Off-pump coronary artery bypass involves precise manipulations for proper positioning the heart without causing hemodynamic compromise. Pericardial stay sutures exerting appropriate traction play an important role in off-pump surgery. We report a rare case in which a congenital pericardial defect was discovered after sternotomy in a patient undergoing off-pump coronary artery bypass.

Introduction Combined aortic and mitral valve disease is usually of rheumatic origin. In these patients we often encounter problem of small valve annuli particularly with aortic annulus. It is still debated whether a small prosthesis should be used or aortic root should be enlarged to prevent Patient Prosthesis Mismatch (PPM). This study was undertaken to review our strategy and feasibility of Aortic Root Enlargement (ARE) in patient undergo Double Valve Replacement (DVR) to avoid mismatch without increase in cost of treatment, morbidity or mortality. Materials and methods We reviewed 11 patients who underwent double valve replacement along with aortic root enlargement between January 2010 and December 2010. Patients at high risk for PPM and whose aortic annulus did not admit minimum of 19 mm aortic valve were selected for aortic root enlargement. Operative procedure involved extension of aortotomy incision between left and non coronary cusp without entering left atrium and reconstructing the defect with autologous Pericardium and implanting appropriate size valve to avoid or decrease PPM Results There were no operative or in hospital mortality. Mean age of patients was 33.83 years (range 12-50).Average body surface area was 1.37 m2 (range 1.1-1.65). Most patients underwent root enlargement for stenotic lesion. Mean cardiopulmonary bypass time was 179 min (range 150-238 min). And mean cross clamp time was 120 min (range 91-155 min). With root enlargement one size bigger valve was replaced in 10 patients and PPM was eliminated in 6 patients while in 5 patient PPM was reduced to moderate level. Other variables like inotropic requirement, duration of ventilation, blood product used and Intensive Care Unit (ICU) stay were comparable to a routine double valve replacement without root enlargement. Conclusions Aortic root enlargement can be safely done even in patients undergoing concomitant aortic and mitral valve replacement. With ARE patients benefit bigger size prosthesis without additional mortality and morbidity.

Primary malignant pericardial mesothelioma is extremely rare, with a reported prevalence of 0.0022% at autopsy series. It is, however, the most common primary malignancy of the pericardium. To date, only few hundred cases have been reported in the literature. Unlike peritoneal and pleural mesothelioma, there has been no definite correlation between asbestos exposure and pericardial disease. Malignant pericardial mesothelioma carries a poor prognosis with no successful treatment strategies and little benefit from radiation and chemotherapy. We report a 28 year-old man with no medical history who presented with two weeks of worsening dyspnea on exertion to minimal efforts and severe orthopnea. We discuss the diagnostic approach and therapy in our patient and provide a review of the literature pertaining to the epidemiology, clinical features of pericardial mesothelioma and its diagnosis and treatment.Key-words: Cardiac neoplasm; Pericardium; Mesothelioma; Constrictive pericarditis; Key Message: Malignant mesothelioma of the pericardium is a very rare neoplasm. Clinical presentation is insidious and invariably followed by progression to tamponade, heart failure or pericardial constriction. Cross sectional imaging followed by biopsy are necessary for a conclusive diagnosis. Successful treatment strategies for this malignancy are lacking so prognosis remains poor.

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