Introduction: The endoscopically harvested vein from thigh usually falls short by half to one length in patients requiring multiple conduits. Increased risk of complications precludes routine endoscopic vein harvest from the leg and an extra incision for open technique is often required thereby nullifying the sole purpose of the former. We employed the endoscope to harvest this extra length of vein from the upper half of the leg with little or no extra risk. Methods: From January 2006 to September 2006 we endoscopically harvested the vein in thigh as well as the leg using the same entry point incision over the medial epicondyle in 40 cases. The only exclusion criterion for the study was a superficial location and subcutaneous visibility of the vein in the leg. We made 3 incisions in each patient of average size 2. 5 cm. Results: Five patients required conversion to the open technique. The average harvest time was 59 minutes. Average length of the conduit was 48 cms. Complications included 1 minor wound infection, 1 case of superficial wound dehiscence, 1 haematoma requiring aspiration and minor erythema at the incision site in 2 patients. Most common complication observed was ecchymosis in 6 patients (5 thigh; 3 leg). None of the patient developed lymphoedema and none required re-hospitalization for vein harvest related wound complications. Conclusion: "Extended endoscopic vein harvest" and avoidance of the open incision was possible in most patients with no additional risk and that the procedure could be routinely employed in patients requiring multiple conduits. (Ind J Thorac Cardiovasc Surg, 2007; 23: 125-127)

IntroductionAlthough many advances have been made since the first successful human valve replacement with mechanical valve by Starr and Edwards 1 and Harken et al 2 in 1960 and the first Hancock II porcine valve Abstract Background: The American College of Cardiology/American Heart Association (ACC/AHA), guidelines for choice of prosthetic valve based on patients' age are difficult to apply to the developing world because of a lower life expectancy and difficulty in maintaining correct levels of anticoagulation for a variety of reasons. While there is general agreement on the choice of prosthetic valves for patients below 40 years of age (mechanical) and above 60 years of age (biologic), the 40 to 60 age group remains a grey zone. The goal of our study was to compare outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age.Methods: From Jan 2003 to July 2008, 250 patients between the ages of 40 and 60, undergoing mitral valve replacement at our institution were randomized to receive either a mechanical or a bioprosthetic valve. Outcomes in the form of incidence of valve thrombosis and thromboembolism, bleeding complications, incidence of prosthetic valve endocarditis and survival were compared in the two groups.Results: Out of 250 patients, 135 patients received mechanical valve and 115 patients were implanted with a bioprosthetic valve. Patients were followed up for a mean period of 3 years (range 6 months to 4.8 years). The incidence of valve thrombosis was higher in mechanical valve as compared to bioprosthetic valve (6% vs. 0.9%, p= 0.04). Similarly there was a higher incidence of thromboembolism in mechanical valves as compared to bioprosthetic valves (4.5% vs. 0%, p=0.03). Bleeding complications occurred more frequently in mechanical than bioprosthetic valve (6% vs. 0.9%, p=0 .04). There was no significant difference in the incidence of prosthetic valve endocarditis (2.2% vs. 2.7%, p >0.05) or survival at three years (96.2% vs. 97.2%, p > 0.05) in the two groups.Conclusions: Patients in the age group of 40 to 60 years undergoing mitral valve replacement with a mechanical valve have a higher incidence of thrombotic and bleeding complications as compared to bioprosthetic valve, even though short term survival is similar. This favours implantation of a bioprosthetic valve in this age group. (Ind J Thorac Cardiovasc Surg 2009; 25: 12-17)

Background Choice of heart valve in the developing countries is an unsettled issue due to illiteracy and noncompliance related increase in incidences of stuck valve and anticoagulant related bleeding and as such international guidelines may not be wholly applicable. The aim of our study was to compare outcomes after mitral, aortic or double valve replacements with mechanical versus bioprosthetic valves. Methods Data of 503 patients who underwent cardiac valve replacement [300 mitral, 125 aortic, and 78 double valve] with either mechanical [bileaflet valve, n=257] or biological [Hancock II, n=246] valve from January 2003 to December 2008, were retrospectively analyzed. Specific outcomes assessed included incidences of valve thrombosis, systemic thromboembolism, anticoagulant related bleeding, structural valve dysfunction, prosthetic valve endocarditis, reoperation and death.Results Both the groups were comparable preoperatively except that patients receiving biological valve were more likely to be female and belonging to a rural setup. 30 day mortality was comparable in both groups. Incidences of valve related complications were significantly commoner in mechanical valve group. Two patients with mechanical valve required reoperation for stuck prosthetic valve at about 3 years after primary operation. There were two deaths in mechanical valve group, both related to stuck prosthetic valve. Prosthetic valve endocarditis was not reported in either group. At 5 years there was no incidence of structural valve dysfunction. Conclusions Mechanical valves are associated with a significantly higher complication rate compared with biological valves in Indian patients. Biological valves thus maybe specifically suited to the Indian scenario. However, in choosing a prosthetic valve, patients' involvement and informed consent should take the utmost importance.