our study was toevaluate outcomes and complications if any associated with thisapproach.Materials and Methods: Between January 2011 and Decemeber2015 , 34 patients (22 male, 12 female) underwent MV procedurethrough superior septal approach. Nine patients underwent MVreplacement, 2 patients underwent MV repair, 8 patientsunderwent double valve replacement, 15 patients underwentMVR and tricuspid valve repair. Eleven among these 34 patientsunderwent redo procedure. The total follow up period was 32.25±2.18 patient-years. The data was collected retrospectively fromthe hospital data base.Results:Post operative complications were re-operation for bleed-ing 2.94%, renal failure 5.88%, deep sternal wound infection2.94%. Four patients (11.6%) needed prolonged ventilation (≥48hours). Three among 20 patients (15%) who were in sinus rhythmpreoperatively developed new onset arrhythmia. One patient(2.94%) had ventricular tachycardia (VT), 2 Patients(5.88%) hadatrial fibrillation (AF). The in hospital mortality was 20.58%. Onepatient (2.94%) died of VT and 2 patients (5.88%) died of lowcardiac output. At the end of follow up 2 patients (5.88%) hadAF. One patient (2.94%) had severe valvular leak.Conclusion: The superior septal approach provides good exposureto MV and subvalvular apparatus. From the limited follow upperiod definitive conclusions could not be drawn on the long termoutcomes of this approach. However this approach appears tohave no significant effect on post heart rhythm and associatedcomplications.

Warm perfusion: A Novel mode of myocardial pres-ervation in Atrial Septal Defects. Prospective studySyedWahid,GNLone,ShadabNabi,FarooqAGanie,NadimKawoosa, AMDarDepartmental/Institutional Affiliation: CardioVascular and Thoracic Surgery,Sher-i- Kashmir Institute of Medical Sciences (SKIMS),Srinagar-190 011,Kashmir (India).

Objective: the primary aim of this study was to evaluate the effect ofcontinuous antegrade perfusion on an empty beating heart with normo-thermic blood to avid myocardial ischemia and the detrimental effects ofcardioplegic arrest on the myocardium.Patients and methods: From September 2011 to November 2016, 25patients underwent ASD repair on beating heart with continuousantegrade normothermic blood perfusion with aortic cross clamp on.Another group of 25 patients were subjected to ASD repair on arrestedheart. Patients’ age and size of defect were similar in both the groups.Preoperative diagnosis was established by 2D echo and colour Dopplerstudy. The normothermic perfusion was kept at 4-5 ml/kg-BW/min in thebeating heart group. CPK –MB and Troponin –I were done after 6 hoursin all the patients.Results: The mean aortic cross clamp time in the beating heart andarrested heart groupwere 20.72±7.08 and 30.56±5.83minutes respective-ly. The mean bypass time in the beating heart and arrested heart groupwere 32.80±7.48 and 47.12±6.28 minutes respectively. There were nodifferences in blood products transfused. ICU and hospital stay weresignificantly less in beating heart group. There was no hospital mortalityin either group. There was no statistically significant difference in CPK-MB and Troponin –I levels between the 2 groups. No major complica-tions were observed during hospital stay. Post operative echocardiogra-phy showed normal LV function and no residual shunt in either group.The ejection fraction and the incidence of postoperative arrhythmias weresimilar in both groups.Conclusion: Beating heart surgery using normothermic blood is a safeand effective technique for the closure of ostium secundumASDwhich issubstantiated by clinical and biochemical assessment.

Surgical Management of Embolized Cardiac Devicesas an Emergency: Experience at SKIMS, Srinagar,Kashmir.Nadeem–ul- Nazeer Kawoosa, G N Lone, A M Dar, A GAhangar, Farooq A Ganie, Syed WahidDepartmental/Institutional Affiliation: CardioVascular and ThoracicSurgery, Sher- i - Kashmir Ins t i tu te of Medical Sciences(SKIMS),Srinagar-190 011, Kashmir (India).

Background: We analyzed our experience with emergent surgical man-agement of displaced/impacted cardiac devices after failure during at-tempts to occlude the defects by transcatheter route during childhood orthereafter.Methods: 5 of 185 patients who underwent device closure of congenitalheart defects during the period from November, 2000 to Oct 2016 wereshifted to OR for surgical management and operated under cardiopulmo-nary bypass/standby cardiopulmonary bypass. Their diagnosis, selectionfor device closure and surgical management techniques are discussed.Results: 2 of 5 patients had failed device closure of patent ductus arteriosuswhose device had embolized to left pulmonary artery. Both had successfulretrieval without cardiopulmonary bypass through left thoracotomy. 2 patientswhohadundergonedeviceclosureforatrialseptaldefect,haddeviceimpactedinright ventricular apex and right ventricular outflow tract respectively. Both ofthem were successfully managed by surgical removal through right atrial ap-proachonbeatingheartcardiopulmonarybypass.5thpatientwhowasa30yearsoldmale patientwas presumed to have amuscular ventricular septal defect. AnattemptwasmadetoclosethedefectbytheAmplazdevicebutitembolizedtoleftpulmonaryartery.Hewasproved tohaveaRSOVinto right ventricularoutflow

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tract and a large subpulmonic ventricular defect. Device had embolized to leftpulmonaryarterywhichhadcrateddissectionof the artery.Devicewas success-fully removedoncardiopulmonarybypasswitharrestedheart.VSDandRSOVwere repaired by double patch technique through combined transpulmonary-transaortic and transatrial approach. Dissected left pulmonary artery wasrepaired.Nomortalitywas observed during the study.Conclusions: Inspite of many advantages with nonsurgical closure ofcongenital cardiac defects, embolization of devices continues to remainthe major challenge for an interventionist.

Single Stage Minimally Invasive Approach of LowerPartial Sternotomy (MILPS) for Abdomino-ThoracicHydatidosis: Single Surgeon ExperienceHaroon Rashid, G N Lone, Muzaffar Ali Khan, FarooqAh Ganie, Mohsin Mushtaq, Syed WahidDepartmental/Institutional Affiliation: CardioVascular and ThoracicSurgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS),Srinagar-190 011, Kashmir (India)

Background: Systemic hydatid cystic disease although rarely en-countered, requires multi staged approach and poses a challengeto a surgeon in terms of accessibility. The objective of the studywas to find a feasible alternative approach to conventional multistaged approach.Methods: 27 of 62 patients with abdominothoracic hydatid disease se-lected out of 484 patients with pulmonary hydatid disease were subjectedto single-staged lower ministernotomy. Primary diagnostic tools werechest radiography, ultrasonography, computer tomography and serology.Preferable mode of management of hydatid cysts was enucleation withderoofing, with no or partial capitonnage without any intracavitorydrainage.Results: 62 of 484 (12.80%) patients had concurrent hepatic and pulmo-nary hydatid cysts. 27of 62 patients were selected for lowerministernotomy. Male: female ratio was 1: 1 and mean age was 25.10.Mean operative time was 85 minutes. Air leak was the commonest post-operative complication and cause of morbidity (22.2%). No patient hadsignificant biliary leakage. Mean hospital stay was 7.4 days. Post-operative recovery was prompt. 1 of 27 patients died (3.7%) due to lateonset, sudden and unexplained hemothorax. Overall results wereencouraging.Conclusion: This approach is expeditious, economical, convenient, min-imally invasive; less painful and cosmetically appealing. This approachalthough requiring a learning curve, can be an excellent alternative tostaged modalities if applied to properly selected patients.

Role of trans hiatal oesophagectomy in carcinomaoesophagus-A retrospective pilot studyNadeem-ul- Nazeer, G N Lone, M A Bhat, A M Dar,Shyam Singh, A G Ahangar, Farooq A Ganie, ZubairAshraf, Syed Wahid, Asrar Qadri, Mohsin Mushtaq, Mohd Amin, FerozAhmad, Haroon RashidSher i Kashmir Institute of Medical Sciences, Srinagar.

Background: Patients with histopathology proved oesophageal carcino-ma were studied retrospectively to determine the role of trans-hiataloesophagastrectomy and overall profile of the patients.Methods: 1432 patients documented to have esophageal carcinomaunderwent transhiatal oeosphagectomy by a team approach with or with-out neoadjuvant chemotherapy with cervical oesophagogastrostomy afterdetailed workup and preparative measures.Results: A total of 1432 patients underwent transthoracic esopha-gectomy. The duration of symptoms were less than three months.Around 56% patients had carcinoma of the middle-third of thethoracic esophagus,42% patients had carcinoma of lower-third of

the thoracic oesophagus while 2% had upper thoracic lesions.Most of our patients had squamous cell carcinoma (59 %) follow-ed by adenocarcinoma (38%). Average blood loss in the serieswas 650 mls. Perioperative and postoperative morbidity was stud-ied. The median follow-up was 4.3 years. Estimated 3-year dis-ease free survival (DFS) was 30.25 %, whereas the 3-year overallsurvival (OS) was 40.25%. Also, the estimated 5-year DFS rateswas 20.65%, whereas the 5-year OS rate was 28.45%.Conclusion: Trans-hiatal oesophagectomy is a procedure suitable forpatients with carcinoma of the oesophagus and affords a surgical optionat an "acceptable price" among carefully selected patients with carcinomaof the oesophagus.

Risk categorisation for surgical repair of double aor-tic arch – data from a 10-year cohortArun BeemanGreat Ormond Street Children Hospital, London

Introduction: Persistence of aero digestive symptoms after surgical re-pair of double aortic arch (DAA) is not uncommon. This retrospectivestudy aims to identify risk factors associated with persistence of symp-toms in children undergoing surgical repair of double aortic arch.Methods: Retrospective study in a single institution between 2005 and2015. All childrenwho had surgery for true vascular ring due to DAAwasincluded. The factors analysed were symptoms, age at onset of symp-toms, diagnostic investigations, associated anomalies, age and weight atsurgery, surgical technique and symptoms at follow-up, patency and dom-inance of the arches, anterior angle subtended at the level of compressionand position of descending aorta in relation to the airway. Data wasanalysed by t-test and anova.Results: 55 children underwent repair of DAA, with a median age of 8months (0-201) and weight of 8.2 kilos . Right aortic arch was predom-inantly dominant. The left arch was atretic distally in 37 children and 6children had associated aberrant subclavian artery. Airway symptomswere predominant in 51 children while 15 children had oesophagealsymptoms. After surgery symptoms persisted beyond three months in31children. Persistence of oesophageal symptoms was longer than therespiratory symptoms (14months vs. 12 months, p=0.3). Univariate anal-ysis showed that the arch angle between 45 and 60 was significantlyassociated with persistence of symptoms. On multivariate analysis, earlysymptomatic relief was seen in male sex, presentation at a younger agesymptoms sans oesophageal compression, absence of chromosomal ab-normality and presence of right sided proximal descending thoracic aorta.Conclusion: In surgical repair of DAA, the branching pattern and archangulation of the DAA plays an important role in predicting the persis-tence of symptoms after repair.

Outcomes Of Right Ventricular Outflow Tract(RVOT) Reconstruction Using Handsewn ValvedConduitsR Jaiganesh, Mubeena, Roy Varghese, RajanSethurathnamThe Madras Medical Mission, Chennai

Aim: To study the outcomes of RVOT reconstruction using hand sewnbovine pericardial/PTFE (polytetra fluoroethylene) valved conduits in ourinstitution for a period of 2years Background: The ideal choice for a valvedconduit has yet to be found. Although homograft conduits remain the pop-ular choice, certain disadvantages such as lack of availability, requirement ofsterilisation and preservation and late complications due to degenerativeprocesses and calcifications- have led us to search for other alternatives.Methods: Between2015-2016,a total of 18 children underwentRV-PAcon-duit using hand sewn conduits. The data was collected frommedical recordsdepartment and analysed for variables like age, sex, diagnosis, preop echo

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details,etc.Theintraoperativedetailswithanycomplicationsintheimmediateand late postoperative course are documented. These patients were followedup in the 3rdmonth after surgery and yearly once thereafter.Results:All the surgical procedures are successful with no mortality. Themean age group was 45.9months with 61%(n=11) males. The most com-mon diagnosis which required a RV-PA conduit is tetralogy of fallot withpulmonary atresia -55%(n=10),followed by cTGA,truncus arteriosus,DORV+PS, TOF with absent pulmonary valve. In all the patients theconduits were made from bovine pericardium on table according to thebody surface area. The valves that were sewn in the conduits were bovinepericardium in 13(72.22%) patients and PTFE in 5(27.77%) patients. Thepostoperative course was smooth with no interventions. There is no con-duit gradient/regurgitation in the postop and followup echo.Conclusion: Hand sewn conduits offer good results as with homografts.The early outcomes after surgery were satisfactory. Long term followupneeded in future for the betterment of its use.

Age related outcome variability after complete atrio-ventricular septal defect repair in small childrenArun BeemanGreat Ormond Street Children Hospital, London

Introduction: While the surgical techniques around repair of completeatrio-ventricular septal defect is standardised, the risks of reoperation orresidual regurgitation in relation to timing of surgery is not well profiled.The present study aims to assess specific age and weight related variableoutcomes following complete atrio-ventricular septal defect repair.Methods: Retrospective analysis of 202 children after repair of completeAVSD repair between 2006 and 2015. Follow up data were available for178 children. End points evaluated include death, presence of at leastmoderate left or right AV valve regurgitation or reoperation for any re-sidual lesions.Results: 25 events were noted in 178 children who had complete followup data. Repair at age less than 3 months had hazard ratio of 3.1 for anyevents, and risk of reoperation of 10% at 1 year post-repair. Similarly,repair at weight of less than 4 kg had higher risk for any events includingdeath or reoperation at 1 year post-repair (12% higher risk for any events;p = 0.004) including 20% higher cumulative risk for death on actuarialestimate in 10 years.Conclusions: While the repair of complete AVSD is standardised now,there remains a higher risk for reoperation and cumulative risk for deathwhen operated in small children. This warrants a revised strategy in thesesmall children including consideration towards staged repair, who presentvery early in life with heart failure.

Evolution of mitral regurgitation in post aortic valvereplacement patientsVijayanand Palanisamy, Karthik Raman, BharathKumar, Sumith Rawal, Swaminathan, Arunsingh, VijayMadhan, Mithun, Sunil, Teja, Shilpa Shree, Naga Sailaskshmi,Vasanthi, Ajit Cherian, Sivakumar Pandiyan, Suresh KumarMadras Medical Mission

Objectives: Frequently aortic stenosis (AS) is encountered with mitralregurgitation (MR) either due to primary pathology affecting mitral valveor secondary to AS. Aim of the study is to analyze the evolution ofMR inpatients undergoing aortic valve replacement (AVR) for calcific AS and toidentify the factors which influences the regression/persistence/progres-sion of MR after AVR.Methodology: From January 2011 to June 2015, 387 patientsunderwent AVR alone, among which 38 patients were found tohave calcific AS as primary lesion, with associated grade2+ MR,constitutes the study population. 27 patients were associated withgrade2+ Aortic regurgitation. Out of 38 patients, 32 patient’s

preoperative and postoperative echo and clinical parameters wereanalyzed for mean follow up of 18.4 months.Result: Among 32 patients, 27 patients MR regressed to mild grade, 4patients had persistence of moderate MR, 1 patient had worsening of MR[mean Jet area prep Vs postop -> 5.37Vs2.55, 8.09Vs4.5, 5.57Vs6.73respectively]. All patient’s functional status improved irrespective of pres-ence ofMR. 13 patients with severe left ventricular dysfunction improveddrastically among which only one patient had persistence of MR. Allpatients were in sinus rhythm in preop and during followup. None ofthem had failure admission/reoperation/late mortality. One patient hadPPMwhomMRworsened. Among 5 patients with minor chordal ruptureto AML, 2patients had persistence of MR.Conclusion:Not all MR to be addressed at the time of AVR. In our study,presence of PPM& minor chordal rupture have negative effect and sinusrhythm& preoperative poor ejection fraction have positive effect on evo-lution of MR. In our study, Pulmonary artery pressure, Left atrial size,Left ventricular dimensions doesn’t showed any correlation withpersistence/worsening ofMR as seen in literature. Depends upon the echoparameters and clinical assessments, patient should be individualised.

ATALE OF HUNDRED CYSTS”’.- A Retrospectiveanalysis of Hundred consecutive cases of pulmonaryHydatid cysts -Deepak Narayanan A, Roy GnanamuthuChristian Medical College Vellore

Aim and objectives: To study the modes of presentation and manage-ment of hundred consecutive cases of pulmonary hydatid cysts.Material and methods: 100 cases of pulmonary hydatid cysts wereevaluated pre and post operatively, 56 males and 44 females with a meanage of 34.2 yrs. Age and sex distribution, modes of presentation preoperative investigations, type of surgical procedure performed, post op-erative complications, post operative length of hospital stay and postoperative follow up of all patients were analyzed.Results:Out of the hundred cases analyzed 56 were females and 44 weremales. The most common symptomwas recurrent cough (44%) followedby cough with hemoptysis (24%). 83% of patients presented with pulmo-nary hydatidosis. 16% presented with lung and liver involvement. Ltlower lobe was involved in 33% of disease followed by Rt lower lobe(28%).hydatid cyst excision was done for 50% of cases followed byexcision and capittonage in 30% of cases. The mean duration ofhospitalisation was 7.2 days. Complications occurred in 15% of patientsand prolonged airleak (9%) being the commonest..Patients were followedup for 6 months and recurrence was detected in 2 patients.Conclusion: Surgery is the main stay in the management of pulmonaryhydatid cysts. Lung preserving surgeries should be the preferred approachin all patients.Radical surgeries should be reserved for cases where irre-versible lung damage has occurred. Close follow up of patients should bedone to diagnose recurrences.

Mediastinitis: incidence, prognosis of early versus latepresentationS Sehrawat, OP Yadava, VAhlawat, A Kundu, AYadav, APrakash, V SharmaNational Heart Institute

Objective: To compare incidence and prognosis of mediastinitis at earlyand late presentation post cardiac surgery.Methods:A retrospective observational study of National Heart Institute,New Delhi of patients who developed mediastinitis post surgery fromOctober 2010 to October 2016.Results: In a cohort of 2653 surgeries (1852 CABG, 525 valvular, 279congenital), 19 patients (0.7%) developed mediastinitis. Total number ofmediastinitis cases were 20 (1 was operated at another hospital). 12 cases

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(60%) presented early (<15 days post surgery), 8 cases (40%) presentedlate (after >15 days). Among those presenting early, in 38.5%, culture wassterile and Klebsiella was predominantly isolated in 33%. 6 cases (50%)required omentoplasty, 5 cases (41.7%) required only debridement.Average hospital stay in this group was 19 days. In the late group,Pseudomonas was the predominant organism (37.5%) and 5 cases(62.5%) required either omentoplasty or PM flap closure. Average hos-pital stay in this group was 41 days.Conclusions: The incidence of mediastinitis is low (0.7%). Morbidity waslower in patients presenting early. Most common organism responsible formediastinitis in early group was Klebsiella and Pseudomonas in late group.

Video-assisted thoracoscopic surgery of sliding hiatushernia- a single Institute experienceSayar Munshi, Binay K SarkarNil Ratan Sircar Medical college

Introduction andObjectives: Slidinghiatusherniaisassociatedwithlaxityof the phrenoesophageal membrane and the cardia of the stomach herniates.Slidinghiatusherniaisdiagnosedbybariumswallowradiography,endoscopy,or manometry. The gastroesophageal junction becomes incompetent andesophagealacidclearanceiscompromisedinpatientswithhiatalhernia,whichfacilitates the development of GERD (gastro-esophageal reflux disease).Majority of these patients with hiatus hernia present with GERD. BecauseGERD may lead to several complications, Surgery should be considered inpatientswith refractory symptoms and inpatientswith complications, such asrecurrentbleeding,ulcerationsorstrictures.Wehaveperformedvideo-assistedthoracoscopic fundoplication in nine patientswith symptomatic hiatus herniawhich has been described here.Materials andMethods: FromMarch, 2015 to September, 2016 a total of9 patients were operated in the department of Cardiovascular and ThoracicSurgery, NRS Medical College & Hospital, Kolkata, West Bengal, India.Results:We had a total of nine patients (male-3, female-6; age range 28 –63 years). Video-assisted thoracoscopic fundoplication was done in allcases through 3-4 port technique. Port size ranged from 5mm to 7cm.Hernia size was moderate (2-5cm). Duration of Surgery was from 90-120minutes. All these cases had smooth postoperative recovery. Feedingcould be started within 48 hours. All these remained free of symptoms tilllast follow-up with definite improvement in quality of life.Conclusion: Thoracoscopic technique using 3-4 ports and 10mm camerawas found to be effective and reproducible with minimummorbidity. Allpatients had significant improvements of symptoms. No recurrence notedtill 18 months follow-up (maximum). Long term study is required to seethe effectiveness of the procedure in the long run.

Paediatric Heart Transplantation – Our Experienceof 33 casesAnitha Chandrasekhar, Ganapathy Subramaniam, SKChowdhury, KG Suresh Rao, KR BalakrishnanFortis Malar Hospital

Introduction: Paediatric heart transplantation has been established as alifesaving procedure for children with end stage heart failure either due tocardiomyopathy or congenital heart disease refractory to medical andsurgical therapy. We report our experience of 33 cardiac transplantationsin children < 18 years.Methods: We retrospectively analyzed the data of 33 paediatric patientswho underwent orthotopic heart transplantation from March 2014 toNovember 2016. The preoperative, intra-operative and postoperative var-iables, survival and follow-up data were studied.Results: Age ranged from 1.4 years to 18 years with a mean age of 10.4years. There were 12 patients in the age group of 0-10 years and 21 in the11-18 years age group. The etiology for heart failure was cardiomyopathyin 88% of the patients (n=29) and 4 had congenital heart diseases (12%).

A right heart hemodynamic study was done in all patients. The meanpulmonary vascular resistance was 2.7 wood units. 1 patient had IABP,1 had ECMO support and 2 patients were on temporary LVAD support(CENTRIMAG pump) preoperatively as bridge-to-HTx. 16 patients wereon ambulatory Milrinone therapy preoperatively for stabilisation. Donorto recipient bodyweight ratio was 1.59 ± 0.9 (range 0.67 to 4.42). Bicavalanastomosis was the procedure of choice. Nitric oxide therapy was usedin all patients during weaning off cardiopulmonary bypass to preventright heart failure of the graft. Operative mortality was 4 out of 33(12%). There were 2 late deaths due to acute events. One year Event freesurvival is 93.1%. All of the 27 surviving patients are asymptomatic andhaving a good quality of life.Conclusion: Heart transplantation is a feasible option for terminally illpaediatric patients. Meticulous pre-operative stabilisation, optimal donorselection, diligent surgical planning and technique, careful postoperativemonitoring and rigorous surveillance for infection and rejection are keysto successful outcome.

Improvement in Clinical Outcomes After Treatmentof the Vascular Conduit in Coronary Artery BypassGrafting SurgeryNiket Arora, Sivakumar Pandian, Suresh Kumar, FemyAbraham, Gomathy Jeeva, S RajanThe Madras Medical Mission

Introduction and objectives: Although arterial grafts are the preferredconduit for CABG surgery, the most widely used conduit is theSaphenous Vein Graft (SVG). However, SVG patency rates remain un-acceptably low, impairing clinical outcomes. We investigated a recentlyapproved intraoperative SVG treatment (DuraGraft) and its effects onclinical outcomes in CABG patients.Materials and methods: Between 4/9/2013 and 31/10/2015, a total of338pts (age: 47-72) were randomized and underwent CABGwith at leastone SVG. SVGs were treated with DuraGraft in 122pts (treatment-group)or bathed in autologous heparinized blood in 139pts (control-group) un-dergoing CABG. Clinical outcomes up to 18±8 months were assessedwith particular regards to repeatrevascularization (RR), myocardial-infarction (MI), death, and a composite of all these major adversecardiac-events (MACE).Results: The average size of the SVG in treatment group was 4.20 ±0.5 mm and was 4.3±0.5 mm in the control group. A total of 674 SVGs(291 in the treatment group and 383 in the control group) were includedwith an average of 2.39 SVGs (treatment) and 2.76 SVGs (control) perCABG. One patient experienced an MI in the treated SVG group whichwas managed with IABP support. There were no in hospital mortality ineither groups. Variable DuraGraft Autologous Blood p=Value n=122 (%)n=139 (%)MI 1 (0.8%) 8 (5.8%) 0.0001* RR 0 (0.0%) 1 (0.7%) 0.0023*Death 0 (0.0%) 0 (0.0%) NS MACE 1 (0.8%) 9 (6.5%) 0.0001*Conclusion: This study demonstrates that DuraGraft treatment of thevascular conduit during the CABG procedure improves clinical outcomesin CABG patients with regards to perioperative MI, RR and MACE.

A Double Trans Atrial Trans Pulmonary ApproachHelps To Preserve Pulmonary Valve Better InTetralogy Of FallotSudheer Gandrakota, Pooja Shetty, CS Hiremath,Krishna ManoharSri Sathya Sai Institute of Higher Medical Sciences , Whitefield,Bangalore

Background: Tetralogy of Fallot (TOF) correction involves varioussurgical techniques to minimise right ventricular outflow tract(RVOT) enlargement to preserve function of the pulmonary valveand post operative right ventricular dysfunction.

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Methods: The retrospective study was conducted in the Department ofCardiothoracic and Vascular Surgery, at Sri Sathya Sai Institute of HigherMedical Sciences, during the period from February 2014 to February2016 on 141 cases who underwent TOF corrections at a median age of2 yrs. 126 (89.36 %) patients had perimembranous VSD and 15( 10.63%) had Doubly Committed VSD. Out of 126 PMVSD cases, 108 ( 85.71%) had Pulmonary valve preserved and 18(14.28 %) neededTransannular patch (TAP). Out of 15 cases of TOF with DoublyCommitted VSD 7 ( 46.6 %) cases had Pulmonary valve preservationand 8(53.33%) cases needed transannular patch.Results:Post operative ECHO assessment in pulmonary valve preservedcases had nil or mild pulmonary regurgitation. RVOT gradients were lessthan 20 in 32 ( 22.69 % ) of cases , between 20-40 in 63 (44.68 %) casesand above 40 in 13( 9.21% ) cases with a maximum gradient of 60.1 (0.7%)case had small residual shunt and 1(0.7 %) case had moderate shunt.We had 9(6.38 %) mortalities. Follow up evaluation was done to a max-imum of 2 years. Re- operation was done in 2 ( 1.41 %) cases.Conclusions: Beingaggressiveandgoinginwithanopenmindinpreservingnative pulmonary valve in Tetralogy of Fallot repair results in early recovery,avoids free pulmonary regurgitation, prevents right ventricular dilatation ordysfunction and later the need for pulmonary valve replacement.

Pushing boundaries for organ acceptance in paediat-ric heart and lung transplantationArun Beeman, Nagarajan MuthialuGreat Ormond Street Children Hospital, London

Introduction: With the imbalance between donation rates and potentialrecipients increasing, heart transplant programs increasingly have to usenon-ideal organs from so-called “marginal donors”. There has been awelcome increase in overall solid organ donation rates in the UK overthe last decade. However, this is largely due to the use of donors aftercirculatory death (DCD) and older and heavier donors and donors for thesmallest recipients remain rare. Other techniques, such as sophisticatedanalysis of organs prior to retrieval, 2 are being attempted, but only theuse of ABO-mismatched transplants has yet to make an impact on num-bers of pediatric heart transplants.Methods: Retrospective analysis of children who underwent heart andlung transplants, where organ acceptance would deviate from convention-al acceptance criteria: these include exceeding weight or height for heartor lungs, ABO mismatch transplants for heart (n = 4), heart from donorwith ALCAPA (n = 1), DCD donor for lungs and possibly for heart (n = 3for lungs), suboptimal function for both heart and lungs, and presence ofnon-metastasizing brain tumours.Results: The immediate postoperative course of these children is compa-rable to those, whose organs satisfied the existing donor criteria for ac-ceptance. There was no unusually high need for extra-corporeal support.The early survival is similar.Conclusion: Widening of donor pool increases the possibility of trans-plant, thereby reducing waiting list mortality and morbidity. While ex-tended criteria in general is attractive in small numbers, more work needsto be done to ensure organ function is better preserved in this group soalso the long term survival. Role of ex-vivo perfusion and DCD donorsneed to be evaluated in a wider scale for paediatric population.

Rejection after heart transplantation: role of 77 con-secutive endomyocardial biopsies in an active hearttransplant centreCManorasMathew, Jose Chacko Periappuram, BhaskarRanganathan, Kochu KrishnanLISIE Heart Institute, Cochin

Introduction & Objectives: Heart transplantation is the best treatmentfor end stage heart failure. Endomyocardial biopsy (EMB) is a gold

standard test for transplant rejection. The objective is to discuss our ex-perience of rejection surveillance with EMB.Materials & Methods: A retrospective analysis of patients whounderwent orthotopic heart transplant between 2013 and 2016 was done.EMB’s were done on 1st week, 1st month, 3rd month, 6th month, 1styear, 18th month and 2nd year post transplant. All biopsies were donethrough the right internal jugular vein. Rejection was graded as per theISHLT nomenclature (0R- no rejection, 1R- mild rejection, 2R- moderaterejection, 3R- severe rejection and AMR- antibody mediated rejection).The standard immunosuppression included Tacrolimus, Mycophenolateand prednisolone.Results and Discussion: A total of 19 heart transplants were done. Wehad three early mortalities (30 day). One year mortality was five. A totalof 77 EMB’s were done. 79.2 %( 61) of biopsies did not show anyrejection (0R). Mild rejection 1R and moderate rejection 2R were seenin 9 %( 7 each) of these biopsies. Severe rejection (3R) and Antibodymedia ted rejec t ion (AMR1) was seen only once. ECHO(Echocardiography) was done while patients were admitted for EMB.Patients who had mild to severe forms of rejection did not have anysymptoms nor did their ECHO show any major change. This shows theineffectiveness of ECHO as a surveillance tool. Steroids showed goodresponse in case of rejection. Everolimus was started for one patient whohad 3R. Rituximab was given to the patient who had AMR1.Conclusions: EMB is invasive but quite safe. ECHO is an inferior toolfor rejection detection. Steroids have shown exceptional benefit. Changeof immunosuppressants may be required. Our experience confirms EMBas an important early marker for surveillance.

Our experience with Reoperations on the aortic rootand ascending aorta following previous cardiacsurgeryKMukesh, VVBashi, Mohammed Idhrees, Aju JacobInstitute for Cardiac and Advanced Aortic Disorders (ICAAD),SIMSHospital,Chennai

Background: First time operations on the aortic root and ascending aortaare performedwith relatively lowmorbidity and mortality. However thereis increased risk in reoperations. In this study we reviewed our experiencewith aortic reoperations over a period of 20 years with the intent ofanalysing our techniques, perfusion strategies and results.Methods:From March 1996 through April 2016,118 patients underwentreoperations on the aortic root and ascending aorta following previous car-diac surgery (mean age 42 yrs, male 62%).The previous operations wereaortic valve replacement (38),coronary artery bypass grafting(32),mitralvalve replacement (20),aortic root replacement(10),ascending aorticreplacement(6),and other procedures(12). The reoperations performed wereaortic valve replacement(59), aortic root replacement(38) and graft replace-ment of the ascending aorta(21). Concomitant procedures included archreplacement, coronary artery bypass grafting, mitral valve replacement andtricuspid valve repair. Follow up period ranged from a minimum of 6months to maximum of 19 years.Results: The mean cardiopulmonary bypass time was 205 mins (range-180 to 264 mins) and the mean myocardial ischemic time was 132 mins.Proximal arch/ascending aortic cannulation was preferred in most casesexcept in cases of dissection where axillary artery/femoral artery was thepreferred site. Custodiol cardioplegia was used in patients requiring aorticroot replacement and with concomitant arch procedures. Selectiveantegrade cerebral perfusion was used in cases requiring distal anastomo-sis under circulatory arrest. Two patients expired in immediate postoper-ative period owing to low cardiac output. Three patients requiredreexploration for postoperative haemorrhage. One patient had cerebro-vascular accident. Two patients developed renal dysfunction postopera-tively not requiring dialysis. None of the patients required prolongedventilator support. There was no deep sternal wound infection. On followup, two patients required reoperation for disease progression (tricuspid

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regurgitation in rheumatic disease and arch dissection in Marfan’s syn-drome )Conclusion: Reoperations on the aortic root and ascending aorta can beperformed safely with low operative risk if meticulous attention to myo-cardial protection, cerebral protection and surgical technique is followed.

Can Endarterectomy be useful in peripheral arterialocclusive disease with critical limb ischemia?Bhuban Mukherjee, Binay K SarkarNil Ratan Sircar Medical college

Introduction and Objectives: Importance of thromboendarterectomy(TEA) had declined with the advent of bypass techniques andavailability of prosthetic grafts, in patients with Peripheral arterialocclusive disease (PAOD). Many of these patients with advancedand complex arterial occlusive disease with critical lower limbischemia required endarterectomy of the tibiopopliteal segmentand of the distal landing zone of the prosthetic graft on the dis-eased arterial segment for optimal revascularization and relief ofsymptoms. We describe a series of eleven patients with advancedperipheral arterial occlusive disease with ulcerating gangrene ofthe lower limb where endarterectomy was done along with pros-thetic bypass grafting (anatomic or extra-anatomic).Materials and Methods: From January,2013 to November, 2016 a totalof 11 patients with advanced peripheral arterial occlusive disease withulcerating gangrene of the lower limb were operated in the department ofCardiovascular and Thoracic Surgery, NRS Medical College & Hospital,Kolkata, West Bengal, India.Results:We had a total of eleven male patients (age range 48 – 65 years).Of these 11 patients, 9 patients had femoral and tibiopopliteal disease andtwo patients had aorto-iliac disease in addition. All patients requiredendarterectomy of the tibiopopliteal segment or femoral segment. Threepatients had extra-anatomic bypass and one patient needed venous patchplasty of lower popliteal artery after endarterectomy. All these cases hadsmooth postoperative recovery with considerable improvement ofsymptoms.Conclusion: The effectiveness of TEA is found to be effective in thesymptomatic improvement and salvage of the limb by improving inflowto distal vessels considering the lower costs, when the indications and theaccuracy of surgical technique are respected. It aided in prostheticgrafting and improved revascularization in of limb-threatening ischemiaand in multilevel complex arterial obstructive disease.

Redo cardiac surgery outcomes: single centreexperienceSujeeth Suvarna, Maria Hayes, Alexandru Cornea, DeliaClune, Edel Costigan, NiamhDunne, Kristo Papa, LauraViolaBlackrock Clinic

Introduction and objective: Redo cardiac surgeries are associated withan increased risk of postoperative morbidity and mortality. These cohortsof patients in the present era are becoming more complex due to multipleco-morbidities. The aim of our study was to analyse our experienceconcerning the immediate post-operative outcomes in this sub-group ofredo patients.Methods: Between January 2012 and June 2016 a total of 1,980 patientsunderwent cardiac surgery at Blackrock Clinic, 80 (4.04%) of whom hadredo surgery. Data analysed included peri-operative, intra-operative andpost-operative details.Results: The mean age was 67.88(SD9.22) years; 57 (71%) were male,23 (29%) were female. Eighty out off 1,980 patients underwent redosurgery (CABG: n= 35/80, VALVE: n= 31/80, CABG + VALVE: n=7/80, OTHER: n=7/80). The mean logistic EuroSCORE was15.61

(SD13.10), mean ITU length of stay 6.86 (SD12.60) Reoperation fortamponade 10% (n=8/80) Postoperative renal dialysis 11% (n=9/80)Stroke 2% (n=2/80) In hospital survival at time of discharge 89%(n=71/80) Mortality: 11% (n=9/80) CABG: 11 %( n=4/35), VALVE:9.67% (n=3/31), CABG +VALVE: 28.57%) n=2/7, OTHER: 0 %. Outof these deaths Emergency: 0%, Urgent: 55 %( n=5/9), Elective: 44 %(n=4/9).Conclusion: Our single centre small volume analysis suggest that redosurgery do present an increased risk of morbidity and mortality than first-time surgery patients. These sub-groups of patients can present new chal-lenges especially when co-morbities exist.

Effectiveness of Sildenafil in PulmonaryHypertensionsecondary to Mitral valve diseaseTinni Mitra, Kallol Dasbaksi,Plaban Mukherjee,Suranjan Haldar, Mohammad Zahid HossainDepartment of CTVS, Medical College, Kolkata, 88, College Street,Kolkata-700073

Introduction: Cardiac surgery in patients with mitral valvular diseasewith severe pulmonary arterial hypertension ( PAH ) is often complicatedwith right ventricular (RV) failure with an adverse consequence on itsprognosis. This necessitates pre and perioperative strategy to reduce PAHand RV dysfunction by inducing relaxation in pulmonary arterial vascu-lature. The final messenger for vascular smooth muscle relaxation, Cyclicguanosinemonophosphate (cGMP), is metabolized by phosphodiesterase( PDE). Among the various PDE, PDE5 is the predominant type in thenormal pulmonary vasculature that may be upregulated after CPB. Theinhibition of PDE5 is therefore a logical step to increase the bioavailabil-ity of cGMP and support endogenous vasodilation in patient with PAH.PDE5 is selectively inhibited by sildenafil, vardenafil, and tadalafil andless selectively by zaprinast and dipyridamole. A prospective randomizeddouble blind study was performed at our institution on the effect of sil-denafil in secondary pulmonary artery hypertension due tomitral valvulardisease.Materials and Methods: Fourteen patients with mitral valvular diseasewith moderate to severe tricuspid regurgitation, diagnosed by trans tho-racic echocardiography (Echo), undergoing mitral valve replacement(MVR) with or without tricuspid valve repair, were enrolled for studybetween September 2014 to July 2016. Those patients with concomitantsignificant aortic valve (AV) disease requiring AV replacement were ex-cluded. Patients with pulmonary artery systolic pressure ( PASP) morethan 50mm Hg at rest were selected from OPD. Patients in group S(sildenafil) were administered oral sildenafil tablets 25 mg three times aday in preoperative period and placebo tablets in C (control group ) in thesame fashion for 2 weeks and Echo repeated. After induction of anaes-thesia pulmonary artery catheter was inserted and PASP was calculatedafter ½ hour after induction. Postoperatively, patients were monitored byEcho after 1 week, 1 month and at 3 months.Results and Analyses: In this study, PASP was significantly lower (P <0.0001) after induction of anaesthesia, after weaning from CPB, and inimmediate postoperative period in S as compared with C group. In groupS, patients required less inotropes than C. Twomortalities was recorded inthe study, one each from each.Conclusion: Because of predominant selective activity of sildenafil inman-agementofpulmonaryhypertensionandimprovementofRVfunctionwithoutcompromising the systemic blood pressure, the use of this drug in patientsundergoingmitral valve surgery should be considered in preoperative period.

Preoperative assessment of myocardial viability fordecision making before CABG in patients with LVdysfunctionRavi Shivdasani, Gopal Murugesan, Vijit K CherianMIOT Hospitals

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Introduction and objective: Left ventricular function is a major pre-dictor of outcome in patients with coronary artery disease. Acuteischemia, stunning and hibernation are among the reversible formsof myocardial dysfunction. Assessment of myocardial viability andischemia continues to be an important issue in patients with ische-mic cardiomyopathy. In patients following myocardial infarction,evaluation of eligibility for revascularization mandates accurate as-sessment of myocardial viability. Different diagnostic methods arecurrently performed are FDG-PET, SPECT and CMR. Evidence ofmyocardial viability usually relies on the demonstration of uptake ofvarious metabolic tracers, such as thallium or fludeoxyglucose bydysfunctional myocardium or by the demonstration of contractilereserve in a dysfunctional region.Material and methods: 217 patients with ischemic cardiomyopathywere retrospectively studied for their preoperative assessment with myo-cardial viability imaging to differentiate among dysfunctional myocardialsegments.Results: 160 patients underwent Rest thallium, 35 patients underwentFDG-PET and 22 patients had CMR. All the patients had preoperativeviability imaging workup and that greatly aided in decision making forsurgical revascularisation. CABG, SPECT, PET and CMR are generallyconsidered the optimal modalities by which viability can be assessed andare excellent predictors of myocardial viability.Conclusions: In patients with ischemic cardiomyopathy, benefit fromrevascularisation with defined viability can be assessed by these methods.Accurate preoperative viability imaging in these patients helps in decisionmaking and results in a significant reduction of peri-operative morbidityand mortality after CABG. However CMR being best, it is not preferredoption because of cost, duration of imaging, requirement to lie flat andother patient factors.

Mid term results in Valve sparing aortic root replace-ment surgeries at a tertiary care centre in a secondtier cityKunal Krishna, Jayakumar TK, Ratish RadhakrishnanGovernment Medical College, Kottayam,Kerala

Introduction & objectives: Valve sparing aortic root replacement pro-vides an attractive alternative to aortic root replacement in patients withaortic root abnormalities even in the emergency setting of an acute type Aaortic dissection.Materials & Methods: From 2014 to 2016 we at our centre have per-formed 12 valve sparing aortic root surgeries which include 11 DavidProcedure & 1 Yacoub procedure for patients with various ascendingaortic & aortic root disease. 50% of patients (n = 12) were in age groupof 40 – 50 yrs while 2 patients were > 55 yrs of age & 3 were <30 yrs . 3were females & others malesv . 50% of these patients were operated fordissecting ascending aortic aneurysm & one was a case of Takayasu’saorto-arteritis. Additional procedures were done in 2 patient. Leaflet pro-lapse was corrected by plication in 2 cases. Mean follow up was 3 years.Results: Except for 2 patients which could be followed up only over phonerest were under regular follow up personally Mortality has been ZERO tillnow including 30 days / late mortality. No episode of neurologic/othersystemic complication post-operatively .All patients were discharged within5 days. 1 case of late onset moderate AR while others had no significant /trivial AR. No incidence of re-operation/conversion to bentall procedure.The quality of life is improved markedly with most of the patients havingno work limitation. Patients are only On antiplatelets resulting in zero inci-dence of anticoagulant induced bleeding manifestations.Conclusion: The Valve sparing procedure certainly provides achallenging option to treat selected young patients with AI inthe presence of AAD. However, current data suggest that it issafe and feasible even in emergency cases. Long-term valve-relat-ed events are rare and aortic valve function remains stableforobjectives.

Heart transplant (Light at the end of the tunnel) –Our experiencePravir Sinha, Pawan K Singh, Ratna Malhotra, MadhavShinde, Asish Asija, Rahul Kumar,Sanjoy Majhi, AdrashKoppula,Kewal KrishanMax Super speciality hospital, Saket,New Delhi

Background:Heart failure is one amongst the leading cause of death inIndia and across the globe. Reliable estimates of heart failure are lackingin India because of absence of surveillanceprogramme to track incidence,prevalence, outcomes and key cause of heart failure. Nevertheless the num-ber of death due to heart failure in India is magnanimous. Despite advance-ment in medical and surgical treatment of circulatory failure like left ven-tricular assist device, “Heart Transplantation” still remains the gold standard.Methods: We reviewed our experience with four patients who requiredheart transplant primarily due to dilated cardiomyopathy. Variablesanalysed included renal, neurological and respiratory dysfunction,arrthymias, length of hospital stay and mortality.Results: The age range for these patients were between 20 years – 56years Among which (3- Males & 1 – Female) None of the patients werereintubated &mean intubation periodwas 18 hours All four patients weredischarged to home. ( In hospital mortality – 0% )Mean hospital stay was18 days (Shortest stay – 12 Days & Longest stay – 34 days) All thepatients received immunosuppression with steroids, mycophenolate (cellCept) & tacrolimus. None of the patients developed acute rejection Onepatient developed respiratory complication in the form of pneumonicconsolidation in right middle lobe requiring frequent bronchoscopicsuctioning and incidentally had prolonged hospital stay. One patient(25%) developed SVT requiring medical cordioversion & none devel-oped any significant ventricular arrthymias. There were no renal or neu-rological complications in any of these patients.Conclusions:Heart transplantation still remains a gold standard for treat-ment of end stage dilated cardiomyopathy. As a result of improved im-munosuppression and advancement in medical management, there is asignificant improvement in functional capacity and quality of life in allsuch patients with significantly reduced complications.

Mid term experience of adult ECMO in IndiaKewal krishan, Pravir Sinha, Chintan Mehta, TaniaMehta, Saurabh Pandey, Arvind, Ravi K Singh,Rajkumar, Rajesh Chand, Rajneesh MalhotraMax Super speciality hospital, Saket,New DelhiBackground: Mid term experience of adult ECMO in India ObjectiveExtracorporeal membrane oxygenation (ECMO) is a rescue therapy forcritically ill patients with reversible cardio-respiratory pathology andthose who have probability of death around 80% despite maximal con-ventional treatment. The positive results of the recent trials have stimu-lated our interest to use ECMO for life treating conditions due to cardio-respiratory failure. Here we describe our experience at a tertiary carecentre in India.

Methods:We established an adult ECMO program for cardio-respiratorysupport in April 2013. In the last 3.5 years, we supported forty fivepatients on ECMO and it was only considered once the conventionaltherapy deemed failing. A retrospective analysis of our patient data wasperformed to collect information regarding patient demographics, indica-tion for ECMO, type of ECMO and outcomes.Results: A total of forty five patients received ECMO between April2013 to October 2016. The mean age was 36.4 yr (range 18 - 57years),29 Male:16 Female. Out of 45 patients 7 were veno arterial (VA) and 38were veno venous (VV) ECMO. In VA ECMO the first patient hadintractable arrhythmias and second had acute viral myocarditis leadingto refractory cardiogenic shock, one was post cardiotomy and one wasmyocardial depression post sepsis. Out of 38 patients of VV ECMO, 17had viral pneumonia, six bacterial pneumonia and three with fulminant

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fungal infection leading to ARDS, one had pulmonary haemorrhage dueto wegener’s granulomatosis and 11 were swine flu related ARDS.ECMO was instituted by peripheral cannulation in all patients. Averagesupport time was 13 days (range 2 to 44 days). 28 patients were success-fully separated from ECMO and 27 survived to hospital discharge. Fourpatients had major complications including pump failure and bleeding,Oxygenator failure and air in the circuit. One underwent lobectomy formultiple bronchopleural fistulae in right lung.Conclusion: ECMO is salvage therapy in patients with life treating re-fractory circulatory shock or severe ARDS. This therapy has the potentialto save lives if applied in time and in appropriate clinical settings.

Predictors of outcome following aortic valve repairfor aortic regurgitation complicating ventricular sep-tal defect – A retrospective studyMahendranath S PrasadSri Chitra Tirunal Institute for Medical Sciences and Technologyobjective: To identify the factors that can predict a durable repair for ARcomplicating VSD on long term follow up.

Methods: A single institute retrospective observational study with thestudy period was between January 2010 and December 2015. The typeof repair was based on the mechanism of AR dictated by the preoperativetransthoracic ECHO findings, validated with intraoperative TEE. All pa-tients were followed up in their 1st month, 6th month & first year follow-ing surgery with transthoracic ECHO for assessing presence and theseverity of AR. Disease recurrence and treatment failure (reoperation)were the end points.Results:RECURRENCE •21.4% (n = 3) who had undergone NCC pli-cation, 9.1% (n=1) who had undergone RCC plication and 33.3% (n = 1)of the patients who had undergone central plication had AR recurrenceduring follow up. None of the patients who had undergone Trussler repair,Yacoub repair and pericardial patch repair of the NCC had AR recurrenceduring follow up. • 8.3 % (n = 1) of the patients with subcommisuralannuloplasty had AR recurrence during the follow up period. The differ-ence between the two groups was statistically insignificant (p = 1.000).REOPERATION • Four percent (n =2) of the patients had aortic valvereplacement with mechanical prosthesis during immediate postoperativeperiod. • Two percent (n=1) of the patients had reoperation for surgicalsite infectionConclusion: • The overall recurrence rate in the study is 8% and reoperationrate is 4%. • The sex of the patient, valve anatomy, preoperative severity ofAR and addition of annuloplasty to aortic valve do not significantly affectthe durability of aortic valve repair. • Further, the effect of age at operation,bodymass index, body surface area, the type of aortic valve repair techniqueand additional surgical procedures on the durability of aortic valve repaircouldn’t be established owing to small sample size.

Comparison of predictive validity of EuroSCORE IIand Society of Thoracic Surgeons [STS] score for clin-ical outcome in patients undergoing open heart sur-gery, a prospective observational studyMohammed Abiduddin Arif, Ramesh Chandra Mishra, Amaresh RaoMalempatiNizam's Institute of Medical Sciences, Hyderabad

Introduction: Preoperative risk scores are an essential tool for riskassessment, cost benefit analysis, and the study of therapy trends.Majority of the studies conducted on predictive validity deal withmortality as the outcome. Even though morbidity can have hugenegative impact on hospital stay, cost of treatment and quality oflife, studies focusing on morbidity as primary outcome are scarce.Objective To compare the predictive ability of European Systemfor Cardiac Operative Risk Evaluation [EuroSCORE] II and the

Society of Thoracic Surgeons [STS] for clinical outcome in pa-tients after cardiac surgery.Materials & Methods: The study was a prospective observational studyconducted in a tertiary care teaching hospital. A total of 50 subjectsundergoing open heart surgery for various etiologies were recruited con-secutively. For each subject EuroSCORE II and STS score were calculat-ed on admission. Occurrence of any major morbidity was considered asfinal outcome. Predictive validity of both the scores was assessed byreceiver operating curve (ROC) analysis. IBM SPSS version 22 was usedfor analysis.Results: Out of the total 50 subjects, elective and emergency were done in84% and 16% respectively. Single procedure was done in 74% and twoand three procedures were done in 22% and 4% of participants respec-tively. The proportion of subjects with uneventful outcome was 88% and12% had eventful outcome ( major morbidity) in study population Thearea under the ROC curve to predict the outcome for EuroSCORE II was0.765 (0.61 to 0.91, p value 0.037) and for STS score it was 0.697 (0.535to 0.859, p value 0.121) was observed for STS score respectively.Conclusion: EuroSCORE II score had better predictive validity com-pared to STS score in predicting morbidity in patients undergoing openheart surgery.

Assessment of Coronary stenosis by ComputationalFluid dynamic studySanjeev Dasrao Muskawad, Shailendra Sharma, JamesThomas, Rushikesh ShindeIndian Institute of Technology Bombay

Introduction & Objectives: Assessment of coronary stenosis is impor-tant exercise for clinical management and planning an appropriate inter-vention. Currently available imaging modalities such as coronary CTangiography can reveal detailed geometric aspects of the coronary ob-struction. The available computing power facilitates building of CADgeometry as well as computation fluid dynamic (CFD ) analysis. Thisstudy illustrates the building of CAD ( computer aided geometry) modeland flow analysis for the range of physiological boundary conditions.Materials & Methods: The CAD geometric models are built with thevariables such as length of stenosis, cross sectional area of obstruction,eccentricity etc. The clinical data from angiography is also idealised tobuild the CAD model. The CAD geometry is imported into ANSYS-Fluent a commercial CFD software. Refined meshing is done for the 3-D fluid volume to achieve grid independence and convergence. The studyis done for the physiological range of inlet flow velocities and outletpressures.Results: The pressure loss across the stenotic lesion ( reduction in crosssectional area) is due to frictional (Poiseuille) losses as well as due toconvective acceleration with flow separation at the exit of of the lesion.The effect of stenosis is visualised by plotting the curve between thevolumetric flows and pressure loss across the stenosis.Conclusions: The Computation fluid dynamic study provides accurateassessment of stenosis. It also helps in estimation of Fractional FlowReserve which is important parameter.

Primary airway tumours in childrenArun Beeman, Nagarajan MuthialuGreat Ormond Street Children Hospital, London

Background: Primary airway tumours are rare in children. Aims andobjectives: To analyse the characteristics of primary airway tumours inchildren managed in our tertiary paediatric airway centre.Methods: Retrospective data collection of all children with primary airwaytumours who were managed in our tertiary paediatric airway centre over thelast 10 years. Data collection included age at diagnosis, sex, symptoms,investigations, surgery, histology, complications and outcome.

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Results: 11 children (male = 7, female = 4) with themean age of 4.5 yearswere reviewed. Frequent symptoms were cough (n = 9), dyspnoea (n = 4)and weight loss (n = 3). Workup included Computerised Tomography(CT scan) and bronchoscopy. Location of tumours were left paratracheal(n = 1), Right main bronchus (n = 2), left main bronchus (n = 4), Rightbronchus intermedius (n = 2), carina (n = 1) and distal (n = 1). Surgeryincluded right pneumonectomy (n = 2), sleeve resection of bronchus (n =6), sleeve lobectomy (n = 1) and excision (n = 2). Histological diagnosiswere inflammatory myofibroblastic tumour (IMFT, n = 9) andmucoepidermoid carcinoma (n = 2). Mean follow up was 4 years withno death. One child with IMFT (ALK-positive) continues to receivechemotherapy (crizotinib) and needed bio-degradable tracheal stent forrecurrent stenosis. One child had insertion of tissue expander inhemithorax.Conclusions: Airway tumours are uncommon in children, and need ex-tensive work up including contrast enhanced CT scan. While majority ofthem can be amenable to local excision, these tumours can, at times,follow a protracted clinical course.

Predictors of Mortality & Morbidity in patients withseverely depressed LV functions: A Single centre ob-servational studyPravir Sinha, Sachin Chatterjee, Soumaya Deep,Sanjeev Malhotra,S K Sinha, Rajneesh Malhotra, Kewal KrishanMax Super speciality hospital, Saket,New Delhi

Introduction: Patients with symptomatic multi vessel coronary arterydisease and severely depressed LV function (EF< 0.30) have significantlyhigher mortality & morbidity than patients with moderate EF. In thissubset, CABG is associated with higher postoperative morbidity & mor-tality compared to patients with normal left ventricular function.Aim and Objectives: Analyse the Predictors of immediate, short, midand long term events occurring after revascularization in patients withCAD with severe LV dysfunction (EF <35%). Effect of revascularisationon functional status, symptomatology (angina class) and LV systolicfunction.Material and Method: Total 114 subjects recruited for the study &followed up at 3, 6 and 12 months. All deaths and re admission eventsalso recorded and analysed Data analysed using student’s t-test or MannWhitney U test as appropriate. Categorical data analysed using chi-squareanalysis or fisher’s exact test. Multiple logistic regression to analyse therisk of predictor variables.Results: Cigarette smoking, renal failure, cerebrovascular disease,peripheral vascular disease, mean NYHA score and arrhythmiawere more frequent in the patients with severe left ventriculardysfunction. Significant difference in No.of diseased vessels,emergency CABG, Cardiac arrest, heart block, thirty-day mortalityrate, length of stay in ICU & hospital after surgery were alsohigher in the ventricular dysfunction group. Multivariate logisticregression analysis showed the NYHA score, postoperativeprolonged ventilation, prolonged ICU stay and postoperative renalfailure were related to the 30-day mortality rate. Prolonged LOSin hospital was related to the female gender & postoperative AF.Conclusion: Although left ventricular dysfunction is itself an importantstrong risk factor in patients undergoing CABG, the early outcome ofCABG in patients with LV dysfunction is acceptable and themanagementof this factor will help to reduce the mortality and total length of stay inhospital with the help of a regular follow-up.

Results of minimally invasive Aortic Valve replace-ment in Octogenarians.SobaranSharma,YasirAhmed,JosephGeorge,UmairAslam,PrakashNanjaiah, Pankaj KumarMorriston Hospital Swansea, United Kingdom

Background: Aortic valve stenosis is the most common acquired valvelesion among octogenarians in the western societies. Octogenarians arethe fastest growing population in the UK, currently 2.5 million growing to5 million by 2030.

Background:Minimally-invasive aortic-valve replacement (mini-AVR)via J-sternotomy has been shown to reduce surgical morbidity. Mini-AVR aims to reduce trauma, post-operative pain, blood loss, ventilationtime, leading to faster recovery and better aesthetic outcomes. Little datais available on the outcomes of min-AVR in the very elderly population(octogenarians). Aims/Objectives We assessed the clinical outcomes ofthe min-AVR in all octogenarians undertaken at our centre.Methods:A single consultant surgeon and his team routinely undertook theminimally-invasive approach via J-sternotomy for all isolated first-time aor-tic valve replacements. Operative records and clinical outcomes of all pa-tients who had undergone min-AVR in our centre between 2006 and 2016were retrieved from the national cardiac surgery database. Patient demo-graphics, pre-morbid status, operative details and outcomes were evaluated.Results: 223 mini-AVRs were undertaken between 2006 and July 2016,out of which 55 patients were aged 80 YEARS or above. Patient demo-graphics were as follows: mean age 83.8 years (range 80-91, SD 2.93),female gender 63.4%, diabetes mellitus 9.8%, pulmonary disease 22.0%,LV function: <30% in 7.3%, 30-50% in 17.1% and >50% in 75.6%,logistic euroSCORE 13.3 (interquartile range 8.44-14.7, SD 9.04).Overall in-hospital and 30-days mortality, stroke, re-exploration rate &conversion to full sternotomy were all 0%, renal failure requiring dialysis1.8% (1/55), permanent pacemaker 1.8% (1/55)Discussions/Conclusion: Despite high logistic EuroSCOREs, we haveshown excellent results in octogenarians by this approach. In this era oftranscatheter aortic-valve implantation, mini-AVR adds to the armamen-tarium of the surgical team.

B i d i r e c t i o n a l G l e n n S h u n t W i t h o u tCardiopulmonary Bypass Our Initial ExperienceJaswinder Singh, Rajiv Nair, Amit Pushkarna, SK Jha,Anurag GargMilitary Hospital (CTC), Pune

Objectives: There is an increasing trend to perform the bidirectionalsuperior cavopulmonary (Glenn) anastomosis without cardiopulmonarybypass at our Centre during last one year. we present our results of off-pump bidirectional Glenn operation [BDG] done a venoatrial shunt todecompress superior vena cava during clamping.Methods:A retrospective study was conducted in patients with function-al single ventricle anomalies who underwent bidirectional Glenn anasto-mosis. A total of 11 patients underwent BDG during this period. Allpatients underwent a complete neurological examination both preopera-tively as well as postoperatively.Results: A total of 11 patients underwent BDG during the study period forsingle ventricle palliation. Two patients were excluded from the study asBDG was performed on cardiopulmonary bypass in these patients. In onecase indication for going on CPB was restrictive PFO and in second casethere was RPA origin stenosis which was corrected before BDG. The meanfollow-up was 11 months. The mean internal venous pressure on clampingthe superior vena cava was 20±4.4 mmHg. All patients were extubated ontable. The mean intensive care unit stay was 3.6±1.08. There were no majorneurological complications apart from treatable convulsions in one case.Conclusions:Off-pumpbidirectionalGlennoperationwithoutcardiopulmo-nary bypass is a safe, simple andmore economic procedure.

Institutional experience of Coronary Artery BypassGrafting in Severe Left Ventricular DysfunctionCol G S Nagi, Lt Col RS SohalMH CTC- Pune

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Backgroung: Despite the ominous prognosis of advanced ischemic car-diomyopathy, coronary artery bypass grafting in this setting remains con-troversial because of concerns over operative risk and lack of functionalor survival benefit.

Aim: This study evaluates our experience with coronary artery bypassgrafting in patients with severe left ventricular dysfunction.Methods: We retrospectively analysed our data base. Out of 3490 coro-nary revascularization surgeries, over a period of 27 years, 1511 patientswere those with left ventricular dysfunction. Out of these 663 patientswere with severe LV dysfunction that is ejection fraction < 30%(414men,249 women, aged 50 to 75 years). The ejection fraction ranged from 22%to 30%.Preoperatively, 86% of patients had angina, 52% had congestiveheart failure and 30% manifested significant ventricular arrhythmia. Theinternal mammary artery was used in 82% of grafts to the left anteriordescending coronary artery. The intra aortic balloon pump was prophy-lactically placed preoperatively in 37% of patients with almost 83% re-quiring IABP support to come off CPB. 63 of these cases were done on anemergency basis.Results: The average crude hospital mortality rate was 8.67%. The mor-tality rate was 6.3% (4 of 63) in patients undergoing emergency surgery.Canadian Cardiovascular Society angina class improved postoperativelyby 1.9 categories and New York Heart Association congestive heart fail-ure class by I category. Left ventricular ejection fraction improved from24.6% preoperatively to 33.2% postoperatively (36% increase) (p <0.001). At 1 and 3 years, respectively, all-cause survival was 87% and80%Conclusions: In patients with coronary artery disease and advanced ven-tricular dysfunction coronary artery bypass grafting can be performedrelatively safely with good medium-term survival. The use of coronaryartery bypass grafting is encouraged for this group of patients and mayprovide a viable alternative to transplantation in selected patients.

Surgical plication of symptomatic giant left atrium-controversy unfoldedChintan Mehta, Rajneesh Malhotra, Kewal Krishan,Adarsh KoppulaDevki Devi Heart and Vascular Institue Max Hospital Saket, New Delhi

Background:Giant left atrium as defined by Kawazoea et al is Left atri-um > 65 mm with or without compressive symptoms. With an incidenceof 0.3% it commonly occurs in patients with chronic rheumatic mitralvalve regurgitation and has a significant impact on postoperative course,complications and outcomes. Surgical placation of symptomatic giant leftatrium is still a controversy.Materials and methods: Retrospective comparative observational studyin all patients with symptomatic giant left atriumwith chronic mitral valveregurgitation referred for surgery at max hospital saket between 2011 to2016. 50 patients were enrolled in the study with 20 patients (40%) whounderwentmitral valve intervention and surgical placation and 30 patients(60%) who underwent mitral valve intervention alone. The primary end-point was reduction in inhospital 30 day mortality and secondary endpoints being reduction in post operative complications –respiratory com-plications , low cardiac output, incidence of atrial fibrillation. Surgicalplacation of the respective segment done as per presentation and descrip-tion by kawazoea.Results: Inhospital 30 day mortality occurred in 1 patient (5%)with sur-gical plication as compared to 3 patients (6%) in patients who underwentmitral valve intervention alone (p<0.05). Post operative elimination ofsymptoms occurred in 15 patients (75%) in patients who underwent sur-gical placation as compared to 10 patients (33.33%) who underwentmitral valve intervention alone. After surgical placation 10% patientshad low cardiac output, 20% had mechanical ventilation >48hours,75% had restoration of normal sinus rhythm in first 48 hours as comparedto patients who underwent mitral valve intervention alone had 20%

incidence of low cardiac output, 30% patients had mechanical ventilationfor > 48 hours, 60% patient had restoration of normal sinus rhythm in first48 hours.Conclusion: Surgical placation of respective compressing segments insymptomatic giant left atrium as described by kawazoea significantlyreduces post operative morbidity.

Prospective analysis of tricuspid regurgitation in pa-tients undergoing mitral valve replacementMuthukumar S, SundarRamanathan, ChandrasekarPadmanaban, Muralidharan SrinivasanG Kupp u sw amy Na i d u Memo r i a l H o s p i t a l ( GKNM)Coimbatore,Tamilnadu,India.

Aims andObjectives:The aim of this study is to evaluate the progressionof TR in patient with mitral valve disease and moderate or more tricuspidregurgitation undergoing Mitral valve replacement alone. To compareclinical outcome and echocardiographic results.Materials and Methods: The study was a prospective non randomisedstudyconducted fromMarch2011 toApril 2013. It included thepatientswithmoderateormore tricuspid regurgitationassociatedwithmitralvalvedisease (Mitral stenosis or mitral regurgitation), who underwent elective mitral valvereplacement (MVR). They were divided into two groups: group1 whounderwentMVRalone,andgroup2whounderwentMVRandtricuspidvalverepair All patients are followedup at 6month,1 and 2 year interval.Results: 74 patients recruited moderate or more TR associated with MR,who underwent elective MVR. In group 1, 45 patients underwent MVRalone, and group 2-29 patient underwent MVR and tricuspid valve repair.The mean NYHA class in preoperative period was 2.71±0.59 ingroup1and2 .57±0.57 in group2. In 2year followup NYHA in group2was significantly reduced to 1.04±0.62 (P.001) which supports in favourof concomitant TV repair After two years follow up the is significantreduction in mean TR grade in group2 (1.11±0.497) compared toGroup2(3.03±0.68 ).Though therewere worsening of TR in group 1,butnot statistically significant (P-0.19). There is significant reduction inRight ventricular dimensions RVID (s) andRVID (d )in group2 comparedwith group1 with (P-0.001).Conclusion:Tricuspid annuloplasty is an easy and safe procedure and it isin case of moderate or more functional (>2+) to achieve better midtermoutcome.

Pulmonary hypertension- post surgical correction oftotal anomalous pulmonary venous connectionShreyas S Runwal, Seetharam Bhat, Girish GowdaSri Jayadeva Institute of Cardiovascular Sciences andResearch, Bangalore

Introduction and Objective: Total anomalous pulmonary venous connec-tion (TAPVC) is a very uncommon cyanotic anomaly comprising 1% of allcongenital heart diseases. Since pulmonary veins drain into the systemicvenous circulation, TAPVC is incompatiblewith life unless a communicationbetween the right and left sides of the heart exists; usually via a patentforamen ovale or atrial septal defect. As the right to left shunt is usually small,right heart dilatation and failure ensues owing to a volume overload. Stenosisand obstruction of varying degree at the junction of the anomalous trunkwiththe vena cava leads to severe pulmonary hypertension which further worsensright heart failure. Without surgery most infants die by 12 months of age.However, post-operativemortality is also high owing to increased pulmonaryvascular resistance and inadequate repair due to obscure anatomy. The pur-pose of this study was to study the pulmonary artery (PA pressures) in postoperative and during follow up.Methodology:We have undergone a retrospective study of 60 TAPVCcases operated at our centre in last 3 years; of which 26 cases ofsupracardiac TAPVC, 25 cases of cardiac type and 6 cases of mixed

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TAPVC and 3 cases of infracardiac TAPVC correction. We have studiedthe PA pressures on 1 and 2 year post surgeries on 2D ECHO and com-pared it to PA pressures of immediate post operative PA pressures.Result: 23 cases had persistent high PA pressure than immediate postOperative PA pressures.Conclusion: In view of persistent increased pulmonary vascular bedresistance, there is possibility of persistent pulmonary hypertension evenafter surgical correction of TAPVC.

A study of difference in left ventricular function inpatients with and without false tendon undergoingmitral valve replacementDinesh D, Rakesh, Prasanna SimhaSri Jayadeva Institute of Cardiovascular Sciences and Research

Background:Left ventricular false tendon are discrete, fibromuscularstucture of varying length and thickness that traverses from septum tofree wall or from free wall or between papillary muscle not related tomitral valve apparatus.Aim and Objective: Our aim is to study the difference in left ventricularfunction in patients with andwithout false tendon undergoingmitral valvereplacement.Methods: It is an observational and prospective study. 29 patients wereincluded who underwent elective mitral valve replacement. Of these 14had false tendon and 15 patients had no false tendon. Patients werefollowed upto 6 months. We compared systolic left ventricular internaldiameter (LVIDs), diastolic left ventricular internal diameter (LVIDd),end systolic volume (ESV), end diastolic volume (EDV), interventricularseptal thickness and Fractional shortening preoperative, immediate post-operative, 1st,3rd and 6th month postoperatively.Results: Patients with false tendon has less left ventricular size whencompared with patients who do not have false tendon at immediate postoperative period, 3rd and 6th month.[LVIDD- immediate post operativeperiod-4.33±0.43 vs 4.90±0.44(p-0.001), 3rd month-4.23±0.48 vs 4.86±0.34(p-0.001), 6th month 4.28±0.44 vs 5.30±0.71(p-0.014); LVIDS-immediate post operative period-3.08±0.51 vs 3.59±0.46(p-0.009), 3rdmonth 2.94±0.48 vs 3.54±0.39(p-0.001), 6th month 2.95±0.43 vs 3.85±0.64(p-0.020)]. But there is no statistical significance in fractional short-ening between these two groups at preoperative, immediate postoperativeperiod, 3rd and 6th month. [Pre-operative period-30.72±4.76 vs 28.99±3.95(p-0.297), immediate postop period-28.76±5.38 vs 27.03±4.08(p-0.337) 3rd month 30.14±5.03 vs 28.76±3.54 (p-0.150), 6th month 29.96±4.94 vs 26.50±3.82(p-0.366)]. There is no difference between twogroups in EDV, ESVand IVSConclusion: Eventhough LV sizes are less in patients with false tendongroup, there is no difference in LV function between these two groups.KEYWORDS: false tendon, LV function, mitral valve replacement.

MidTermResult ofMitral valve Repair in RheumaticHeart DiseaseAshok Kumar Chahal, Divya Arora , Kuldeep Lallar,Shamsher Singh LohchabPt. B D Sharma Post Graduate Institute of Medical Sciences Rohtak,Haryana

Objective:Mitral valve repair is challenging one in rheumatic heart dis-ease due to complexity of lesions. The appropriateness of valve repair forpatients with rheumatic heart disease, even when repair appears to betechnically feasible, remains controversial.We present themid term resultof mitral valve repair in rheumatic etiology.Methods: A retrospective analysis of patients operated for mitral valverepair from 2007 till 2015 was done to determine the valve related out-comes, survival, functional status, residual lesions, freedom from reoper-ation, infective endocarditis, and need for valve related redo surgery.

Results: The Mitral valve repair was done in 238 patients. Themale:female ration was 103:135. The mean age was 30 ± 11 yrs. Mitralstenosis was present in 42.4%, Mitral regurgitation was present in 22.7%and 34.9% patients were having mixed lesions. The mean follow up was81± 43 months. The follow up was 90.75%. The early and late mortalitywas 4.62% and 2.91 %. The readmission rate was 9.71%. The thrombo-embolic and bleeding complications were present in 1.94% patients.Significant mitral stenosis and regurgitation was present in 6.25% ofpatients. The rate of redo procedure was 4.12%.Conclusion: The mid term results of mitral valve repair in rheumaticetiology are excellent with freedom from anticoagulant related complica-tions.

To study the outcome of Double versus single valvereplacement for Rheumatic heart diseaseDasari Kalyani Rama, Abha Chandra, D Rajasekhar,Vanajakshamma, Alok SamantaraySri Venkateswara Institute ofMedical Sciences, Tirupati, Andhra Pradesh

Introduction: Surgery for combined mitral and aortic valve disease hasbeen associated with high operative mortality. 10 years survival rate hasbeen better for AVR (72.1%), than DVR (62.3% ) or MVR (54.4%).Clinical presentation vary for regurgitant and stenotic lesions. This studywas designed to access the outcome and follow-up results of Doubleversus single valve replacement for Rheumatic heart disease. Aims &objectives To assess the preoperative clinical, hemodynamic risk factorsand surgical predictors for long-term survival after valve surgery.Material & methods: This prospective study was conducted betweenApril 2015 and October 2016. There were total 86 patients whounderwent MVR [n=42], AVR [ n=20] and DVR [ n=24] under conven-tional cardio pulmonary bypass. Clinical and haemodynamic parameterswere studied pre op, at discharge & SD Variables±at 3 months follow up.Results: were expressed in mean DVR (n= 24) AVR (n= 20) MVR (n=42) Age 0.8±38.5 0.6±48.5 0.5 Sex M:F±37 15/9 12/8 12/30 Pre OPNYHA 3 3 3 Post OP NYHA 1.1+0.10 1.2 + 0.06 1.3+ 0.08 NSR/AF14/10 16/4 10/32 CT ratio (Preop/postop) 64.3/62.3 67.3/62.3 68.6/61.5Pre OP LAD 3.02±54.6 57.6+3.01 2 Post OP LAD±65.4 3.1±51.7 4.1±52.4 1 Pre OP LVESD±63.3 2.8±51.4 2.01 Post op LVESD±3.1 52.1±52 2.74±51.0 2.1±51 0.4 Pre OP LVEDD±51 3.2±32.4 4.0±32.5 3.6Post OP LVEDD±32 1.1±31 1.3±31 2.1 There was improvement inNYHA class±31 &LVEF.The cardiac dimensions LAD, LVESD,LVEDD,LVESD decreased and gradients across valve lowered. The hos-pital mortality was 2% (1/86)Conclusion: DVR In patients with rheumatic heart disease should beconsidered whenever indicated as it has comparable in-hospital mortalityand better late survival than isolated aortic or mitral valve replacement.The Left ventricular dimensions should be taken into account to deter-mine the time of the surgery.

Role of assessment of Sub Mitral density in gradingseverity of mitral stenosisTSudheendra,Rakesh Naik, Prasanna SimhaSri Jayadeva Institute of Cardiovascular sciences,Bangalore

Introduction:Mitral valve involvement in rheumatic heart disease is thecommonest cause of mitral stenosis. The assessment of severity of mitralstenosis is done pre operatively with echo using parameters like mitralvalve anatomy, planimetry, mitral valve flow and PA pressures. Thisstudy compares the sub mitral density with standard assessment tools likeWilkins score and Tendolkar grading and to determine whether sub mitraldensity can be used as a parameter to assess the severity of mitral valvedisease. Sub mitral density is calculated using 2D echo in short axis viewand measuring the sub mitral area. Wilkins score is estimated pre

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operatively using echo while Tendolkar grading is intra operative gradingof severity of disease. AIM: To determine the feasibility to use the submitral density as a tool in pre operative assessment of severity of mitralvalve stenosis.Methods: Study was done with pre operative assessment of 35 patients inSri Jayadeva institute of Cardiovascular sciences ageing from 20 to 60yrsage. All patients were evaluated pre operatively with echo for Wilkinsscore and Sub mitral density assessment. Intra operative assessment doneusing Tendolkar grading. Sub mitral density was compared with Wilkinsscore and Tendolkar grading. Statistical analysis done using ANOVA andfischer test.Results: The present study shows that severity of mitral stenosis usingsub mitral density does not correlate well with the assessment usingWilkins score or Tendolkar’s grading. Comparison of sub mitral densitywith Tendolkar grading done with ANOVA test and p value was 0.868.On comparison with Wilkins the p value 0.213, using fischer extract test,again not significant. Statistical analysis does not show significant p valuecomparing both Wilkins and Tendolkar grading.Conclusions: sub mitral density cannot be used as a reliable tool forassessment of severity of mitral valve stenosis.

Aortopulmonary Window: Our SeriesSubhash Kumar Kadim, Parvez, Vikas SR, Mayuri S,Soumik Pal, Sathyanarayan J,Syed Mudassar, ShioPriye, Durgaprasad Reddy BVydehi Institute of Medical Sciences and Research Centre

Introduction and Objectives: Aortopulmonary window is a rare con-genital heart defect resulting from abnormal separation of the truncusarteriosus into aorta and pulmonary artery. An AP window is found in0.2% of patients with congenital heart disease. We have conducted astudy of cases of aortopulmonary window at our institution.Materials and Methods:We performed a retrospective study of patientswith an aortopulmonary window at our institute from June 2006 toJune 2015. A total of 13 patients were included in the study from 6months to 10 years. 8 patients were males (62%) and 5 patients werefemales (38%). All the patients were subjected to routine blood investi-gations, chest x-ray, transthoracic echocardiography, and cardiac cathe-terisation. All the patients had a proximal type of APwindow. All patientsunderwent AP window repair under cardiopulmonary bypass and generalanaesthesia. Closure was done with a PTFE patch after exposing thedefect through the ascending aorta.Results: Post operatively all patients recovered well. Two patients devel-oped lower respiratory tract infection in the post operative period, whichwas treated with antibiotics. All patients were followed up at 3 monthswith routine transthoracic echocardiography.Conclusion: Aortopulmonary window is a rare cardiac malformation,which if left untreated will cause irreversible pulmonary vascular disease.But, timely diagnosis and prompt surgical intervention will give a newlease of life.

Complete AV Canal Defect Repair: Our ExperienceParvez Ahamed, Subhash Kumar Kadim, Vikas SR,Mayuri S, Soumik Pal, Sathyanarayan J, SyedMudassar, Shio Priye, Durgaprasad Reddy BVydehi Institute of Medical Sciences and Research Centre

Introduction and Objectives: Atrioventricular septal defects constitute4% of all congenital cardiac malformations. Patients with complete atrio-ventricular septal defect rarely survive for decades without surgical treat-ment. We have conducted a study to evaluate the results of complete AVcanal defect patients who have undergone complete repair.Materials andMethods: We performed a retrospective study over a pe-riod of 8 years in our institute from January 2007 to January 2015, which

included all he patients with complete AV canal defects who have under-gone total repair. A total of 19 patients were included in the study whoseage ranged from 4 months to 18 years of age. 11 patients were males(58%) and 8 were females (42%). All patients were subjected to routineblood investigations, chest x-ray, transthoracic echocardiogram, and car-diac catheterisation. All patients were operated under general anaesthesiaunder cardiopulmonary bypass. Surgical repair of AV canal defect wascompleted by double patch technique. 2 patients who had pulmonarystenosis underwent pulmonary valvotomy and reconstruction of RVOTwith an autologous pericardial patch. 3 patients required mitral valvereplacement.Results: 17 patients survived surgery. One patient had died in the post opperiod due to severe pulmonary hypertension. Two patients developedlower respiratory tract infection in the post-operative period, which wastreated with antibiotics. The rest of the patients have had an uneventfulpost op period. The patients have come for follow up at 3 months and 1year and had no complaints.Conclusion: Complete AV canal defect is a relatively uncommon con-genital heart disease, which may be associated with other associatedcardiacmalformations such as TOF. Surgical repair is curative and overallmortality is generally low. Patients at extremes of low weight and age andsevere pulmonary hypertension have worse outcomes.

Ventricular Septal Defects with Near systemicPulmonary Pressures - Our experienceElavarasan C, B Kasinathan, GK Jaikaran, HaroonShakirInstitute of Child Health, Egmore

Introduction: Ventricular septal defects (VSD) with severe pulmonaryhypertension (PHT) patients are the difficult ones to intervene. They carryincreased risk of perioperative morbidity and mortality especially whenthe pulmonary pressures are near systemic.We share our experience of 20cases of VSD with near systemic pulmonary pressures managed by dou-ble flap patch closure and use of pulmonary vasodilators.Methodology: 20 children having VSD with severe PHT those with nearsystemic pulmonary pressures (aorto-pulmonary pressure difference <10mm hg) were included in the study. All children were treated pre-operatively with oral sildenafil. Intraoperatively, we administered half thedose of phenoxybenzamine directly into main pulmonary artery just beforecross-clamping.We closed theVSD in all cases by double flap patch closuretechnique using goretex patch. All childrenwereweaned off bypass with theuse of phenoxybenzamine, milrinone, adrenaline and dopamine infusionand continued post-operatively. All children were electively ventilated for24-72 hours. Elective tracheostomy was done if unable to wean after 72hours. Children were also started on oral sildenafil and bosentan as needed.Results: Of the twenty children, seven were in the age group 1-5 yearsand thirteen were in the age group 6-10 years. Average duration of ven-tilation was 114 hours. 11 children needed tracheostomy. Average dura-tion of ICU stay was 7-8 days. Complications encountered were PHTcrisis, RV failure, Heart block and Reintubation. Mortality was encoun-tered in 2 cases the cause being RV failure and septicemia. All remaining18 children remained stable during follow up. Shunt across the flap valvedisappeared in 16 children by 6 months. PHT regressed to mild/moderatelevels in 15 children by 1 year duration.Conclusion: Ventricular septal defectswith severe PHTchildren can be effec-tively managed by double flap patch closure surgical technique with judicioususe of pulmonary vasodilators.

The role of preoperative cardiac catheterisation inpredicting outcomes of surgery for shunt- associatedPAHPooja Shetty, Prayaag Kini, C S Hiremath, KrishnaSSIHMS, Whitefield, Bengaluru

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Objective: This study was conducted to determine the efficacy of cathstudy for determination of operability in shunt lesions and to analysewhether an improvement in pulmonary saturation alone, a fall in pulmo-nary artery mean or diastolic pressure or a combination of the two wasbetter in prognosticating postoperative outcomes especially post-operative PAH and need for continuing milrinone longer in the post-opperiod.Methods: 100 (M=62, F=38) patients who had PAH due to associatedshunt lesions were serially studied between Jan 1, 2013 to Jan 1, 2016. 62patients received a three-months course of sildenafil and then cathetrised.All 100 patients underwent a preoperative cath study and pulmonaryartery systolic and end-diastolic pressures, pulmonary and systemic satu-ration, pulmonary wedge pressures, systemic saturation, were measuredand the same parameters after administration of 100% oxygen for 10minutes.Results: Average age of the patients was 12.8+/-1.28 years. Of the 100patients who underwent cath, (ASD=20, VSD =43, PDA=20, AVCD=8,APW =4,TAPVC=4, Lutembacher=1), longer ICU stay( mean 5.5+/- 2.2days) and ventilation, and need for continuing milrinone( more than threedays) was seen in 34 patients. Follow-up datawas available in 91 patients.Multivariate regression analysis and Pearsons rank linear correlation co-efficients were calculated for each of the hemodynamic parameters incorrelation with the immediate post-op residual PAH and PAH at thirdmonth follow-up.Good inverse co-relation of postop and residual PAH was seen withdegree in fall in PA end diastolic pressure (r=0.72 ). The strongest corre-lation was seen with combination of both fall in PAEDP and improve-ment in pulmonary artery saturations (r=0.77), indicating best outcomesand least post-op and residual PAH.Conclusion: The study inferred that a combination of both fall in PAEDPand improvement in pulmonary artery saturation with oxygen adminis-tration during preoperative cath may be a better prognosticator of post-operative outcomes in patients with shunt-associated PAH, than a fall inthe PA mean alone or a fall in PVR alone, or improvement in PA satura-tions alone which amounts to lesser post-operative residual PAH andshorter ICU ventilator need with lesser need for continuing milrinonefor postoperative residual PAH.

Bidirectional Glenn on Cardiopulmonary Bypass: Acomparison of Three TechniquesSachin Talwar, ManikalaVinod Kumar,Ashima Nehra,Poonam Malhotra Kapoor,Neeti Makhija,VishnubhatlaSreenivas, ShivKumaryChoudhary,BalramAiranDepartments of Cardiothoracic and Vascular Surgery, ClinicalNeuropsychology, Cardiac Anaesthesiology& Biostatistics, All IndiaInstitute of Medical Sciences,New Delhi, India

Objective: To analyze the intraoperative and early results of the bidirec-tional Glenn (BDG) procedure performed on cardiopulmonary bypass(CPB) using three different techniques.Methods: Between September 2013 and June 2015, 75 consecutive pa-tients (Meanage 42.2±34.4 months) undergoing BDG wererandomlyassigned to either Technique I: Open anastomosis or Technique II: SVC(superiorvenacava) cannulation orTechnique III: intermittent SVCclamping.Wemonitored the cerebral NIRS (near infrared spectrophotom-etry), SVC (superior vena cava) pressure, CPB time, ICU (intensive careunit )stay, and neurocognitive function.Results:Patients in technique III had abnormal lower NIRS values duringthe procedure (57 ±7.4) compared to technique I and II (64 ±7.5 and 61±8.0, p=0.01). Postoperative SVC pressure in technique III was higherthan other two groups (17.6 ±3.7 mmHg v/s 14.2 ±3.5 mmHg and 15.3±2.0 mmHg in technique I and II respectively, p=0.0008). CPB time washighest in technique II (44 ±18 min) compared to technique I and III (29±14 min & 38 ±16 min, p=0.006) respectively. ICU stay was longer intechnique III (30 ±15 hours) compared to the other two techniques (22

±8.5 hours and 27 ±8.3 hours in techniques I and II respectively, p=0.04).No patient experienced significant neurocognitive dysfunction.Conclusion: All techniques of BDG provided acceptable results. The opentechniquewas faster and its use in smaller childrenmerits consideration. Thetechnique of intermittent clamping should be used as a last resort.

Polytetrafluoroethylene patch versus autologous peri-cardial patch for right Ventricular outflow tractreconstructionSachin Talwar, IntekhabAlam, PalletiRajasekhar,Sivasubramanian Ramakrishnan, Shiv Kumar Choudhary, BalramAiranCardiothoracic Center, All India Institute ofMedical Sciences, NewDelhi– 110029, India

Objective:Patients of TOF with pulmonary annular hypoplasia, recon-struction of right ventricular outflow tract (RVOT) often requiresa transannular patch (TAP). The present study aims to compare the outcomes ofTOF repair usingPolytetrafluoroethylene (PTFE) patch versus autologousglutaraldehyde fixed pericardial patchRVOT reconstruction.Materials and methods: 103 consecutive patients undergoing TOF repairin whom TAP was required were randomized into two groups: Group I(pericardial patch), Group II (PTFE patch). Postoperative outcomes in termsof postoperative heart rhythm, duration of mechanical ventilation, mediasti-nal and pleural drainage, length of stay in intensive care unit (ICU) andhospitalmortality were assessed. A separate team of cardiologists indepen-dently evaluated pre and postoperative gradients across the RVOT, degree ofpulmonary insufficiency, right ventricular systolic function.Results:There were no significant differences between the two groups interms of the incidence of postoperative arrhythmias, duration of mechan-ical ventilation, length of intensive care unit or hospital stay. The require-ment of inotropes was no different in the PTFE patch group as comparedto the Pericardial patch group (16.84 ± 7.04 vs. 17.90 ± 6.71, median19vs. 20, P =0.825). The re-exploration rate was higher in the PTFEgroup as compared to thepericardial patch group (6vs. 1). PostoperativeEchocardiography revealed no difference in the RV systolic functionbetween the two groups before discharge.Conclusion:In patients undergoing TOF repair, using a PTFE patch yieldscomparable results. However, the efficacy of PTFE will only be establishedonce mid-termand long-term results are available.

Results of surgery for discrete membranous subaorticstenosisSachinTalwar, Abhishek Anand, Shiv KumarChoudhary,Balram AiranCardiothoracic Center, All India Institute of Medical Sciences, NewDelhi, India

Background: We reviewed the long term results of surgery for discretesubaortic membrane from a single institute.Methods: A retrospective review of medical records of all patients(n=148) who underwent resection of subaortic membrane (SAM) fordiscrete subaortic stenosis between 1990 and 2015 at the All IndiaInstitute of Medical Sciences, New Delhi, India was undertaken.Results: Median age at surgery was 9.0 years (9 months -47years). There was one early death. Preoperative peak left ventric-ular outflow tract (LVOT) Doppler gradient was 83.4 ±26.2 mmHg (range: 34 to 169 mmHg) and aortic regurgitation(AR) was present in up to 52.5% of patients (No AR- 47.5%,Mild AR – 25.7%, Mod AR- 19.8%, Sev AR- 6.9%). The LVOTgradient reduced to 15.1 ± 6.2 mm Hg and the difference wassignificant (p<0.001). The actuarial freedom from gradients were93.2 ± 0.03 % at 5 years, 88.5 ± 0.04% at 10 years and 78.1 ±0.07% at the end of 15 years of followup. 14 patients (9.4%) whohave had residual/recurrent significant gradients are on medical

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followup or awaiting surgery. Overall there was improvement inAR for operated patients with freedom from AR of 92.6 ± 0.03%at 15 years. Freedom from reoperation at 15 years was 94 ±0.03%.Overall Kaplan-Meier survival at 10 years was 93.0 ±3.9% (95% CI: 79.6, 97.7).Conclusions: The overall long term results of surgery for discrete SAMare acceptable. Resection of membrane along with septal myectomy de-creases the risk of recurrence.

Immediate and early post operative sequelae of off-pump total cavopulmonary connectionSachin Talwar, Aabha Divya, Neeti Makhija, Shiv KumarChoudhary, Balram AiranCardiothoracic Centre, All India Institute of Medical Sciences, NewDelhi, India

Background: Extracardiac total Cavopulmonary venous connection(TCPC) is emerging as the operation of choice in single ventriclepalliation. In our study, we used off pump extracardiac TCPC toeffectively avoid the harmful sequel of CPB and reduce subse-quent long term ICU and hospital stay.Methods: Between 2012 and 2015, 72 consecutive patients,underwent single ventricle palliation via TCPC without cardiopul-monary bypass.Results: Intraoperatively, mean SVC clamp time was 15.19±3.8min andIVC clamp time was 16.93±3.31 min. In the early results, there were threeearly deaths. One patient required revision of the Fontan circuit due tonarrowing at the anastomosis between the graft and the inferior vena cavathat was caused by placement of excessive sutures to control bleeding. Nopatient required conversion from off CPB to CPB. The median inotropicscore was 4.73±5.9, mean time to extubationwas (9.5±5.82 hours), drainagein ICUwas 551.57ml±452.77ml and average ICU staywas 2.27±3.09days.The average daily pleural drainage was 163.7±88.01 ml, time to removal ofpleural tubes was 15.76±8.4 days and the total hospital stay was 17.03±8.62days. In immediate follow-up, all surviving patients (n=69) reported to bedoing well subjectively with normal ventricular function on echocardiogra-phy. Patients continued to remain on antiplatelet and anticoagulation therapy(INR≈2.0). No thrombotic events were reported.

Conclusions: Off pump extracardiac TCPC is a low risk procedure, ef-fectively avoiding the harmful effects of CPB and improving early post-operative course. There is decreased ICU stay resulting in lesser ICUexpenses. Decrease in patient morbidity is seen with lower pleural drain-age and shorter hospital stay.

Mid-Term Results Of Correction Of Tetralogy OfFallot With Absent Pulmonary ValveSachin Talwar, Aabha Divya, Shiv Kumar Choudhary,Balram AiranCardiothoracic Centre, All India Institute of Medical Sciences, NewDelhi, India.

Background: Tetralogy of Fallot and absent pulmonary valve (TOF/APV) is associated with significant pulmonary artery dilatation and air-way compression.Methods: We performed a retrospective review of 73 consecutive pa-tients who underwent repair for TOF/APV between January 2005-August 2015. Mean age was 6.4±5.6 years (28 days—22 years). Theright ventricular outflow tract (RVOT) was reconstructed using variedtechniques. Freedom fromRVOT gradients and re-operation was studied.Results:There were four (5.5%) early deaths, two each in infants and olderchildren. Median ICU stay was 2 days (range, 1 to 12 days). Mean ICU stayfor, infants (<1 year old) and children (1-18 year old) and adults (>18 year),was 6.5±6.04, 2.75±2.45, and 2.33± 1.03 days, respectively (p=0.0762).Median hospital stay was 6 days (range, 4 to 15 days). Mean hospital stayfor, infants and children and adults was 7±2, 78 days, 675±2.39, and 6.33±1.63 days, respectively (p=0.325). Mean follow up was 65 ± 36.6 months(median 56 months, range 7 to 126 months). Fourteen (21.21%) had nopulmonary regurgitation as compared to 21 (31.81%) patients, 8 (12.12%)patients and 19 (28.78%) patients hadmild, moderate and severe pulmonaryregurgitation. There were five (7.5%) reoperations.Five and ten year survival was 95% ± 2.12 and 92.3 %±3.45 respectively.Freedom from RVOT reoperation was 93 ±2.62% and 89±3.87% at 5 and 10years.Conclusions: In contrast to children and adults with TOF/APV, infantscarry significant early mortality. But the mid-term outcome for patientswho survive the initial repair of TOF/APV is acceptable.

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