Cardiac myxoma is the most common type of primary cardiac neoplasm. Over 70% of all cardiac myxomas originate from the left atrium (LA) and 18% from the right atrium (RA). Most myxomas present with constitutional, embolic, and obstructive manifestations. We are presenting a case where a part of myxoma got embolized intra-operatively. Using trans-oesophageal echocardiography, we were able to diagnose and image the transit of the tumor from the left ventricle to the left atrium. We removed the embolized tumor from the left atrium and prevented a dreaded complication like stroke, mesenteric ischemia, renal infarct or limb ischemia, which would have resulted in increased morbidity or mortality of the patient.

Left ventricular (LV) mass is a rare condition, of which the most common is thrombus. Echocardiography is a very useful modality of investigation to evaluate the LV mass. We are reporting a case of LV mass presenting with neurological symptom. The diagnosis of this mass was dilemma as the echocardiographic features were favoring tumor as well as thrombi. Mass (a) measuring 3.8 cm × 1.9 cm attached to the left ventricle apex appeared to be pedunculated tumor and mass (b) measuring 2.4 cm × 1.8 cm attached to the chordae of anterior mitral leaflet resembled a thrombus or an embolized tumor entangled in the chordae. A differential diagnosis for the LV mass is thrombus, tumors such as fibroma, and vegetation. Preoperative detection of a thrombus leads to an alteration in surgical steps. A large and mobile thrombus with or without a hemodynamic alteration is an indication for surgical removal to prevent stroke, myocardial infarction, mesenteric ischemia, renal infarction, gangrene of the limbs, and mortality.

Context Protamine is used ubiquitously in all cardiac surgeries for reversal of heparin. Risk of postoperative bleeding is increased with inadequate heparin reversal or due to anticoagulant side effects of protamine; hence, it is important to dose protamine properly. This study compares 80% protamine dose with full dose on postoperative bleeding and transfusion needs in OPCAB. Aims The aim of our study was to find whether lower dose of protamine could reduce postoperative bleeding and need for blood product transfusions in off pump coronary artery bypass grafting as compared to the regular dose of protamine. Settings and design This was a double-blinded randomised controlled trial where patients posted for off pump CABG meeting the inclusion criteria were included in the study. Methods and material Ninety patients were randomised to two groups, group F receiving full dose of protamine of 1 mg per mg heparin used, and group L received 0.8 mg per mg. Postoperative activated clotting time, bleeding at 1 h, 4 h, 24 h and total drainage till drains removal and blood product transfusion requirements were noted. Statistical analysis used: SPSS software. Results Both groups were matched in demographics, preoperative cessation of heparin and aspirin and platelet counts. Both groups received equal heparin dose, activated clotting time before protamine, activated clotting time post protamine in OT and ICU were equal as were the conduits used. There was no significant difference between the groups in post-operative drainage over time or in the need for blood product transfusions. Conclusions Eighty per cent of the dose of protamine can adequately reverse the heparin used during off pump cardiac surgery without any increase in incidence of postoperative bleeding or need for blood product transfusions.

Ketamine, a phencyclidine derivative has got a unique set of actions among anaesthetic drugs causing dissociative anaesthesia. It has been mainly used for induction of anaesthesia and intraoperative analgesia. Recently, there has been a resurge in ketamine owing to its efficacy as an infusion for perioperative and postoperative analgesia. The aim of this study was to compare intravenous infusion of ketamine with thoracic epidural bupivacaine-fentanyl infusion in managing postoperative analgesia in patients undergoing thoracotomy. METHODS: 62 patients posted for elective thoracotomy for decortication were randomised into two groups. Patients in group K (n=32) received 0.5 mg/kg bolus followed by an infusion of 2 mcg/kg/min infusion of ketamine and patients in group E (n=30) received thoracic epidural bupivacaine fentanyl infusion for 48 hrs post-surgery. Numerical rating scale (NRS) pain scores were noted at rest and on cough every 4 hrs till 48 hrs post-surgery. Ramsay sedation scores, incidence of side effects, and dose of rescue analgesics were also noted. RESULTS: NRS scores were significantly lower in Group K compared to group E, both at rest and on cough (p=0.002 and p=0.001). There was no difference in the levels of sedations or the need for rescue analgesic of paracetamol (p=0.356) though there was a difference between need for second rescue analgesic of tramadol (p=0.034) in group E. CONCLUSION: Low dose ketamine infusion provides better postoperative analgesia post thoracotomy compared to thoracic epidural infusion.