Temucin Noyan Ogus

Rhabdomyolysis Following Accidental Intra-arterial Injection of Local Anesthetic

Drug-induced myopathy, also named Nicolau syndrome, is a well-known phenomenon following intramuscular injection of certain agents, most commonly reported with penicillin or diclofenac. The mechanism responsible for the pathology is proposed to be incidental administration of the drug into the small arterioles. In this report, we present a Nicolau syndrome-like case that developed following accidental injection of a local anesthetic agent into the femoral artery during coronary angiography.

Aorta non-clamp technique in case of sclerotic ascending aorta during coronary artery bypass grafting

We read with great interest the manuscript by Antunes MJ in which the author presented an open-anastomosis technique for proximal vein-graft anastomoses in case of sclerotic ascending aorta [1]. We present our comments on the paper from a few technical aspects. A similar technique has already been published by our group in 2006 [2]. We routinely prefer fibrillation without intermittent cross-clamping in the presence of calcification at the ascending aorta. Cardiopulmonary bypass is instituted by cannulation of right atrium and aortic arch, axillary artery, femoral artery or disease-free segment of ascending aorta depending on the extent of the atherosclerotic aortic disease [2]. We always institute a vent to prevent myocardial distension and permit unloading. A left ventricular vent through the right superior pulmonary vein, a pulmonary arterial vent or, sometimes, both may be inserted. A pulmonary arterial vent is safer and does not require special care of the perfusionist against air embolism when compared with a left ventricular vent [3]. We start with the distal anastomoses to the easily accessible coronary arteries as the cooling is started. At 29—30 8C, the heart usually fibrillates spontaneously; however, the patient is cooled down to 28 8C. The mean arterial pressure is kept 65 mm Hg until all the distal anastomoses are completed [2,3]. Additionally, following each distal anastomosis, heart is defibrillated, by which, we believe the conduction tissue replenishes the energy stores. Moreover, this measure is helpful to prevent bundle or branch blocks whichmay occur in the postoperative period [3]. Necessarily, consecutive anastomoses are performed with consequent fibrillation and defibrillation periods [2,3]. Before anastomosing the internal thoracic artery to the left anterior descending artery, we perform the proximal anastomoses. Proximal anastomoses are performed to the clean segments of the ascending aorta [1—3] if available on low flow with mean arterial pressure of 20—25 mm Hg, otherwise to the innominate or the internal thoracic artery [2,3]. We place ice bags around the head of the patient and the table is tilted to place the patient in the Trendelenburg position during low flow. Each proximal anastomosis lasts 3 min and, between each proximal anastomosis, flow is increased to normal. The bypass of the internal thoracic artery to left anterior descending artery is fashioned during re-warming to attenuate the hypothermic period. At the end of the bypass procedure, the heart is defibrillated if necessary [2,3]. Single or multiple clamping of the aorta during conventional cross-clamp cardioplegia and intermittent cross-clamp fibrillation techniques carries high risk of embolisation of the atheromatous material in the presence of a calcified ascending aorta [1—3]. The aorta non-clamp technique is a safer alternative in this particular group of patients. It may be performed on a fibrillating or decompressed beating heart [1]. However, we believe the institution of a vent is important for better myocardial protection.

Coronary Bypass Surgery in a 105-Year-Old Patient with Cardiopulmonary Bypass

Coronary artery bypass grafting is one of the routine daily surgical procedures in the current era. Parallel to the increasing life expectancy, cardiac surgery is commonly performed in octogenarians. However, literature consists of only seldom reports of coronary artery bypass grafting in patients above 90 years of age. In this report, we present our management strategy in a 105-year-old patient who underwent coronary artery bypass grafting at our institution.

Pressure-Regulated Tepid Blood Reperfusion in Patients Undergoing Emergency Coronary Revascularization after Myocardial Infarction

We read with great interest the manuscript entitled ‘‘Timing of Revascularization after Acute Myocardial Infarction’’ by Abd-Alaal and colleagues in which they compared the results of myocardial revascularization after acute myocardial infarction (AMI) in patients who underwent coronary artery bypass grafting (CABG) at 3 different times: group 1 in the 1 24 h, group 2 between 24–72 h, and group 3 after 14 days. They concluded that myocardial revascularization performed within 24 h after ischemia is associated with significantly higher risks of mortality and morbidity than procedures performed beyond 72 h.

Fibrillation without cross-clamping in the pesence of sclerotic ascending aorta.

Coronary artery bypass grafting is one of the most commonly performed cardiovascular surgery daily practice procedures. Among the patients, only about 10–20% requires additional special care and alternative protective measures; otherwise, surgery is routinely performed on-pump, off-pump, intermittant cross-clamp fibrillation . . . etc. There is not a widely accepted concensus about the best technique for the high risk patients and the real difference between myocardial protection techniques would come true when tested among high risk patients.

Familial Atrial Septal Defect with Atrioventricular Conduction Abnormalities

The occurrence of several cases of atrial septal defect in the same family is rare. A family in which the father and his two daughters presented with atrial septal defect associated with atrioventricular conduction abnormalities is described.