The immediate postoperative hemodynamics in 43 patients with severe pulmonary arterial hypertension who underwent mitral valve replacement between January 2000 and September 2001 were studied prospectively. The mean age was 30.6 years. There was mitral stenosis in 19 (44.1%), mitral regurgitation in 9 (20.9%), and mixed lesions in 15 (34.9%). In 36 patients (83.7%, group 1) pulmonary arterial pressure was sub-systemic, with a mean of 58.1 mm Hg and pulmonary vascular resistance of 743.4 dyne x s x cm(-5). Seven patients (16.3%, group 2) had supra-systemic pulmonary arterial pressure of 83.2 mm Hg and pulmonary vascular resistance of 1,529 dyne x s x cm(-5). Lung biopsies were taken from the right lower lobe in 24 patients. Operative mortality was 5.5% in group 1 and 28.5% in group 2. After mitral valve replacement, the pulmonary arterial pressure and vascular resistance decreased significantly in group 1. In group 2, pulmonary arterial pressure decreased significantly but pulmonary vascular resistance remained elevated. Pulmonary vascular changes did not progress beyond grade III (Heath-Edwards' classification). Mitral valve replacement is safe even in the presence of severe pulmonary arterial hypertension as long as pulmonary arterial pressures are below systemic pressures. Lung biopsy did not help in identifying patients with irreversible pulmonary arterial changes.

A 47-year-old man who had a pacemaker implanted 2 years earlier, recently developed a fever and had been on antibiotics for 2 months. He presented with pulmonary emboli, and underwent lead extraction and emboli removal. Histopathology demonstrated Aspergillus. Amphotericin B was continued postoperatively. This rare case of pacemaker lead endocarditis suggests that vigorous medical and surgical intervention can be curative.

In 1,459 open heart operations performed between July 1995 and March 2000, sternal closure was delayed in 30 patients (2%) because of hemodynamic instability limiting primary sternal closure in 12 and uncontrollable bleeding in 18. Two patients died in the immediate postoperative period while the chest was open, due to persistent low cardiac output secondary to myocardial failure. The sternum was closed in 28 patients at an average of 22 ± 0.3 hours (range, 8 to 48 hours) postoperatively. Two patients died in the late postoperative period prior to hospital discharge after sternal closure. Nonfatal wound infections occurred in 8 patients. The 26 survivors (86.7%) were discharged and followed up for a mean of 11.2 months. This study demonstrates that delayed sternal closure is an effective method of dealing with unstable hemodynamics and uncontrollable hemorrhage.

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Background: With the advances in percutaneous intervention techniques, the majority of patients referred for coronary artery bypass grafting (CABG) are on aspirin and clopidogrel. Standard guidelines suggest to stop clopidogrel 5 days and continue aspirin before surgery. We aim to report our centre experience on effects of continuation of preoperative clopidogrel on postoperative bleeding and use of blood products after off- pump CABG (OP-CABG).Methods: This retrospective study included 120 consecutive patients who underwent isolated OP-CABG operation between Nov 2019 and March 2021 in our centre. Data was obtained from hospital records. Patients were divided into two groups: Group-1: this group consists of 86 patients. All patients included were elective CABG cases with preoperative Clopidogrel 75 mg discontinued 3-5 days before surgery. Group-2: this group consists of 34 patients. All patients included were urgent CABG cases with preoperative Clopidogrel 75 mg discontinued 24 hours before surgery. Aspirin 75 mg was continued in both groups till surgery. Preoperative, intraoperative and postoperative data was recorded.Results: 120 patients were enrolled in the study. There was no statistical significance in postoperative bleeding, re-exploration and use of blood products between the two groups. However, use of total arterial vascularisation and operative time was significant among the groups. The postoperative outcome was similar in both the groups.Conclusions: OP-CABG can be done safely in patients requiring urgent surgery. However, clopidogrel should be stopped 3-5 days in patients undergoing elective surgeries as it influences graft selection, prolongs operative time and exposes the patients to unnecessary risks.