Minimal right vertical infra-axillary thoracotomy can be performed with favorable cosmetic and clinical results for atrial septal defects closure. Infra-axillary thoracotomy provides a good alternative to standard median sternotomy for patients with atrial septal defects.

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O chronosis is a rare metabolic disorder associated with a homogentisate 1,2-dioxygenase deficiency.1 The transmission is autosomal recessive, and homogentisic acid (HGA) is the end product of the tyrosine and phenylalanine metabolism. Accumulated HGA is observed in connective tissue and in eliminated urine.1 The usual clinical signs include arthropathy; manifestations affecting the ears, eyes, and skin; and genitourinary and cardiovascular complications. The accumulation of HGA can involve cardiac structures, especially the aorta, coronary vessels, and heart valves. In the elderly, the pericardium can be involved.2 Pathologic examinations of the aortic valve and ascending aorta have revealed intracellular and extracellular deposits of ochronotic pigments. The extracellular deposits are, in part, degenerated cells that resemble valvular calculus.3 Few reports have described ochronotic patients with severe cardiac involvement. We present the case of a man in whom ochronosis of the aortic and mitral valves was diagnosed intraoperatively. Case ReportIn May 2013, a 72-year-old man who had severe aortic stenosis and mitral insufficiency presented at our clinic with dyspnea. He had no history of endocarditis or rheumatic fever. His medical history included progressive degenerative arthritis affecting his knees and spine, confirmed by means of musculoskeletal examination. Results of routine laboratory tests were normal. Echocardiograms revealed severely calcified aortic valve leaflets and a mean aortic valve gradient of 55 mmHg. The calculated aortic valve area was 0.5 cm 2 . Mitral valve leaflet malcoaptation and grade 4/4 mitral insufficiency were detected. The patient's left ventricular function was normal. Cardiac catheterization yielded normal coronary arteries.The patient underwent surgery to replace his aortic and mitral valves. A dark-green sternum was initially noted. The aortic and mitral valve leaflets, intima of the ascending aorta, and left ventricular outflow tract all contained black pigment (Fig. 1). Alkaptonuria was suspected. We replaced the native valves with a 25-mm mechanical aortic prosthesis and a 29-mm mechanical mitral prosthesis (Medtronic, Inc.; Minneapolis, Minn). The patient recovered uneventfully and was discharged from the hospital on postoperative day 10.After surgery, the patient revealed that he had noticed dark discoloration of his urine since early childhood. Results of a general examination included black pigmentation of the sclera of both eyes and the cartilage of the outer ears (Fig. 2). Radiographs of the knees and spine showed calcification and severe degeneration of the vertebral discs.Pathologic examination of the explanted native aortic and mitral leaflets revealed ochronosis (Fig. 3), and high HGA levels in the patient's urine confirmed the diagno-

IntroductionMyocardial protection is important in preventing the damaging effects of a cardiopulmonary bypass (CPB) on the myocardium, including ischemic and reperfusion injury (1). Eliminating or reducing myocardial injury can improve the clinical prognosis of patients undergoing cardiac surgery. Cardiac biomarkers are associated with the degree of cardiac injury and cardiac troponin I (cTnI), lactate, and creatine phosphokinase-MB (CKMB) are especially sensitive biomarkers for evaluating cardiac cell damage (2-4). Pyruvate, lactate, glucose, and insulin are respiratory substrates indicating heart perfusion. The level of pyruvate in the blood increases in the anaerobic state and pyruvate is converted to lactate under these conditions (3-5).Sevoflurane, a potent inhalation agent, decreases the inflammatory response and improves myocardial function after CPB (6). Dexmedetomidine, a selective and specific α-2 adrenoceptor agonist, has been frequently used as a sedative or adjuvant anesthetic drug in cardiac surgery. Dexmedetomidine has also been known to have some neuroprotective effects; however, data are insufficient for its cardioprotective effects in human studies. Remifentanil, a fast-acting opioid, has been generally used in cardiac surgery for cardiac protection before sternotomy (7).This study compared the cardiac effects of sevoflurane plus dexmedetomidine with those of sevoflurane plus remifentanil during adult cardiac surgery with CPB by examining levels of lactate, pyruvate, CKMB, and cTnI in patient blood samples. The hypothesis is that a difference Background/aim: Myocardial protection is an important factor of open heart surgery and biological biomarkers (lactate, CKMB, cardiac troponin I, and pyruvate) are used to assess myocardial damage. This study compares the effects of dexmedetomidine and remifentanil on myocardial protection during coronary artery bypass grafting (CABG) surgery. Materials and methods:Patients scheduled for elective CABG surgery (n = 60) were included in this study. Anesthesia induction was introduced with propofol, fentanyl, and vecuronium bromide. Anesthesia was maintained with remifentanil infusion and sevoflurane in the remifentanil group (Group R) and with dexmedetomidine infusion and sevoflurane in the dexmedetomidine group (Group D). Blood samples for biochemical markers were taken from the coronary sinus catheter before cardiopulmonary bypass (T1), 20 min after aortic cross-clamping (T2), 20 min after removal of the aortic cross-clamping (T3), and 10 min after separation from cardiopulmonary bypass (T4).Results: Demographic data were similar between the groups. Lactate level at the T2 period and CKMB levels during the study period were lower in Group D than in Group R. In both groups, all values except pyruvate significantly increased over time. Conclusion:The dexmedetomidine-sevoflurane combination may improve the cardioprotective effect in comparison with remifentanilsevoflurane in CABG surgery.

These results that have been obtained from a group of large number of patients imply that the glutaraldehyde-preserved bovine pericardium patches may be preferable in the closure of cardiac defects because of their low complication rates and ease of use.