The number of patients with adult congenital heart disease (ACHD) in Japan has dramatically increased. Anesthesiologists, therefore, are often tasked to provide anesthetic management for ACHD patients requiring cardiac surgery. Intraoperative transesophageal echocardiography (TEE) is a useful modality for evaluating surgical competence and cardiac function in this population during cardiac surgery. Yet devices or materials implanted in previous surgeries often impede the view of the heart intraoperatively.
TEE checkpoints for total cavo-pulmonary connection (TCPC) conversion include detection of stenotic lesions in the Fontan circuit and evaluation of both atrioventricular valve function and ventricular function. These points are same as those for TCPC in small children.
Right ventricular function can be a major concern for us in tailoring anesthetic management for patients with CHD. The challenge often goes beyond the complex shape of the right ventricle (RV). Huge dilation of the RV and/or the artificial materials implanted earlier make it difficult to visualize the RV itself and to evaluate the size and contractility of the RV. Several metrics such as the RV myocardial performance index and velocity of tricuspid annular systolic motion are available for this purpose. None of the methods, however, is sufficient in itself to reliably evaluate RV function for every case in this population. Oftentimes the direction of the ultrasound cannot be accurately aligned to the tissue movement or blood flow by the TEE approach. Intraoperative RV function should be evaluated comprehensively by a combination of methods suitable for the case at hand.
We would like to report our experience with a case of acute Type A aortic dissection where preoperative CT images led us to suspect pulmonary artery dissection. A patient was diagnosed with Stanford A acute aortic dissection based on a CT taken during an outpatient visit. The radiology department read these CT films and pointed out findings which could have been a dissection that extended from the main stem to the periphery of the pulmonary artery. On the CT, there was a delay in contrast enhancement of the pulmonary artery false lumen. Blood flow was maintained through the true lumen, and there were no apparent signs of a pulmonary infarction. In actuality, a transesophageal echocardiography and surgical findings revealed signs of a hematoma around the pulmonary artery, but there were no signs of a pulmonary artery dissection.
Pulmonary artery dissection is an extremely rare condition. In this case, the CT findings appeared to suggest this condition, but there was no actual dissection of the pulmonary artery. Hematomas forming around the pulmonary artery can produce CT images that appear very similar to pulmonary artery dissection, so a detailed investigation is essential in order to differentiate between these two conditions.
Posterior reversible encephalopathy syndrome (PRES) presents with symptoms such as headache, seizure, and visual disturbances. On computed tomography or magnetic resonance imaging, PRES is characterized and diagnosed by high intensity areas in the occipital and temporal lobes. This is the first report of an adult patient with PRES due to iatrogenic hypertension because of spinal cord protection. Though the hypertension-induced PRES is treated by lowering blood pressure, in this case, maintaining cerebrospinal perfusion pressure was necessary for spinal cord protection. Earlier diagnostic imaging is important to assess the neurological symptoms after thoracoabdominal aortic replacement.
A 98-year-old woman with dementia was admitted with a left femoral trochanteric fracture. Transthoracic echocardiography on admission revealed severe aortic stenosis (aortic valve mean pressure gradient of 55 mmHg, peak aortic jet velocity of 4.87 m/s) with normal ventricular systolic function. Internal fixation was planned 4 days after admission. Chest X-ray findings immediately before the operation indicated slightly worsened cardiomegaly with increased pulmonary vascular shadow. In the operating room, lumbar plexus block and sacral plexus block were performed under real-time ultrasound guidance with nerve stimulation, and a mixture of 7.5 ml ropivacaine 0.75% and 7.5 ml lidocaine 2% was injected for each block. The intraoperative course was uneventful, but chest X-ray on postoperative day 1 revealed severe pulmonary congestion and bilateral pulmonary effusion. There was also new T-wave inversion on the electrocardiogram and modest elevation of cardiac troponin I. Transthoracic echocardiography was immediately performed, revealing reduced left ventricular ejection fraction with akinesis of the mid to apical walls that extended beyond a single epicardial vascular distribution. Although coronary angiography was not performed, the findings strongly suggested Takotsubo cardiomyopathy (TCM), and conservative therapy was given. A few weeks later, the ventricular function returned to normal, and the diagnosis of TCM was confirmed. It is possible that not only the femoral fracture itself but also inadequate stress regression during surgery may have been triggers of TCM. It is not clear whether TCM occurred before, during or after surgery, but a thorough examination for potential preoperative heart failure was required.
In pheochromocytoma resection, circulatory management is difficult because of excess catecholamine secretion, which can cause rapid elevation of blood pressure, tachycardia, as well as pulmonary edema. Therefore, it is necessary to determine the water volume within the lung in addition to the circulating blood volume. In this study, we used a Volume View Catheter during pheochromocytoma resection and measured factors such as Extravascular Lung Water Index (ELWI) and Global End Diastolic Volume Index (GEDI). Here, we report successful stable anesthetic management under severely changing hemodynamic conditions, where based on the measurements, an appropriate infusion volume was maintained and cardiovascular agents were appropriately used.
We present a case report demonstrating the efficacy of carotid artery ultrasonography (CAU) and transesophageal echocardiography (TEE) to evaluate brain blood flow in a patient with acute aortic dissection that occurred during cardiopulmonary bypass (CPB).
A 75-year-old woman was scheduled for mitral valve plasty, tricuspid valve plasty, and maze operation for mitral valve regurgitation. We started CPB using an arterial cannula and aortic cross-clamp placed in the ascending aorta. We then performed the surgery and released the aortic cross-clamp.
Instantly, the left radial arterial pressure reduced and an aortic dissection began developing.
Despite rebuilding after CPB, blood flow in the bilateral common carotid arteries was observed only in the false lumen by CAU and TEE. Adding an arterial cannula to the right axillary artery, we induced adequate blood flow in the true lumen. We then performed an ascending aortic replacement. When we stopped the right axillary arterial inflow after finishing the replacement, we detected using CAU that the blood flow of the right common carotid artery was reduced. We added a bypass to the right subclavian artery from the replaced graft to get adequate blood flow.
There are several methods to evaluate brain blood flow, such as orbital ultrasound, CAU, near-infrared spectroscopy, blood pressure in superficial temporal artery, and TEE during surgery. It is important to understand the advantages and disadvantages of each method. It is also vital for anesthesiologists to confirm the monitoring systems for brain blood flow in surgery by using them properly and quickly, in the case of complications during CPB, such as aortic dissection, occur.
A patient with diabetes mellitus treated with neutral protamine hagedorn insulin was scheduled for open heart surgery. During the procedure, she experienced shock after the protamine infusion. Therefore, we attempted cardiopulmonary resuscitation and promptly resumed the cardiopulmonary bypass procedure, after which the patient recovered from her illness with no complications.
Patients receiving protamine infusions should be closely monitored, and resuscitation must be promptly attempted should they develop shock.
We report 3 cases of patients with bowel perforation that occurred prior to surgery for congenital heart disease in the neonatal period. Emergent laparotomy is indicated for bowel perforation. However, the patient outcomes and infection risk from heart surgeries succeeding ileostomy, colostomy, or other laparotomies are unclear. We determined the timing for ileostomy, colostomy, or other laparotomies and heart surgery in consideration of the cardiac conditions of the patients (necrotizing enterocolitis with patent ductus arteriosus in an extremely low-birth-weight infant, intussusception with hypoplastic left heart syndrome, and idiopathic colonic perforation with complete transposition of the great arteries [type I], respectively). In all the cases described herein, favorable outcomes were obtained with no complications during the perioperative period in the heart surgeries.
The patient was a female neonate aged 0 days, diagnosed with Ebstein's anomaly before birth. She was delivered by urgent cesarean section due to low amniotic fluid and fetal bradycardia. Since conservative treatment was not effective due to continued hypoxia and circulatory failure, an urgent Starnes operation was performed. After a cardiopulmonary bypass in the procedure, respiratory failure with clearly deteriorated airway compliance was observed, and extracorporeal membrane oxygenation was considered. However, high frequency oscillatory ventilation successfully improved the respiratory failure. High frequency oscillatory ventilation may be useful for treating respiratory failure during Starnes operations for neonates with Ebstein's anomaly.
We report the case of a patient with cardiac papillary fibroelastoma (CPF) of the aortic valve detected via transesophageal echocardiography (TEE) that was not identified preoperatively. A 71-year-old woman with triple vessel disease and old myocardial infarction was scheduled to undergo elective off-pump coronary artery bypass grafting (CABG). After the induction of anesthesia, TEE revealed mobile pedunculated masses at the aortic valve arising from the endocardium of the left and non-coronary cusps. Aortic valve regurgitation and valve stenosis were not observed, and similar mobile pedunculated masses were not identified in any other valves. However, since patients with such lesions are at risk for thromboembolic complications, stroke, myocardial ischemia, and acute aortic valve dysfunction, resection of the masses combined with CABG under cardiopulmonary bypass was scheduled. The surgery was performed without incident, and the patient had a successful recovery with no cardiac and neurological complications. Pathological examination revealed a diagnosis of CPF of the aortic valve.
Background: Jehovah's Witnesses are widely known for their prohibition on the acceptance of blood transfusion.. Especially, cardiovascular surgery in Jehovah's Witnesses poses unique challenges.
Case presentation: We report 46 Jehovah's Witnesses who underwent cardiovascular surgery under cardio-pulmonary bypass between 2001 and 2015. The operative procedures included 3 coronary bypass graft surgeries, 22 valve procedures, 19 aortic surgeries, and 2 ventricular septal perforation. Elective surgery was 31 cases and emergent surgery was 15 cases. Operative time was 307±115 minutes, anesthetic time was 379±117 minutes, cardiopulmonary bypass time was 148±77 minutes, and aortic cross clamp time was 88±37 minutes. Intraoperative hemoglobin (g/dL) nadir was 6.1±2.0, and postoperative hemoglobin nadir was 6.7±2.0. The fatal case within 24 hours after cardiovascular surgery was 2 patients.
Conclusions: We did not transfuse packed red blood cell, fresh frozen plasma and platelets. Bloodless cardiovascular surgery in Jehovah's Witness patients was performed in both elective and urgent situations.
This study aimed to investigate the incidence of venous thromboembolism (VTE) after total joint arthroplasty of the lower limbs. The utility of screening tests, the risk factors for VTE, and the correlation between the thrombosis-affected side and operated side were also assessed.
This retrospective study included 107 patients admitted to our hospital for total hip arthroplasty and total knee arthroplasty. We compared the intra- and postoperative factors of patients with and without VTE.
VTE was diagnosed in 15 of 107 patients. The postoperative D-dimer level was elevated in all cases independent of the occurrence of VTE, and its sensitivity and specificity for the diagnosis of VTE were low. On the other hand, venous ultrasonography of the lower limbs was useful for the early diagnosis of VTE resulted in no adverse events. No risk factors were identified and there was no correlation between the thrombosis-affected side and operated side.
Our results suggest that venous ultrasonography of the lower limbs be performed in all cases after total joint arthroplasty of the lower limbs. Use of D-dimer level alone to diagnose VTE could lead to misdiagnosis.
Background: Acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is a serious complication and associated with adverse outcomes. In recent study, postoperative AKI is detected in 3.4∼57% in patients undergoing TAVI. However, the diagnostic criteria varied, and many of them used only changes in serum creatinine. The Valve Academic Research Consortium (VARC)-2 criteria was updated and was based on both serum creatinine and urine output. We identify the incidence of AKI after TAVI using VARC-2 criteria.
Method and results: We included 66 patients received either transfemoral (TF, n=49) or transapical (TA, n=17) between February 2014 to September 2015. Overall incidence of AKI was 25.8% (17/66) using VARC-2 criteria. The incidence of AKI was more frequently in TA (64.7%) than TF (12.2%). Multivariate analysis showed a significant impact of TA on AKI (HR: 8.18, P=0.004).
Conclusion: According to the VARK-2 criteria, AKI was developed in 25.8% after TAVI. TA approach was strongly associated to AKI.