Extracorporeal life support in critically ill adults.

Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.

[GAS MICROEMBOLISM DURING EXTRACORPOREAL CIRCULATION].

INTRODUCTION: Over the past 20 years, there are many studies, where great attention is paid to the gas and material embolism as the cause of cognitive impairment in patients undergoing surgery with cardiopulmonary bypass. PURPOSE: To identify the filter capacity of 4 extracorporeal circuits for removing gaseous microemboli in various interventions on the heart and aorta. MATERIAL AND METHODS: Work carried out on 60 patients operated on acquired heart and aorta under cardiopulmonary bypass. We used 4 different extracorporeal circuits, divided into groups of 15 patients. Quality and quantity of gaseous microemboli recorded in real time on the device BCC-200 GAMPT (Germany). RESULTS: According to two indicators: Vol. Red (reduction in the volume of gas microemboli) and Fl (filter index) the best results were obtained after statistical processing systems Medtronic and Terumo, followed by Maquet system and Eurosets. CONCLUSION: BCC-200 device allows identifying the sources of gaseous microemboIi. The perfusionist, having on-line information time about the number of microemboli coming in heart-lung machine can increase patient safety, using the capabilities of a particular extracorporeal circuit and minimize the amount of emboli from entering the patient's arterial line.

Evaluation of systemic inflammatory response in cardiovascular surgery via interleukin-6, interleukin-8, and neopterin.

AIM: The aim of this study was to evaluate the serum levels of interleukin-6 (IL-6), IL-8, and neopterin as a sign of systemic inflammatory response syndrome after open-heart surgery. In this study, we evaluated the influences on the levels of IL-6, IL-8, and neopterin of coronary artery bypass grafting (CABG) and valve replacement surgeries with and without the use of extracorporeal circulation (ECC). MATERIALS AND METHODS: This prospective study was performed in 30 patients. In this study, we evaluated patients who underwent valve replacement surgery (group 1, n = 10), CABG with ECC (group 2, n = 10), or CABG using the beating-heart technique (group 3, n = 10). With the Human Investigation Ethics Committee consent, blood samples were obtained from the patients before the surgery (T0) and after 1 hour (T1), 4 hours (T2), 24 hours (T3), and 48 hours (T4) of protamine injection. IL-6, IL-8, and neopterin levels were measured using commercial enzyme-linked immunosorbent assay kits. RESULTS: The demographic data and preoperative and operative characteristics of the patients were similar. Neopterin IL-6 and IL-8 levels significantly increased first at the fourth hour after the surgery. When compared to the levels before the surgery, this increase was statistically significant. Unlike the other 2 groups of patients, those who experienced CABG with the beating-heart technique (group 3) had decreased neopterin levels at the first hour after the surgery, but this decrease was not statistically significant. Neopterin levels increased later in the OPCAB group, but these increased levels were not as high as the neopterin levels of groups 1 and 2. Neopterin reached maximum levels at the 24th hour and, unlike groups 1 and 2, in group started to decrease at the 48th. CONCLUSIONS: Complement activation, cytokine production, and related cellular responses are important factors during open-heart surgery. It is certain that ECC activates the complement systems, and activated complement proteins cause the production of several cytokines. In our study, neopterin levels in patients who underwent beating-heart method surgery were lower than those in the other groups, and these levels started to decrease at the 48th hour. These data suggest that the systemic inflammatory response was less activated in that patient group. The beating-heart method might be an important alternative in CABG surgery to minimize the complications and mortality related to surgery.

Gastrointestinal complications and cardiac surgery.

Gastrointestinal (GI) complications are an uncommon but potentially devastating complication of cardiac surgery. The reported incidence varies between .3% and 5.5% with an associated mortality of .3-87%. A wide range of GI complications are reported with bleeding, mesenteric ischemia, pancreatitis, cholecystitis, and ileus the most common. Ischemia is thought to be the main cause of GI complications with hypoperfusion during cardiac surgery as well as systemic inflammation, hypothermia, drug therapy, and mechanical factors contributing. Several nonischemic mechanisms may contribute to GI complications, including bacterial translocation, adverse drug reactions, and iatrogenic organ injury. Risk factors for GI complications are advanced age (>70 years), reoperation or emergency surgery, comorbidities (renal disease, respiratory disease, peripheral vascular disease, diabetes mellitus, cardiac failure), perioperative use of an intra-aortic balloon pump or inotrope therapy, prolonged surgery or cardiopulmonary bypass, and postoperative complications. Multiple strategies to reduce the incidence of GI complications exist, including risk stratification scores, targeted inotrope and fluid therapy, drug therapies, and modification of cardiopulmonary bypass. Currently, no single therapy has consistently proven efficacy in reducing GI complications. Timely diagnosis and treatment, while tailored to the specific complication and patient, is essential for optimal management and outcomes in this challenging patient population.

Prevention of lung injury in cardiac surgery: a review.

Inflammatory lung injury is an inevitable consequence of cardiac surgery with cardiopulmonary bypass. The lungs are particularly susceptible to the effects of the systemic inflammatory response to cardiopulmonary bypass. This insult is further exacerbated by a pulmonary ischemia-reperfusion injury after termination of bypass. Older patients and those with pre-existing lung disease will clearly be less tolerant of any lung injury and more likely to develop respiratory failure in the postoperative period. A requirement for prolonged ventilation has implications for morbidity, mortality, and cost of treatment. This review contains a summary of recent interventions and changes of practice that may reduce inflammatory lung injury after cardiac surgery. The review also focuses on a number of general aspects of perioperative management, which may exacerbate such injury, if performed poorly.

[Case of neuroleptic malignant syndrome following open heart surgery for thoracic aortic aneurysm with parkinson's disease].

An 80-year-old woman with Parkinson's disease was scheduled for open heart surgery to repair thoracic aortic aneurysm. Parkinson's symptoms were normally treated using oral levodopa (200 mg), selegiline-hydrochloride (5 mg), bromocriptine-mesilate (2 mg), and amantadine-hydrochloride (200 mg) daily. On the day before surgery, levodopa 50mg was infused intravenously. Another 25 mg of levodopa was infused immediately after surgery. Twenty hours later, the patient developed tremors, heyperventilation, but no obvious muscle rigidity. Two days after surgery, the patient exhibited high fever, hydropoiesis, elevated creatine kinase, and a rise in blood leukocytes. She was diagnosed with neuroleptic malignant syndrome. She was intubated, and received dantrolene sodium. Symptoms of neuroleptic malignant syndrome disappeared on the fourth postoperative day. The stress of open heart surgery, specifically extracorporeal circulation and concomitant dilution of levodopa, triggered neuroleptic malignant syndrome in this patient. Parkinson's patients require higher doses of levodopa prior to surgery to compensate and prevent neuroleptic malignant syndrome after surgery.

The inflammatory response to miniaturised extracorporeal circulation: a review of the literature.

Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar to sepsis. Aetiological factors include surgical trauma, reperfusion injury, and, most importantly, contact of the blood with the synthetic surfaces of the heart-lung machine. Recently, a new cardiopulmonary bypass system, mini-extracorporeal circulation (MECC), has been developed and has shown promising early results in terms of reducing this inflammatory response. It has no venous reservoir, a reduced priming volume, and less blood-synthetic interface. This review focuses on the inflammatory and clinical outcomes of using MECC and compares these to conventional cardio-pulmonary bypass (CCPB). MECC has been shown to reduce postoperative cytokines levels and other markers of inflammation. In addition, MECC reduces organ damage, postoperative complications and the need for blood transfusion. MECC is a safe and viable perfusion option and in certain circumstances it is superior to CCPB.

[The efficacy and safety of tranexamic acid and epsilon-aminocapronic acid in cardiac surgery under extracorporeal circulation].

Sixty patients who had undergone cardiosurgical operations under extracorporeal circulation (EC) were enrolled in the study. All the patients were divided into 2 groups: (1) 40 patients were injected tranexamic acid (TA) (its loading dose was 15 mg/kg; maintenance infusion 1 mg/kg/h throughout the operation; 500 mg in the primary packing volume for an EC apparatus (EA); (2) 20 patients received epsilon-aminocapronic acid (ACA) (its loading dose was 5 g; 5 g in the primary packing volume for an EA and 10 g for infusion after EC). The effects of TA and ACA on the fibrinolytic system were evaluated from the time of XIIa-kallikrein-dependent fibrinolysis (sec) and the concentration of D-dimer (mg/ml). The hemocoagulation system (activated partial thromboplastin time, thrombin clotting time, prothrombin time with the determination of the international normalized ratio, fibrinogen) was studied. The thromboelastogram (the time R, K, and alpha-angle, MA) was analyzed. The indices were determined at the beginning and end of, and 12 hours after surgery. The analysis of the clinical efficacy and safety of the agents was based on the following perioperative data: the incidence of adverse reactions and complications associated with the administration of the agents, the frequency and amount of transfused donor blood components, the volume of blood loss, and the rate of resternotomies. The laboratory and clinical findings lead to the conclusion that TA (Tranexam, OOO "MIR-PHARM") has a 4-fold antifibrinolytic activity as compared with epsilon-ACA. The more pronounced TA-induced suppression of fibrinolysis affects the clinical course of a perioperative period in this group, which manifests itself as a reduced blood loss volume during and after surgery and a lower frequency of use of donor blood elements. By taking into account these data, TA may be recommended as one of the blood-preserving technology components during cardiosurgical operations under EC.

Impact of intraoperative myocardial cellular damage on early hemodynamics after off-pump versus on-pump coronary artery bypass surgery.

BACKGROUND: Due to the surgical trauma a small amount of myocardial cellular damage is inherent during coronary artery bypass grafting (CABG). The purpose of the present study was to assess the degree of myocardial cellular damage after off-pump (OPCAB) and on-pump CABG (ONCAB) as measured by cardiac troponin I (cTnI), creatine kinase (CK), its MB isoenzyme (CK-MB) and myoglobin (Myo) and to examine its impact on early hemodynamics after surgery. METHODS: Ninety-nine consecutive OPCAB patients, operated between 01/1999 and 01/2004, were enrolled in the present study and compared to 99 ONCAB patients operated during the same period of time, who were matched for baseline data and mean number of grafts per patient. Early hemodynamics, cTnI, CK/CK-MB and Myo were measured preoperatively and at 1, 6, 12, 24 and 48 hours (h) postoperatively. Perioperative inotropic support, clinical data and potoperative outcome were recorded prospectively. RESULTS: The two groups were similar concerning preoperative characteristics. The mean number of distal grafts/patient was 2.1 +/- 1.0 in OPCAB and 2.1 +/- 0.8 in ONCAB patients (mean +/- SD). There was no significant difference among the groups regarding early hemodynamics in terms of cardiac index (CI), systemic vascular resistance index (SVRI), and left ventricular stroke work index (LVSWI), and inotropic support. However, cTnI, CK/CK-MB but not Myo levels were significantly lower in OPCAB compared to ONCAB patients at 1, 6, 12, 24, 36 and 48 h postoperatively (P<0.05). CONCLUSIONS: Off-pump surgery results in equal early hemodynamics despite a significantly lower release of cTnI and CK, suggesting a reduced myocardial cell damage as compared to ONCAB surgery.

Circulating leptin, zinc, and copper levels after extracorporeal circulation.

OBJECTIVE: The role of leptin in the acute stress response to extracorporeal circulation has been well documented, however, the relationship between leptin and zinc has not been investigated previously. We aimed to research the circulating leptin, zinc, and copper levels before, during, and after the extracorporeal circulation, and effect of preoperative zinc administration to these. METHODS: Twenty patients who were taken to elective coronary artery bypass grafting operations using extracorporeal circulation were taken to this research and divided into two equal groups (n1, n2). In both groups blood samples were taken just before the operation (T0), at the end of operation (T1), and at the first postoperative day (T2). In the second group (n2) oral zinc (50 mg, once a day) was administered to patients for 5 days, preoperatively. The serum leptin, zinc, and copper levels were studied. RESULTS: In group n1 circulating leptin levels were significantly increased at T2 when compared to T0 and T1 (p<0.05); zinc levels were decreased at T2 when compared to T0 and T1 (p<0.05); copper levels were decreased at T2 when compared to T0 (p<0.05), and decreased at T1 when compared to T0 (p<0.05). In group n2 circulating leptin levels were significantly increased at T2 when compared to T0 and T1 (p<0.05); zinc levels were decreased at T2 when compared to T0 and T1 (p<0.05); copper levels were increased at T2 when compared to T1 (p<0.05). CONCLUSIONS: These results indicate that circulating leptin levels increase after the extracorporeal circulation as an acute response, while zinc and copper levels decrease at the same period. Preoperative zinc administration does not prevent the leptin response after extracorporeal circulation.

Pulmonary complications of cardiopulmonary bypass.

Pulmonary complications after the use of extracorporeal circulation are common, and they range from transient hypoxemia with altered gas exchange to acute respiratory distress syndrome (ARDS), with variable severity. Similar to other end-organ dysfunction after cardiac surgery with extracorporeal circulation, pulmonary complications are attributed to the inflammatory response, ischemia-reperfusion injury, and reactive oxygen species liberated as a result of cardiopulmonary bypass. Several factors common in cardiac surgery with extracorporeal circulation may worsen the risk of pulmonary complications including atelectasis, transfusion requirement, older age, heart failure, emergency surgery, and prolonged duration of bypass. There is no magic bullet to prevent or treat pulmonary complications, but supportive care with protective ventilation is important. Targets for the prevention of pulmonary complications include mechanical, surgical, and anesthetic interventions that aim to reduce the contact activation, systemic inflammatory response, leukocyte sequestration, and hemodilution associated with extracorporeal circulation.

Inflammatory response and extracorporeal circulation.

Patients undergoing cardiac surgery with extracorporeal circulation (EC) frequently develop a systemic inflammatory response syndrome. Surgical trauma, ischaemia-reperfusion injury, endotoxaemia and blood contact to nonendothelial circuit compounds promote the activation of coagulation pathways, complement factors and a cellular immune response. This review discusses the multiple pathways leading to endothelial cell activation, neutrophil recruitment and production of reactive oxygen species and nitric oxide. All these factors may induce cellular damage and subsequent organ injury. Multiple organ dysfunction after cardiac surgery with EC is associated with an increased morbidity and mortality. In addition to the pathogenesis of organ dysfunction after EC, this review deals with different therapeutic interventions aiming to alleviate the inflammatory response and consequently multiple organ dysfunction after cardiac surgery.

Depressed postoperative cardiac performance. Prevention by adequate myocardial protection during cardiopulmonary bypass.

Depressed postoperative myocardial performance (low output syndrome) requiring inotropic drugs or balloon counterpulsation is due to subendocardial ischemic damage. Before July, 1972, we needed inotropic drugs in 30 to 52 per cent of 189 patients undergoing coronary revascularization or aortic or mitral valve replacement in whom we used ischemic arrest, profound topical hypothermia, and ventricular fibrillation. The mortality rate ranged from 10 to 17 per cent. Our experimental studies show that morbidity and death in such cases are caused by ischemic injury to the heart resulting from inadequate myocardial protection during bypass. Based on these experimental studies, we have, since July, 1972, employed the following principles clinically: (1) Maintain beating empty heart whenever possible; (2) maintain adequate coronary perfusion pressure (less than 80 mm. Hg); (3) avoid extreme hemodilution; (4) avoid ventricular fibrillation; (5) avoid prolonged hypothermic arrest, limiting ischemic periods to less than 15 minutes; (6) repay myocardial ischemic oxygen debt with total (vented) bypass; and (7) optimize DPTI/TTI (supply/demand ratio) pre- and postoperatively. These principles were followed in 189 consecutive operations, and postoperative inotropic drugs were needed in only 12. The principles were violated in 4 of the 12 patients (6 per cent), and 5 others had identifiable causes of myocardial depression; low output syndrome was unexplained in only 3 patients (1.7 per cent).

Resistance and tolerance of the myocardium to ischemia.

Since 1967, the authors have abandoned coronary perfusion in valve, particularly aortic, surgery. Some of the difficulties encountered during defibrillation at the period where coronary perfusion was always used have dramatically decreased. Extra-corporeal-circulation is now performed under moderate hypothermia--28 to 30 degrees C--which gives excellent myocardial protection for aortic cross clamping time of 30 to 60 minutes. In coronary artery surgery, the same technique is now used, after having wrongly believed previously that coronary perfusion was indicated. In conclusion, we feel that coronary perfusion is not indicated any more but in very exceptional cases.

[Prevention of gas microemboli during cardiac surgery. Numerical control of cardiac cavity purging by an ultrasonic detector]. / Prévention des micro-embolies gazeuses en chirurgie cardiaque. Contrôle numérique du débullage des cavités cardiaques par détecteur à ultra-sons.

Despite all precautions taken by cardiac surgeons to eliminate air remaining in the cardiac cavities and pulmonary veins at the end of cardiopulmonary bypass, many micro bubbles probably remain and pass into the systemic circulation with a risk of deteriorations of cerebral or myocardial function. Over the last four years we have used ultrasound to try to prevent the risk of preoperative gas microemboli: the machine is equipped with a detector (a quartz oscillator coupled to a piezoelectric transducer emitting a continuous beam of ultrasound at a frequency of 5 Mhz) which allows the following variables to be determined: the time interval from the onset of detection, the total quantity of bubbles (arbitrary units) in the examined regions, the quantity of bubbles detected over a given time interval which can be adjusted from 15 to 120 seconds. The passage of bubbles is also indicated by light and sound alarms. The smallest diameter of bubbles which can be detected is about 10 mu. There are periaortic probes adaptable to the calibre of the ascending aorta, transcutaneous probes for carotid artery detection and a left ventricular probe. In a preliminary series of 74 valve replacements in adults, this apparatus was used immediately after terminating cardiopulmonary bypass after we had thought that the cardiac cavities had been satisfactorily purged of air, and whilst active aspiration was continued in the ascending aorta distal to the periaortic probe: the total quantity of bubbles detected varied from less than 50 to more than 2000 AU, over a variable period of time which may exceed 20 min after termination of cardiopulmonary bypass. The total quantity of bubbles recorded after mitral valve (582 +/- 154 AU) or combined mitral and aortic valve replacement (685 +/- 167 AU) was generally greater than after isolated aortic valve replacement (335 +/- 126 AU). Therefore, after cardiopulmonary bypass, and despite all efforts at purging the air, we showed that numbers of microbubbles were ejected into the ascending aorta for a variable period of time: only some of them were eliminated by active aspiration through a trocar placed distal to the periaortic probe. The right coronary ostium was poorly protected against microbubbles because of its anatomical situation (6 cases in this series). We therefore established a protocol for the use of this apparatus to aid the purging of the cardiac cavities and pulmonary veins before stopping cardiopulmonary bypass: the manoeuvres, guided by the ultrasound probes, are performed before the left ventricle is allowed to eject blood into the ascending aorta.(ABSTRACT TRUNCATED AT 400 WORDS)

[Surgical replacement of the aortic arch]. / Remplacement chirurgical de la crosse aortique.

Deep hypothermia with circulatory arrest is the usual method of cerebral protection during replacement of the aortic arch. However, this technique only gives the surgeon a limited period of time to carry out aortic repair. It also requires that cardiopulmonary bypass be prolonged to rewarm the patient which may cause many complications. Selective carotid artery perfusion may also be used. When this perfusion is derived from the principal arterial line the aorta must be clamped to perform the repair. In addition, there is some uncertainly as to what constitutes adequate cerebral perfusion at normal temperature or during moderate hypothermia. In order to reconcile the advantages of both methods whilst avoiding the disadvantages, the authors described a new technique of cerebral protection in 1984. The principle was to selectively perfuse the carotid arteries with blood cooled to 6 to 12 degrees C via a separate heat exchanger while maintaining the central temperature in moderate hypothermia (25 to 28 degrees C rectal). In order to carry out an "open" distal anastomosis, the main cardiopulmonary bypass is stopped whilst carotid perfusion is maintained (350 to 500 ml/min). When the distal anastomosis has been completed, general cardiopulmonary bypass is restarted and the patient rewarmed. Using this technique. 158 patients aged 25 to 83 (average 55 years) were operated between January 1984 and July 1997. The operative indications were for different anatomic situations (114 patients had chronic lesions and had planned operation and 50 patients were operated as an emergency for acute dissection of the ascending aorta requiring replacement of the aortic arch). The average duration of cardiopulmonary bypass was 121 minutes and the duration of circulatory arrest was 31 minutes. The electroencephalogram recorded continuously during these operations showed return of cerebral activity after an average of 12 minutes and perfectly normal activity after an average of 66 minutes. The hospital mortality was 17% (27 deaths). Death was directly related to a neurological accident in 6 patients. All the others recovered within a normal period and were perfectly conscious at the 24th hour. Twenty non-lethal neurological complications were observed. The type of lesion, age and gender had non significant influence on the outcome of the patients: neither did the duration of circulatory arrest and of cerebral perfusion. No correlations could be established between the duration of cerebral perfusion and the frequency of neurological complications. In the authors' experience, the technique of selective anterograde perfusion of the brain with cooled blood during surgery of the aortic arch has shown its value. It does not require prolonged cardiopulmonary bypass and does not limit the time available to repair of the aorta. It should therefore be considered to be the method of choice for cerebral protection during this type of surgery.

[Acute renal failure after extracorporeal circulation with aortic counterpulsation in surgically treated patients]. / Insuffisance rénale aiguë après circulation extracorporelle chez des opérés avec contrepulsion aortique.

In a series of 604 adults operated on for cardiac surgery with cardiopulmonary bypass (CPB), 21 (3.5%) underwent circulatory assistance by intra-aortic balloon pump (IABP); in 5 of them (24%), acute renal failure (ARF) was observed. ARF occurred in only 26 (4.4%) of the other patients who did not require IABP. Evolution of ARF and its factors were therefore investigated in those patients having received IABP. ARF was defined as serum blood urea nitrogen (BUN) greater than or equal to 16 mmol X 1(-1), urinary urea/BUN less than 10, creatinine clearance less than 40 ml X min-1 X 1.73 m-2. Some perioperative features were compared between patients with postoperative ARF and those without ARF. ARF occurred in the 5 patients with IABP during, or immediately after, weaning from IABP. ARF was more frequent in patients operated on for mechanical complications of myocardial infarction with a significant more severe haemodynamic status. They had significantly longer CPB and aortic clamping times. The prognosis depended on the cardiac failure and not on the ARF. In patients with mechanical complications of infarction, early IABP seemed to be the predominant preventive measure. Other therapeutic implications are suggested, particularly the use of dopamine (1 to 3 micrograms X kg-1 X min-1) because of its renal vasodilating action which can contribute to the maintenance of urinary flow.

[Importance of carotid artery studies prior to coronary surgery]. / Carotis vizsgálat jelentösége coronaria mütétek kapcsán.

The incidence of cerebral complications following extracorporal cardiac operations is reported to be approximately 2%. One of the possible reasons behind these complications is the presence of significant carotid stenosis as coexistent disease to the cardiac illness requiring surgery. Because of the common etiology carotid stenosis coexists mainly with a coronary artery disease. The authors make known their own screening methods based on the correct exploration of medical history and on the proper physical examinations. Coexistent significant carotid stenosis was revealed in 3.6% of 1056 patients who underwent coronary surgery within the period of 41 months. In all of these cases prophylactic carotid endarterectomy was performed. In twenty cases within this group the carotid reconstructions were performed simultaneously with myocardium revascularization. Staged endprocedures were performed in the other 18 cases. There was no surgical mortality and only one patient suffered major stroke. The authors emphasize the importance of carotid screening among patients awaiting coronary surgery especially in patients who previously sustained cerebral ischemic attacks, the presence of carotid bruits or any other known localization of obliterate arterial disease and finally in all patients over 60 years of age.

[Endocarditis after extracorporeal circulation surgery].

Between January, 1976 and April 1988, 1279 patients underwent open-heart operation in Ren Ji Hospital. Thirty three patients were complicated by infective endocarditis postoperatively, an incidence of 2.58%. Medical treatment was carried out in 29 cases and thirteen were cured. In another three patients of valve prosthetic endocarditis, replacement of prosthetic valve was necessary for their cure. In our series, Gram negative bacilli had been proved by blood culture, autopsy and arterial thrombi in thirteen patients and candida in four, mixed infection in five and staphylococcus aureus in only one case. One should not rely on positive blood culture for the diagnosis. Echocardiographic studies are helpful to early diagnosis and proper treatment. The presence of vegetation or signs of prosthetic valve failure are strong indication for reoperation. In prevention, in addition to strict aseptic technic in the operating room, special emphasis should be focused on the preventive administration of sensitive antibiotics against hospital borne pathogens. All indwelling catheters in arteries and veins, tracheal tubes and urethral catheters should be removed after 72 hours. Efforts to prevent infection after reoperation are important measures for the prevention of infective endocarditis after open-heart operation.