Vojislava Neskovic

Postendarterectomy common carotid artery pseudoaneurysm.

Pseudoaneurysm (PSA) formation is an uncommon complication in carotid surgery. PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, embolization from the thrombotic material within the PSA, hemorrhage after rupture, or compression on the adjacent structures. We present a case of a symptomatic common carotid PSA that occurred 14 months after routinely performed eversion carotid endarterectomy.

Off-pump myocardial revascularization using the Octopus tissue stabilizer system.

Off-pump coronary artery bypass surgery (OPCAB) has changed the approach to contemporary coronary surgery. Development of new surgical devices and techniques has reduced morbidity and mortality during off-pump surgery. From March 2000-April 2002, a total of 136 patients underwent open heart surgery using off-pump technique and fast-track anesthesia at Dedinje Cardiovascular Institute. Octopus Medtronic coronary stabilizer was used for stabilization of targeted vessel. Arterial grafts were used 169 times and saphenous vein 69 times. Average number of anastomoses was 1,830,73 per patient. One patient (0.74%) died. Three patients (2.21%) underwent surgery revision due to postoperative bleeding and one (0.74%) because of graft dysfunction. Perioperative myocardial infarction was registered 2 times (1.47%), pneumothorax 3 times (2.21%), postoperative arrhythmias 11 times (8.09%), transitory ischemic attack once (0.74%) and deep wound infection once (0.74%). Twelve patients (8.82%) required prolonged inotropic support. Angiographies early revealed patent grafts in 8 patients (5.88%). OPCAB is a safe and effective alternative approach to coronary artery revascularization. Use of coronary stabilizer has improved the safety and quality of OPCAB surgery.

High thoracic epidural anesthesia for coronary artery bypass graft surgery

Introduction High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympathetic blockade. Effects of high thoracic epidural anesthesia Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity. Results of clinical studies Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress. High thoracic epidural anesthesia technique The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended. Conclusion There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.

[Myocardial dysfunction in septic shock--a case report].

INTRODUCTION Sepsis is characterized by generalized inflammatory response induced by infection. The incidence of myocardial dysfunction in sepsis is unknown as well as its impact on survival, independently other organ system dysfunction. CASE REPORT A female patient, age 36, with clinical signs of septic shock was admitted to the Intensive Care Unit. After initial therapy of septic shock, patient was still haemodynamically unstable. Transthoracic echocardiography showed left ventricular dysfunction (EF = 20%), with mitral regurgitation 2-3+, tricuspid regurgitation 3+, and estimated systolic right ventricular pressure of 53 mm Hg. Inotropic drug, dobutamine, was initiated, which led to significant improvement of hemodynamic parameters. Eight days after the initiation of therapy the clinical improvement was observed and the control transthoracic echocardiography was performed. It showed the improvement in left ventricular size and function, with EF of 57%, and reduced mitral regurgitation to 2+, and tricuspid regurgitation to 1+. DISCUSSION A hyperdynamic state is typically present in sepsis. Myocardial dysfunction in sepsis is characterized by decreased ejection fraction, ventricular dilatation and impaired contractile response to volume loading. Cardiac output can be measured using pulmonary artery catheter, transthoracic and transoesophageal echocardiography, or by pulse contour analysis. In this patient, myocardial dysfunction was detected by echocardiography, which helped in clinical decision making to administer inotropic agent. The recovery of myocardial function was also confirmed by echocardiography. CONCLUSION Echocardiography can be used in septic patient for diagnosis of myocardial dysfunction, decision making, follow-up of the response to inotropic therapy, and detection of the complete recovery of cardiac function.