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Dengue fever (DF) is the most common and widespread arbovirus infection worldwide. It is endemic in the tropical and sub-tropical areas of the world especially in Southeast Asia, the Pacific, East and West Africa, the Caribbean and South America with cyclical epidemics. Major epidemics of DF have occurred in India and Southeast Asia in the last two decades. We have outlined the anaesthetic management of a 64-year-old man with DF who needed urgent Coronary artery Bypass graft surgery.

Leukocytosis and fever in the absence of infection are common phenomena in post surgical period. The systemic inflammatory response syndrome induced by surgical trauma is a well-known entity, with resultant release of variety of inflammatory cytokines leading to fever and/or leukocytosis in spite of the absence of infection.To know the association of leukocytosis and fever with infection in immediate post cardiac surgical period.It was a retrospective, observational study including 569 patients, who underwent cardiac surgeries in our institute. All demographic data, comorbidities and other factors associated with fever and/or leukocytosis were analyzed. The sensitivity and specificity of fever and/or leukocytosis were analyzed for the diagnosis of infection.Out of 569 patients; 49 patients (9%) had evidence of infection on microbiological culture. Mean total leukocyte counts (TLC) on zero and 1st postoperative days were associated with infection with a sensitivity (75.5% and 63.3%) and specificity (15.8% and 24.0%) respectively. Mean maximum temperature (Tmax) on zero and 1st postoperative days were associated with infection with a sensitivity (20.4% and 24.5%) and specificity of (82.5% and 83.3%) respectively. The combined sensitivity and specificity of leukocytosis and fever for the diagnosis of infection on 2nd postoperative day was 14.3% and 91.5% respectively.Fever and leukocytosis are poor predictors of diagnosing infection on the first two postoperative days. However, fever and leukocytosis combined together have low sensitivity (14.3%) with high specificity (91.5%) for the diagnosis of infection on the 2nd and subsequent postoperative days.

Increased pulmonary vascular resistance can be detrimental to the cardiac output in post-operative cardiac surgical patients. Pulmonary vasodilator therapy by systemic pharmacologic agents is non-selective. Inhaled nitric oxide is a selective pulmonary vasodilator and does not cause systemic hypotension. In this prospective study, 14 adult post-operative cardiac surgical patients with pulmonary hypertension underwent inhaled nitric oxide therapy and their hemodynamic changes were evaluated. Inhaled nitric oxide was administered in doses of 5 ppm-25 ppm. The result was a decrease in pulmonary vascular resistance from 456.57 +/- 137.13 to 357.64 +/- 119.80 dynes-sec- Continued. - See Free Full Text.

Cardiac herniation, a rare entity, is seen most commonly after traumatic rupture of the pericardium or following pneu-monectomy with partial pericardiactomy. It is rarely seen to occur following closure of a sinus venosus atrial septal defect through the port access technique. A review of the literature in English did not reveal any such case report.

The development of minimally invasive techniques represents a significant improvement in the repair of atrial septal defect by total endoscopy. Robot-assisted repair obviates the need for a sternotomy or thoracotomy. This is the case report of a 45-year-old male, who underwent atrial septal defect repair through the total endoscopic technique. The peri-operative management and associated problems in the post-operative period have also been described.

Although quality assessment of coronary artery patients can be done by 30 days risk-adjusted operative mortality, it is still insufficient to study the outcome after primary coronary artery bypass graft surgery (CABG). In our study, we attempted to determine the factors, which can help predict operative mortality before and after CABG.The study population consisted of 1000 prospective patients who underwent primary isolated CABG. Assessment was done by dividing the patients into two groups, i.e. non-survivors ( n= 12) and survivors ( n= 988). Data were analyzed using both univariate and multivariate models.On univariate analysis, recent acute myocardial infarction, intra-aortic balloon counterpulsation (IABC), left ventricular ejection fraction (LVEF)25%, ventilator-associated pneumonia (VAP), tracheostomy, re-exploration, ventricular arrhythmias, low cardiac output (CO), multiple blood transfusions, post-operative renal dysfunction and longer intensive care unit and hospital stay were found as risk factors for mortality. Multivariate analysis showed that LVEF25%,VAP, ventricular arrhythmias and low CO independently predicted mortality. Prior knowledge of these risk factors can help not only in predicting the outcome and the risks but also helps to plan the surgical and post-operative course of the patients to improve the morbidity and mortality.Our data suggest that operative mortality can be predicted prior to and after surgery considering factors such as LVEF, use of IABC, onset of ventricular arrhythmias and low CO.

Recent advances in minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery and atrial septal defect closure. The present study examines the feasibility, safety and efficacy of this technique.Between September 1997 and December 2004, 430 patients underwent mitral valve surgery through right anterolateral thoracotomy. The mitral valve was repaired in 62 patients, and 368 patients underwent mitral valve replacement. During same period, 336 patients underwent surgical closure of atrial septal defect. In all cases femoral artery and femoral venous cannulation was used for cardiopulmonary bypass. There was no approach-related limitation to surgical exposure, nor complication in cannulation of femoral vessels through the groin. Mean duration of cardiopulmonary bypass and cross-clamp time was 90 +/- 48 min and 51 +/- 29 min, respectively. Mean intubation time was 14.8 hours (range: 8-28 hours). Mean duration of intensive care andhospital stay was 26 hours (range: 18-38 hours) and 7 days (range: 5-17 days), respectively. In the atrial septal defect group, the mean cardiopulmonary bypass time and aortic cross-clamp time was 29 +/- 14 min and 19 +/- 8 min, respectively. Mean intensive care unit stay and mean hospital stay was 9.8 +/- 2.6 hours and 4.0 +/- 1.9 days, respectively. Hospital mortality was 0.46% (2/430) in the mitral valve group while there was no hospital mortality in atrial septal defect group. At a mean follow-up of 38.0 +/- 6.2 months there was one late death and two re-operations in the patients who underwent mitral valve surgery.Port-access approach is safe, offers faster recovery, cosmetic advantage, more patient satisfaction: it obviates the complications due to re-entry in redo cases and offers same efficacy as conventional operation. Furthermore, it is an excellent approach for mitral valve surgery in patients who had previous cardiac procedures. It has become our standard approach for repair of atrial septal defect and isolated mitral valve procedures.

Post-myocardial infarction, anteroseptal dysfunction or akinesia is treated by septal reshaping to improve the surgical outcome in patients with severe left ventricular dysfunction.Between February 2003 to December 2003, 30 consecutive patients with previous anterior wall myocardial infarction and severe ventricular dysfunction underwent septal reshaping. All the dyskinetic and akinetic septal areas were excluded using an oval dacron patch which was sutured from the healthy septal area to the anterior wall, resulting in formation of a new apex. There were two mortalities in the group. After a mean follow-up of 4.2 +/- 1.6 months (1-7 months) it was seen that this procedure resulted in significant reduction of ventricular volume, increase in ejection fraction, an improvement in New York Heart Association class from 2.9 +/- 1.1 to 1.7 +/- 0.3, and a better apical geometry.In selected patients with left anterior descending artery occlusion resulting in anteroseptal dyskinesia or akinesia, septal exclusion technique provides good clinical and morphological results with significant improvement in left ventricular function.

Following renal transplantation, patients for coronary artery bypass grafting are subjected to high morbidity and mortality during the perioperative period because of the risk of major infections, renal impairment or rejection, and myocardial infarction. We describe the perioperative management of one such high-risk patient.

To reduce surgical trauma and the drawbacks associated with sternotomy, we performed robotically controlled, video-assisted mitral valve surgery, using either the port-access or the transthoracic clamp technique.Between September 1997 and September 2000, 221 patients (78 males, 143 females) underwent mitral valve surgery through a small right minithoracotomy using the port-access endovascular cardiopulmonary bypass system. Mitral valve exposure was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000) allowing stabilization and voice-activated camera positioning. Twenty-six patients underwent mitral valve repair and 195 had valve replacement. In 197 patients, mitral valve surgery was the primary operation, while 24 were redo cases. Skin-to-skin mean operating time was 3.5 +/- 1.2 hours and aortic cross-clamp time was 58 +/- 16 min, mean intensive care unit stay was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. There was no re-exploration for bleeding. There was no late death or re-operation on mean follow-up of 16.4 +/- 12.2 months. Patients showed improvement in their NYHA functional class from 2.6 +/- 0.5 to 1.4 +/- 0.8 postoperatively. Outcomes were compared with those of our previous 220 patients who underwent mitral valve surgery with the median sternotomy approach.The use of video and robotic assistance in port-access mitral valve surgery not only minimizes the length of the incision, but also gives full visualization of the entire mitral valve apparatus. This approach provides comparable results with the sternotomy approach, as well as marked advantages of reduced intensive care unit stay. ,ower blood transfusion requirement, better cosmesis and earlier hospital discharge.

The incidence of reoperative coronary artery bypass grafting is increasing with an increase in the number of patients undergoing coronary artery bypass surgery. The clinical outcome of redo coronary artery bypass grafting without cardiopulmonary bypass and conventional coronary artery bypass grafting using cardiopulmonary bypass are different.We compared clinical parameters in patients who underwent off-pump (n=156) versus on-pump (n=194) redo coronary artery bypass grafting performed between January 1995 and December 2001 in our institute, to determine if off-pump surgery has improved the surgical outcome of redo coronary artery bypass grafting and emerged as an ideal technique. Patients who underwent on-pump redo surgery required more postoperative blood transfusion (86.53% on-pump v. 12.82% off-pump. p=0.001), prolonged ventilatory support (24 hours) (16.49% on-pump v. 7.7% off-pump, p=0.021) and higher inotropic support (23.71% on-pump v. 10.89% off-pump, p=0.003). On-pump redo coronary artery bypass grafting was also associated with a prolonged stay in the intensive care unit (40+/-6.2 hours on-pump v. 20+/-4.1 hours off-pump, p=0.001) and longer hospital stay (9+/-4.2 days on-pump v. 5+/-3.4 days off-pump, p=0.001). In-hospital mortality was higher in on-pump patients than in off-pump ones (7.7% v. 3.2%); however, this was not statistically significant (p=0.114).Off-pump redo coronary artery bypass grafting is a safe method of myocardial revascularization with lower operative morbidity and mortality, less requirement of blood products and early hospital discharge, compared with conventional on-pump redo coronary artery bypass grafting.