SIR IR-Bolus administration of remifentanil may be associated with bradycardia, hypotension and chest wall rigidity. Remifentanil-induced bradycardia under 1 MAC sevoflurane anesthesia in children was attributed to a negative chronotropic effect (1); remifentanil may also decrease systemic vascular resistance (2). We would like to describe our experience regarding an inadvertent administration of high-dose remifentanil during remifentanilbased desflurane anesthesia in a child.A 6-year-old girl, 20 kg in weight with pelviureteric obstruction was scheduled for pyeloplasty. She had unilateral renal agenesis with the other kidney ectopic in the pelvic region with normal serum urea and creatinine levels. She had a history of hypertension (treated with nifedipine and enalapril), recurrent urinary tract infections and anemia (hemoglobin: 8.4 mgAEdl )1 ). Her heart rate (HR) was 105 bAEmin )1 and arterial blood pressure (BP) was 100/ 60 mmHg in the surgical ward.Anesthesia was induced with a remifentanil infusion (RI), propofol and atracurium; maintained with desflurane, RI and morphine. Surgery was performed via a lumbar incision. During surgery the patient was mildly hypertensive (up to 132/94 mmHg) and tachycardic (127-146 bAEmin )1 ) despite a total dose of 3 mg morphine, 20 mg atracurium, and 600 ml of isotonic solution administered. RI rate was gradually increased to 1.25 lgAEkg )1 AEmin )1 , while endtidal concentration of desflurane was held between 4% and 6%. Arterial blood sampling revealed; pH: 7.29, pCO 2 : 4.7 kPa (36 mmHg), pO 2 : 30 kPa (229 mmHg), HCO 3 : 17.5 mmolAEl )1 , lactate: 0.5 mmolAEl )1 , Cl: 113 mmolAEl )1 (normal range: 98-106), hemoglobin: 7.8 mgAEdl )1 .At the 85th minute of surgery while the BP was 122/ 72 mmHg and HR 133 bAEmin )1 the surgeon complained about inadequate muscle relaxation. A bolus of 500 lg remifentanil instead of atracurium was administered

Congenital subvalvular aortic stenosis may be associated with anomalies of the mitral valve. In this case, we present a patient with severe mitral valve regurgitation due to a perforation in the anterior mitral leaflet detected 4 months after an operation for relief of subaortic stenosis. A 10-year-old male patient who was operated for subvalvular aortic stenosis in another clinic was admitted to our hospital, and transthoracic echocardiography revealed severe mitral valve regurgitation due to a defect that was demonstrated at the anterior valve leaflet. The perforated area at the mitral valve zone A1 was repaired with a PTFE patch. The patient was successfully operated for the mitral valve perforation and the postoperative course was uneventful. In our case, the perforation in the anterior mitral leaflet implies a possible implementation of inappropriate surgical technique which necessitated a second surgical intervention after the initial operation.

Postmyocardial infarction ventricular septal defect (VSD) carries a high mortality and, even after successful surgery, residual defect is common. A 75-year-old woman was admitted with the diagnosis of hyperacute anterior myocardial infarction. Primary percutaneous intervention was performed by stenting of a totally obstructed segment in the proximal left anterior descending artery. The patient's condition deteriorated on the second postprocedural day with a 3/6 pansystolic murmur at the mesocardium. Echocardiography revealed an apical anteroseptal VSD and moderate pulmonary hypertension. She underwent surgical VSD closure with a Gore-Tex patch and coronary artery bypass grafting to the left anterior descending and circumflex arteries. The patient's condition continued to be unstable due to septicemia and hemodynamically significant residual VSD. After medical management of septicemia, the residual defect was successfully closed using a 10-mm Cardio-O-Fix septal occluder under fluoroscopic and transesophageal echocardiographic guidance. The clinical condition of the patient was then stabilized and there was no significant residual shunt on echocardiography on the third postprocedural day.

Aiming to increase mixing at the atrial level, atrial septal stenting was performed in two pediatric cases with cyanotic congenital cardiac diseases. The first case was a 3-month-old male infant with transposition of the great arteries. The second case was an 18-month-old male infant with increased central venous pressure due to postoperative right ventricular outflow tract obstruction. Premounted bare stents of 8 mm in diameter were used in both cases. The length of the stent was 20 mm in the first case and 30 mm in the latter. The procedure was accomplished without any complications. In the first case, oxygen saturation increased approximately 20-25% with no significant interatrial gradient. In the latter, central venous pressure decreased from 16 to 8 mmHg immediately after the procedure. The patient was weaned from the ventilator on the second day and discharged from intensive care unit on the fifth day. Follow-up echocardiograms of both patients showed patent stents with good position relative to the atrial septum. Stenting of the atrial septum seems to be a safe and effective method to create a reliable, nonrestrictive interatrial communication.

We report on a case involving a 10-month-old infant who received prolonged ECMO therapy following cardiac surgery for multiple ventricular septal defects (VSD). The patient was successfully weaned from 92 days of ECMO support without any long-term deficits.