Left atrial myxoma is the most common variant of cardiac tumour, rarely presenting with systemic embolization involving 3 limbs and intra cranial bleed simultaneously. Our case aims to discuss appropriate management strategy in such cases. This case presents a 34 year old lady with acute limb ischemia both lower limb and right upper limb with intracranial bleed with no signs of congestive heart failure diagnosed with LA Myxoma on preoperative routine 2d ECHO cardiography. She underwent embolectomy of right brachial artery and bilateral femoral artery, common iliac artery and abdominal aorta with excision of LA Myxoma planned for 4 weeks later. In patients presenting with acute limb ischemia and intracranial bleed, the definitive surgery of LA myxoma excision should be postponed for 4 weeks to prevent risk of systemic heparinisation causing worsening of neurological functions while acute limb ischemia should be addressed immediately.

DISCUSSION – Left brachiocephalic vein is 6 cm long; it begins behind the sternal end of the clavicle, anterior to the cervical pleura by union of the left internal jugular vein and the left subclavian vein. It descends obliquely to the right, behind the upper half of the manubrium sterni, up to the sternal end of the first right costal cartilage, uniting here with right brachiocephalic vein to form SVC. The aortic arch is inferior to this vein. The left retro-aortic bracheocephalic vein is rare entity which was first described by Kerschner.[(1)](#ref-0001) Incidence of left retro-aortic bracheocephalic vein is noted between 0.2 to 1%.[(2)](#ref-0002) Aorto-pulmonary window is a rare cardiac condition, first described by Eliotson in 1830[(3)](#ref-0003) with an incidence of 0.2% - 0.3% of all congenital cardiac lesions.[(4,5)](#ref-0004) Three standard approaches for surgical closure of aorto-pulmonary window have been described in literature include: trans-aortic approach, trans-window approach, trans-pulmonary approach. Trans-window approach is also known as sandwich repair of aorto-pulmonary window.[(6)](#ref-0006) The left retro-aortic brachiocephalic vein with tetralogy of fallot and coarctation of aorta are noted. The left retro-aortic brachiocephalic vein with aorto-pulmonary window is very rare case and has not been reported previously. In our case the patient was admitted for AP window closure after complete pre-operative evaluation. Cardiac computed tomography reported 2.2cm aorto-pulmonary window with the left retro-aortic brachiocephalic vein. After obtaining parental consent for surgery, median sternotomy was performed. Thymus was excised and pericardium was opened longitudinally. By careful dissection, the left brachiocephalic vein was identified behind the distal ascending aorta adjacent to the AP window. Aorta was dissected off the brachiocephalic vein meticulously. Due to left retro-aortic brachiocephalic vein, aortic cannulation had to be done more caudally to avoid obstruction of vein. Aorta was cannulated and clamped without injury to the brachiocephalic vein. Attention was paid to avoid injury of the brachiocephalic vein during encircling the SVC for snaring. Aorto-pulmonary window was closed with PTFE patch through trans-window approach under mild hypothermia.[(6)](#ref-0006) Clinical implication of retro-aortic brachiocephalic vein is very important. More caudal cannulation of SVC is required in left brachiocephalic vein; but in AP window setting, this is more difficult as work space for closure of the defect is also required. Injury may occur to the vein during clamping of aorta. Left retro-aortic brachiocephalic vein may cause technical difficulty during central venous line placement through left arm approach. CONCLUSION- Being the rarest combination of left retro-aortic brachiocephalic vein and aorto-pulmonary window, certain things have to be taken care of like clamping of aorta, SVC cannulation, central vein catheter insertion, snaring of SVC. Pre-operative CT scan is also important to avoid intra-operative surprises.

Aortopulmonary Window is a rare congenital heart defect comprising 0.1-0.2% of the total spectrum. Spontaneous closure of this defect is unknown and survival into childhood and adult life is rarely seen. Severe pulmonary artery hypertension develops and causes dilatation of the pulmonary artery. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension.

Iatrogenic aortocoronary dissection is a rare but potentially fatal complication of coronary catheterizations. Although the incidence is comparatively low, dissection often leads to procedure failure with increased risk of myocardial infarction and death. Iatrogenic aortocoronary dissection is principally caused by disruption of intima at the ostia of the right or left coronary artery during interventional procedures and appears as luminal filling defects, the persistence of contrast or intimal tear outside the coronary lumen. Dissection could propagate in the anterograde direction causing subtotal or total occlusion of the coronary lumen or extend in the retrograde direction into the sinus of Valsalva, ascending aorta, aortic arch or descending aorta resulting in hemodynamic instability. We present a case of Right Coronary Artery dissection leading to Type-A aortic dissection suffered during diagnostic coronary catheterization. This required emergency supracoronary replacement of the ascending aorta with an aortic interposition tube graft and venous grafts to coronary arteries

Mediastinitis is a serious complication after cardiac surgery. While bacteria are the more common pathogens, fungal infections are rare. Post-operative Aspergillus mediastinitis is considered to be a catastrophic infection, affecting patients with specific predisposing factors undergoing cardiothoracic surgery. The patient outcome after aspergillus mediastinitis is extremely poor despite antifungal therapy and surgery. The diagnosis is usually delayed and relies on direct visualization and culture. Clinical features of post-operative Aspergillus mediastinitis could be minimal, underlining the necessity for a low index of suspicion in cases of culture-negative mediastinitis. Antifungal therapy including amphotericin B or voriconazole along with surgical debridement forms the mainstay of treatment.