Notes

Comparison Investigation of A few Bradyrhizobium diazoefficiens Genomes Show Certain Mutations Acquired in the course of Option for a greater Mobility Phenotype and also Adaption to Clinical Problems.
Dr. Pifithrin-μ cost O.P. Yadava, CEO and chief cardiac surgeon of National Heart Institute, New Delhi, India, and editor-in-chief of Indian Journal of Thoracic and Cardiovascular Surgery in conversation with Prof. David Taggart from University of Oxford, England, discuss the current status of off-pump coronary artery bypass surgery including the indications and issues related to training.
This report describes a modified defibrillation technique during cardiac surgery using a combined internal (epicardial) and external (transthoracic) defibrillation system.

We routinely used 30J (J) shock between the epicardial pad placed directly onto the right atrium and the left anterolateral transthoracic pad placed in the left anterolateral chest wall directly to the skin in the area of the cardiac apex under the nipple.

Thirty-two patients whom developed ventricular fibrillation (VF) during surgery were managed in theatre using this method. A single 30J shock was successfully given in 29 patients while the remaining three required an additional shock with the same amount (30J).

We believe that this technique is safe and complications free. It is easy to perform especially in patients with difficult access such as redo operations.
We believe that this technique is safe and complications free. It is easy to perform especially in patients with difficult access such as redo operations.The parallel supply of the pulmonary and systemic circuits complicates the management of single-ventricle lesions. Achieving a balance between the two limbs of the circulation forms the basis of optimizing the systemic oxygen delivery, with the oxygen availability being highly sensitive to alterations in pulmonary/systemic blood flow ratio (Qp/Qs). The identification of a 'balanced' circulation is challenging wherein various parameters should be evaluated in close conjunction with each other. The prompt identification of circulatory maldistribution should be backed up with a sound management strategy aimed at attaining an equitable systemic and pulmonary perfusion. Any degree of ventricular dysfunction compromises the total output (Qp + Qs) supplying the two circuits explaining the role of inodilators in improving the myocardial performance in addition to lowering the systemic vascular resistance and optimizing Qp/Qs in setting of a single-ventricle physiology. Moreover, the pulmonary circulation is modulated by a multitude of factors intricately linked to the single-ventricle lesion, including anatomical characteristics unique to the underlying lesion (branch pulmonary arterial and venous stenosis), preoperative interventions, associated aortopulmonary and venovenous collaterals, plastic bronchitis, pulmonary arteriovenous fistulae, underlying ventricular dysfunction,, and many others. The article highlights the physiology, diagnosis, therapeutic optimization of a single-ventricle circulation, and the peculiarities pertaining to the pulmonary circulation of the uni-ventricular lesions.Thymic masses are one of the most common tumors in the anterior mediastinum. Nevertheless, because the thymus originates in the third and fourth pharyngeal pouches and descends into the anterior mediastinum, ectopic thymic tissue may be found anywhere from the angle of the mandible to the superior mediastinum. Ectopic cervical thymoma (ECT) is an extremely rare tumor that originates from ectopic thymic tissue trapped during the migration of the embryonic thymus and is often misdiagnosed as a thyroid tumor or other neck masses. Herein, we report an unusual case of ectopic cervical thymoma associated to myasthenia gravis (MG).Traumatic manubriosternal joint dislocation in blunt thoracic trauma is of rare occurrence with only few case reports in the literature. We present a rare case of occult manubriosternal dislocation that was evident only after cervico-dorsal spine fracture correction. Thirty-one-year-old gentleman sustained multiple fractures of C6, C7, and D1 vertebral bodies; bilateral transverse process of C7, D1,and D3; left transverse process of D12; right transverse process of D4; and right clavicle fracture along with bilateral multiple rib fractures after fall from bike at high velocity. The patient was awake, alert, and moving all 4 limbs. The patient underwent right chest drain insertion in high dependency unit. His displaced cervico-thoracic spine was fixed with plate and intrapedicular screws. It was after fixation of spine that type II manubriosternal dislocation was clinically appreciated. He underwent fixation of manubriosternal joint using simple steel wires. Post-operatively he remained pain-free with stable manubriosternal joint. Role of manubrio-vertebral column in such a scenario is discussed.We report a case of a 53-year-old lady who was incidentally diagnosed to have giant anterior mediastinal mass while undergoing preoperative evaluation for another surgery. She came for surgery after 2 years when she became symptomatic. A large 6.7-lb (2800 g) tumor occupying both hemithoraces and engulfing heart was excised in its entirety through a clamshell thoracotomy under cardiopulmonary bypass standby. Histopathology revealed the final diagnosis as well as differentiated liposarcoma. She is now able to walk 2 km without any symptoms at the end of a 24-month follow-up.
The emergence of minimally invasive thoracic surgery has positively impacted postoperative recovery. Robotic-assisted thoracoscopic surgery (RATS) has been shown to have equivalent short- and long-term outcomes as compared with video-assisted thoracoscopic surgery (VATS). The introduction of RATS offers a three-dimensional high-definition image, improved ergonomics, and wristed movement. The purpose of this paper was to define the learning curve of RATS.

This study is a retrospective review of a single surgeon's RATS experience in a community hospital. All patients who underwent RATS between December 2011 and April 2014 were included. The cohort was divided into 2 groups "early" and "late." These groups were created based on the date before or after February 2013, respectively. Data is presented as means and percentages. Significance was defined as a
value < 0.05. All categorical variables were evaluated with Fisher's exact
test and all continuous variables were compared via a paired
test.

Seventy-nine patients were identified with a mean age of 59. There were 39 patients in the early group and 40 in the late. Rates of conversion to open thoracotomy (13% vs 10%,
 = 0.74) and operative time (180 vs 204min,
 = 0.34) did not demonstrate any statistical significance between the two cohorts. Postoperative morbidity (21% vs 28%,
 = 0.60) and mortality (3% vs 0%,
 = 1.00) were equivalent between both groups. There was a higher percentage of lobectomies performed during the late group (38% vs 65%,
 = 0.02). Furthermore, these lobectomies were performed at a faster rate in the late group.

Based on our experience, the complexity of the operations that can be performed robotically increased with the number of operations performed without an impact on postoperative morbidity and mortality.
Based on our experience, the complexity of the operations that can be performed robotically increased with the number of operations performed without an impact on postoperative morbidity and mortality.
The era of percutaneous aortic valve intervention has challenged the continuing indication for surgical aortic valve replacement (SAVR).

The aim of this study is to evaluate clinical outcomes of the elderly patients who underwent surgical aortic valve replacement via median sternotomy, in order to assess the impact of surgery on patient outcomes and discharge destination.

The study involves a retrospective observational analysis in a single centre, including all octogenarian patients who underwent aortic valve surgery between January of 2011 and July of 2016. The study assessed pre-operative co-morbidities and post-operative outcomes, including long-term mortality and discharge destination following on from surgery.

The mean age of patients was 82.7years (± 2.9), 67% of whom were male. The mean EuroSCORE II was 8.1 (± 7.6). The most common pre-operative co-morbidities were dyslipidaemia (82%), hypertension (80%), and ischaemic heart disease (78.8%). The median length of stay was 10days (± 6.9days). Dits, and proceduralist discretion should still be used.
Acute renal failure is a serious complication following cardiac surgery. This may lead to fatal outcome if not treated timely. Continuous renal replacement therapy (RRT) has shown improvement in outcome. There is no clear consensus on the timing of the initiation of RRT in these patients. This study evaluates the factors predicting favourable outcome in this group of patients.

Patients undergoing cardiac surgery between January 2015 and December 2018 are included in this retrospective study. RRT is required in 24 patients out of 2254 operated during this period. Patients are divided into groups, survivors (group 1,
 = 8) and dead (group 2,
 = 16). The preoperative information is accessed from the hospital information system and intensive care unit data. Multivariate analysis of pre continuous renal replacement therapy (CRRT) bicarbonate level, pH, potassium, time of initiating CRRT and central venous pressure is performed.

The incidence of acute renal failure requiring RRT is 1.06%. Patients in two groups were similar in demographics and presence of risk factors. There was difference in the pre RRT bicarbonate level (
 = 0.007). On multivariate analysis, pre RRT bicarbonate levels predict survival (
 = 0.003). ROC curve for pre RRT bicarbonate predicts survival for value above 16.83mg/dl with 80% sensitivity and 78.6% specificity.

Bicarbonate level in blood predicts the best evidence for initiating the renal replacement therapy in of acute renal failure following cardiac surgery. When urine output drops to < 0.5ml/kg and not responding to infusion of furosemide, RRT must be initiated at sodium bicarbonate in blood above 16.9mg%.
Bicarbonate level in blood predicts the best evidence for initiating the renal replacement therapy in of acute renal failure following cardiac surgery. When urine output drops to less then  0.5 ml/kg and not responding to infusion of furosemide, RRT must be initiated at sodium bicarbonate in blood above 16.9 mg%.
Left ventricular ejection fraction may remain normal or even higher despite significant impairment of contractility in cases of mitral regurgitation. The aim of this study is to evaluate the changes in left ventricular function after mitral valve replacement and to study the role of global longitudinal strain in detecting early left ventricular dysfunction using speckle tracking.

Study involved 31 patients who underwent mitral valve replacement for mitral regurgitation. Patient's preoperative and postoperative echocardiography (conventional parameters and global longitudinal strain) and other parameters like functional status, radiological findings, and electrocardiogram were recorded to evaluate left ventricular function.

All patients presented in advanced stage with New York heart association class III (67.7%) and IV (32.3%). There was significant decline in left ventricular ejection fraction (with the mean value from 64.58 to 40.13%) and global longitudinal strain (- 15.57 ± 4.98to
 8.97) in the immediate postoperative period (~ 7days).
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