Objective: Hemodynamic deterioration during positioning of the heart has been the most critical complication of off-pump coronary artery bypass surgery. Pre-operative use of intra-aortic balloon pump has been shown to prevent this complication in high risk patients. The role of balloon pump in high risk patients has been questioned by our group. We modified the role of balloon pump in our patients, thus avoiding the conversion to cardiopulmonary bypass. Methods: 4063 off-pump coronary bypass surgeries were performed by a single surgeon in our center, over thirteen years. 130 intra-aortic balloons used between July 2002 and December 2015 were removed from the theater, once the distal anastomosis was performed. We studied this group of patients for-time and need for insertion, duration of balloon used, local insertion problems and survival. Results: Initially, we inserted intra-aortic balloons in high risk patients. We observed that, patients with low ejection fraction and patients with critical left main coronary artery disease were not the ones who actually needed balloon pump support. It was the patients who had ongoing ischemia, with preserved left ventricular function, and ST depression intra-operatively, who needed balloon pump support to perform complete anatomical revascularization. Conclusions: Intra-aortic balloon pump has helped us to position the heart without hemodynamic instability, thereby avoiding conversion to cardiopulmonary bypass. This enabled us to perform off-pump surgery in virtually all areas of the heart, thus maintaining perfect hemodynamics.

Whether coronary artery bypass grafting (CABG) should be performed on- or off-pump remains a matter of debate. We aim to present our experience with off-pump CABG. Early clinical outcome and adverse events were analyzed over the time course of the study. Methods: A total of 4310 patients undergoing isolated off- pump CABG from January 2002 until December 2016 at the Malabar Institute of Medical Sciences in India were included. Preoperative, intraoperative, and postoperative, as well as follow-up data were prospectively collected. To analyze the differences of patient characteristics and outcomes over time, five-year periods were created (early: 2002-2006; middle: 2007-2011; late: 2012-2016). Traditional techniques of quality control monitoring were applied. Results: The mean age of our patients was 59 ± 9 years, and 13% (533) were female. Postoperative mortality was observed in 0.7% (25), acute renal failure and stroke in 0.2% (8) each, and mediastinitis in 1.2% (53) of the patients. Despite the progressive worsening of the patient risk profile, significant improvement in mortality was observed over time, while stroke, acute renal failure, and mediastinitis remained similar. Continuous quality control monitoring revealed that the system was within the control boundaries for the entire period of the study. The current probability of 30-day mortality or conversion to on-pump CABG is about 0.5%. Conclusion: Off-pump CABG is safe and effective for patients undergoing CABG. It can provide superior results compared to on-pump CABG, particularly when performed by a dedicated off-pump surgeon.

Development of a simple, reusable stabilizer for beating heart surgery has been long overdue. Every time a disposable stabilizer is used and discarded, we add to the carbon footprint we leave behind. We had been working on developing such a stabilizer, and had finally come up with a simple indigenous (reusable) metallic stabilizer (SIMS). We have used it for over 600 consecutive off pump coronary artery bypass (OPCAB) with excellent results. The anatomy of the stabilizer is described here along with a comparison of this stabilizer with the commercially available one.

We present a case of extracranial internal carotid artery (ICA) aneurysm, which presented as an inflammatory submandibular swelling in the upper part of the right side of the neck. The lack of frank pulsatility and signs of inflammation though was a bit confusing, the Doppler and CT angiogram clinched the diagnosis. We were able to surgically resect and reform the ICA using the native vessel itself, which is an unusual technique, which we thought was worth presenting.

We hereby report a case of Kawasaki disease in a 32 year old male, with giant aneurysm of both coronary arteries and severe LV (left ventricular) dysfunction who underwent OPCAB (off pump coronary artery bypass grafting) two years ago. He presented with acute myocardial infarction of his anterior wall of left ventricle. He was stabilised with medical management and was taken up for surgery when his enzymes became normal. His LV function had improved over the time and now has a good ejection fraction.