A 37-year-old male underwent elective thoracoabdominal aortic surgery for chronic aortic dissection. After aortic cross-clamping, there was an immediate decrease in amplitude of motor-evoked potential (MEP). Comprehensive management for increasing spinal cord blood flow resulted in prompt recovery of the MEPs within ten minutes. There was no postoperative neurological deficit. The multimodal treatment, including appropriate blood transfusion, adequate blood pressure control and selective intercostal artery reimplantation, was effective to recover the amplitude of MEPs and not to induce the neurological damage.
A 25-year-old woman with hypertrophic obstructive cardiomyopathy underwent elective cesarean section under epidural anesthesia. Two percent lidocaine was injected via 2 epidural catheters inserted at T12/L1 and L4/5. Surgery was commenced following the dermatomal level of analgesia reached T8. Intravenous oxytocin was administered immediately after delivery for uterine contraction. However, the patient subsequently developed dyspnea and hypotension. Transthoracic echocardiography revealed diffuse left ventricular hypokinesis and exacerbation of tricuspid regurgitation. Based on these findings, acute exacerbation of chronic heart failure due to volume overload secondary to rapid uterine contraction was suspected. Subsequently, the patient was placed in semi-Fowler's position and on assisted respiration using mask ventilation, which stabilized her hemodynamic status. This case demonstrates that adequate evaluation of hemodynamic status is important for anesthetic management of patients with cardiac disease.
In Heyde syndrome, acquired von Willebrand disease develops due to aortic stenosis, and coagulation disorder may be problematic in the perioperative period. We report a case in which Heyde syndrome was suspected based on repeated anemia and a history of fecal occult blood immediately before aortic valve replacement. Surgery was performed before obtaining von Willebrand factor (vWF)-related test results. Thus, a dried and concentrated human blood coagulation factor VIII/vWF complex preparation was administered with the aim of preventive supplementation during surgery. Heyde syndrome is not a rare disease and should be suspected in a patient with aortic stenosis with a history of gastrointestinal hemorrhage. In such cases, tests should be performed as early as possible and supplementation of vWF should be considered as needed.
We report a case in which transcatheter closure of an atrial septal defect with an Amplatzer septal occluder device (ASO) and transapical transcatheter aortic valve implantation (TAVI) were performed sequentially under the same anesthesia. A patient was diagnosed with severe aortic valve stenosis and severely depressed left ventricular function. The patient had undergone balloon aortic valvuloplasty in the past, and a left to right shunt remained.
We inserted an outflow and an inflow catheter into the right axillary artery and the right femoral vein, respectively. ASO was performed without percutaneous cardiopulmonary support (PCPS), which was on standby. TAVI was performed with low flow PCPS.
We used a pulmonary artery catheter and transesophageal echocardiography for monitoring and to avoid circulatory collapse.
We provided anesthesia for Kawasaki disease-associated coronary artery aneurysmorrhaphy that required emergency coronary artery bypass grafting (CABG) for postoperative myocardial ischemia. The patient was a 43-year-old woman who was diagnosed with Kawasaki disease at the age of 12 years. She had developed chest pain and underwent CABG and right coronary artery aneurysmorrhaphy for complete occlusion of the left anterior descending coronary artery and a right coronary artery aneurysm. Severe bradycardia and hypotension occurred 7 hours postoperatively and she was diagnosed with myocardial ischemia in the perfusion area of the right coronary artery, for which extremely urgent CABG was successfully performed. Surgery and anesthesia for Kawasaki disease-associated coronary artery disease requires careful management with consideration of the effects of the vascular pathology characteristics of Kawasaki disease.
Recently, transcatheter balloon aortic valvuloplasty (BVP) was performed in pediatric patients with congenital aortic stenosis (AS). We reported on cases in which neonates and infants were under general anesthesia. We will discuss three cases; Case 1: One-month-old baby; echocardiography demonstrated a transvalvular pressure gradient (PG) of 63 mmHg and left ventricular (LV) hypertrophy. Case 2: Four-dayold baby; PG of 90 mmHg with LV endocardial fibroelastosis. Case 3: Two-day-old baby; PG of 100 mmHg and a diagnosis of critical AS. BVP was performed in each of these cases. Choosing drugs with few hemodynamic effects and careful fluid management, including blood transfusions in some cases, is important. Furthermore, appropriate inotropic agents were administered for the case with severely damaged LV function. Hemodynamic changes, particularly coronary flow, LV function, and aortic insufficiency (regurgitation), during and after the procedure must be understood to minimize afterload and tachycardia.
We report the case of a 84-year-old female who developed cardiac arrest due to major bleeding during mediastinal irrigation for poststernotomy mediastinitis after cardiac valve surgery. The treatment of poststernotomy mediastinitis requires antibiotic therapy, reoperation, debridement, and mediastinal irrigation, followed by vacumm-assisted closure. Mediastinal irrigation often has a short operation time, and hence, a central venous catheter and transesophageal echocardiography are not routinely employed during this procedure. However, incidence of major bleeding as a complication of poststernotomy mediastinitis has been reported to be 5.3%, and mortality varies from 33% to 53%; therefore it is necessary to prepare for management of major bleeding during mediastinal irrigation. In this case, placement of a large-bore intravenous line prior to beginning irrigation would have been appropriate approach. Safe and effective anesthetic protocol for patients with poststernotomy mediastinitis after cardiac surgery should involve measures such as placement of an intravenous line to manage major bleeding and to prepare for cardiac surgery.
Postoperative elevation of blood lactate levels are associated with increased morbidity and length of stay following a cardiopulmonary bypass (CPB). The causes of hyperlactatemia are various and the reasons not fully understood. In this case of long term hemodialysis, the cause of hyperlactatemia after CPB was unknown during the patient underwent mitral valve replacement. Continuous hemodiafiltration and percutaneous cardiopulmonary support could not save the patient. The major cause of hyperlactatemia was considered to be multiple organ failure due to peripheral circulatory failure or sepsis. Future investigations were needed to establish the data for adequate pressure and flow during CPB in patients of long term hemodialysis.
Extraskeletal Ewing's sarcoma rarely invades the cardio-vascular system. This report concerns a pediatric patient who underwent open-heart surgery for the resection of Ewing's sarcoma.
An 8 year-old boy presented an Ewing's tumor in the posterior mediastinum, which had invaded the azygous vein, superior vena cava, and right atrium. After emergency spinal decompression, resection of the cardiac tumor was scheduled. Our anesthesia plans aimed to prevent tumor incarceration and embolisms. The possibility of right heart failure and conduction disturbance due to tumor invasion were also considered. After the patient was carefully transferred to the operating table, anesthesia was induced with intravenously. A percutaneous cardiopulmonary support device and an external pacemaker were prepared in case of an emergency. The tumor was observed closely by trans-esophageal echocardiography (TEE) and successfully removed while the patient was under cardiopulmonary bypass.
This case demonstrated that successful resection of cardiac Ewing's tumor required gentle postural change, sufficient preparation of medical staff, sufficient blood for transfusion, a percutaneous cardiopulmonary support device and external pacemaker, close observation of the tumor by TEE, and the selection of an anesthesia method capable of maintaining stable cardiovascular dynamics.
A 42-year-old woman with severe mitral regurgitation (MR) was scheduled for robotic mitral valve plasty. She developed right ventricular failure after surgery due to air embolism in the right coronary artery. Maximal values of CKMB at this time were 130 U/l, and right ventricular wall motion on transthoracic echocardiography (TTE) had fully recovered with no local asynergy about 10 days after surgery. Finally, electrocardiography showed poor progression of the R wave in leads II, III, and AVF, but with no abnormal Q wave or negative T wave.
We speculate that our patient's clinical features were secondary to the air embolism causing a small subendocardial infarction with myocardial stunning. De-airing following robot-assisted surgery is difficult since the patient's position cannot be changed due to the robotic arm being inserted into the patient's thoracic cavity.
A 71-year-old man was admitted upon with acute abdominal pain with impending shock status. Computed tomography (CT) revealed a large (80 mm) abdominal aortic aneurysm ruptured to the retroperitoneal space. Also, the iliac vein was stained by contrast-medium. Aortic occlusion balloon catheter was inserted via the right femoral artery stabilizing the hemodynamics and the patient was transferred to an operating room. After the anesthetic induction, a skin incision was started followed by tracheal intubation. The landmark technique catheterization of the right internal jugular vein was performed. Central venous blood showed partial pressure of oxygen (PvO2) as 400 mmHg and oxygen saturation (SvO2) as 98 %, very close to those from an radial artery (PaO2 472 mmHg, Hb 3 g/dL, pH 7.02, BE −25). Transcutaneous ultrasonic examination confirmed the central venous catheter in place not into carotid artery. After graft replacement of AAA, PvO2 and SvO2 values returned to the normal range. In case of ruptured AAA, abnormally high value of Pvo2 and Svo2 can occur by the perforation of AAA into the large vein system. In such a case and also in a routine procedure, the use of ultrasound guidance is strongly recommended to avoid the inadvertent insertion of the central venous catheter into the artery system.
In this case, hemodynamic collapse occurred due to the systolic anterior motion (SAM) of the mitral valve after a mitral valvuloplasty (MVP). Intravenous administration of cibenzoline, a sodium (Na+)-channel blocker, reduced left ventricular outflow tract (LVOT) obstruction and the mitral regurgitation (MR) resulting from the SAM, and the hemodynamic condition was improved.
SAM is a well-known complication after MVP. The Venturi effect created by increasing the blood flow velocity at the narrowed LVOT causes the anterior leaflet of the mitral valve to be drawn into the LVOT. Effective perioperative management suppresses the left ventricular contraction, and increases the pre-load and after-load. This requires discontinuation of inotropic drugs, administration of vasoconstrictors, and expansion of intravascular volume. Considering the pathogenesis of SAM, therapies for hypertrophic obstructive cardiomyopathy, such as a beta (β)-blocker, a calcium antagonist, or a Na+-channel blocker, can be effective for treatment of SAM after MVP. A short-acting β-blocker is convenient, and commonly used for the perioperative management of SAM. The essential cause of SAM after MVP is myocardial hypercontraction rather than tachycardia. A Na+-channel blocker is effective for attenuation of the left ventricular pressure gradient (LVPG) because it has more of a negative inotropic effect than a negative chronotropic effect. Therefore, we suggest that if a β-blocker is unavailable, or is insufficient for decreasing the LVPG, cibenzoline is effective for SAM after MVP.
Fast-track extubation has been widely used in pediatric cardiac surgical patients. On-table extubation is, however, not well established in such patients, particularly in neonates due to the inherent risk of opioid-induced apnea. In addition, reports on thoracic epidural anesthesia in neonates are scarce. Here, we demonstrate the successful on-table-extubation in a low-birth-weight neonate who underwent ligation of a patent ductus arteriosus under combined general and thoracic epidural anesthesia since the latter offered an excellent analgesia without involving opioids at all.
Here, we report the impact of activities of daily living (ADL) and presence or absence of subjective symptoms on outcome in 14 patients with acute lower extremity arterial occlusive disease undergoing vascular surgery. Mean patient age was 81±9 years, the percentage of patients with American Society of Anesthesiologists physical status class 3 was 64%, and the rate of cerebro- and cardiovascular complications was 93%. Eight patients (57%) had low ADL, four of whom underwent diseased limb amputation. Four patients (29%) did not have subjective symptoms, two of whom underwent diseased limb amputation. One patient with low ADL died from multiple organ failure in hospital after vascular surgery. Anesthesiologists involved in the perioperative management of such surgeries should recognize that low ADL and absence of subjective symptoms influence the outcome of vascular surgery in patients with arterial occlusive disease.
We reported a case involving a male who showed difficult anticoagulant management with unexpected heparin resistance during the third great vessel replacement operation. He had showed a normal anticoagulant response after the heparin injection in previous operations. The antithrombin activity did not show anything unusual so the cause was not cleared.
We used argatroban as a substitute anticoagulant. After that, he showed the appropriate anticoagulant response and the activated clotting time (ACT) was prolonged, so we could induce the extra corporeal circulation (ECC). After a short period, we stopped the argatroban injection in anticipation of the protracted anticoagulant effect. However, he suffered from a difficult hemostasis that lasted for long time after the ECC.
A 26 year-old-woman at 29 weeks gestation was referred to our hospital urgently for the management of pregnancy complicated by acute decompensated heart failure and ventricular tachycardia. Dilated cardiomyopathy was suspected by her medical history and echocardiographic findings. After consulting with obstetrician, cardiologist and anesthesiologist, we prioritized treatment of heart failure. Five hours after the treatment, sustained ventricular tachycardia occurred, although heart failure was improved. Because fetal bradycardia was also recognized, we underwent emergency caesarean section under general anesthesia. We carried out the delivery of the fetus, while performing electrical defibrillation. Our perioperative management was successful without any complication in the mother or the child. After that, we performed myocardial biopsy and confirmed the diagnosis of dilated cardiomyopathy.
Paraplegia is a major potential complication of thoracic endovascular aortic repair (TEVAR). We investigated the postoperative courses of 7 patients with paraplegia that developed after TEVAR performed at our hospital. Among 54 patients who underwent TEVAR in the period from October 2014 to February 2016, 7 developed paraplegia, of whom 5 and 2 had a stent graft indwelling in the descending aorta and Zone 2, respectively. For treating paraplegia, cerebrospinal fluid drainage (CSFD) was performed in 5 patients. As for the postoperative course, paraplegia persisted in patients who did not receive CSFD, while those treated with CSFD in an early stage tended to demonstrate a higher level of paraplegia improvement.
A 60-year-old woman diagnosed with thoracoabdominal aortic aneurysm underwent reconstruction of all visceral arteries and of the right internal iliac artery under cardiopulmonary bypass and Y-shaped graft replacement. The intraoperative course was uneventful. Upon admission to the intensive care unit immediately after surgery, the patient had a pulseless electrical activity due to a drastic decrease in blood pressure. Her blood pressure was restored after the initiation of chest compression and with adrenaline intravenous infusion. Accumulation of pericardial effusion and dissection from the ascending to the descending aorta was found on transesophageal echocardiography. After retrograde dissection was discovered, the patient was immediately taken back to the operating room, where aortic arch replacement was performed. Transesophageal echocardiography was an effective diagnostic tool for postoperative hemodynamic instability.
A 78-year-old man with effort angina pectoris was scheduled for elective off-pump coronary artery bypass surgery. After starting anastomosis of the saphenous vein graft to the posterior descending artery, the patient's hemodynamics suddenly collapsed and he developed cardiac arrest. Cardiac pacing was immediately started, but it was ineffective. Neither direct heart massage nor several injections of vasopressors had an immediate effect. Simultaneous transesophageal echocardiography examination revealed massive gas bubbles in the ascending aorta, and these gas bubbles were suspected to be the cause of the cardiac compromise. After removal of the gas bubbles, spontaneous circulation was recovered. The origin of the gas bubbles was considered to be the air from the air blower that was used to maintain optimal visualization of the operative field. The speculated mechanism for this phenomenon is as follows: The air from the suture site migrated into the collateral artery, which was connected to the septal perforator and the subsequent left anterior descending artery; the air proceeded through the left anterior descending artery in both an antegrade and retrograde fashion; and the left coronary arteries were filled with massive air, which caused the cardiac arrest.
The present study was designed to investigate the changes in ocular blood flow measured by laser speckle flowgraphy (LSFG) and regional cerebral tissue oxygen saturation (rSO2) during aortic arch surgery with cardiopulmonary bypass (CPB) using antegrade selective cerebral perfusion (ASCP).
Twenty-one patients undergoing aortic arch surgery with CPB using ASCP were enrolled in this study. Ocular blood flow using LSFG and rSO2 were measured at the following four points: (1) after the administration of anesthesia; (2) 30 minutes after the beginning of CPB; (3) 30 minutes after the beginning of ASCP; and (4) 60 minutes after cessation of CPB. Percentage change in ocular blood flow and rSO2 at measurement points (2), (3), and (4) was calculated when the values of ocular blood flow and rSO2 at measurement point (1) ware defined as the reference flow. Percentage change of ocular blood flow in the measurement points (2) and (3) was significantly reduced compared with the baseline value of the measurement point (1). On the other hand, percentage change of rSO2 at measurement point (2) was significantly increased compared with the baseline value of the measurement point (1). Measurement of ocular blood flow by LSFG with combination of rSO2 monitor might be feasible for optimal cerebral monitor during aortic arch surgery with SCP.
【Purpose】 We aimed to identify the incidence and risk factors of postoperative atelectasis in pediatric cardiac surgery with cardiopulmonary bypass (CPB).
【Method】 Patients who underwent elective cardiac surgeries with CPB with age ranging from 1 month to less than 13 years in Osaka Medical Center and Research Institute for Maternal and Child Health between January and December 2013 were enrolled. The incidence and risk factors of intraoperative atelectasis were evaluated.
【Result】 In total, 226 patients were enrolled in this study. Because of lack of catheter examination data of 48 patients, the data of only 178 patients were analyzed. Postoperative atelectasis was found in 58 patients (32.6%). Multivariate analysis revealed that age (OR, 0.96; 95% CI, 0.94~0.99; p=0.039) and CPB time (OR, 1.01; 95% CI, 1.00~1.01; p=0.0002) were significant risk factors of postoperative atelectasis.
【Conclusion】 Postoperative atelectasis occurred in 32.6% of patients, and young age and longer CPB time were significant risk factors.
Purpose We examined the association between chronic kidney disease (CKD) and postoperative cognitive dysfunction (POCD) in patients undergoing coronary artery bypass grafting.
Methods Data were collected on 315 patients. They were divided into three groups according to the severity of CKD, as determined from glomerular filtration rate (eGFR): >60 (n=137), 30~60 (n=145), <30 ml/min/1.73 m2 (n=33). Four cognitive tests were performed preoperatively and 1 week after surgery. POCD was defined as a decrease of at least 20% from baseline in performance on more than one test.
Results Risk factors and the degree of craniocervical and aortic atherosclerosis were similar for the three groups. Except the percentage of patients with severe white matter lesions (WML) increased with lower eGFR (respectively 28%, 34%, 45%) and the incidences of POCD were 40%, 50%, 64%, respectively (P<0.05). Multivariate analysis revealed that 7 factors were correlated with POCD: male, age, cervical atherosclerosis, lower educational level, preoperative cognitive decline, WML and CKD.
Conclusion Patients with CKD are at higher risk for POCD due to their high prevalence of WML.
Aim of the Study: To investigate the association between intraoperative cerebral oxygen saturation (rSO2) decline and length of postoperative intensive care unit (ICU) stay following cardiovascular surgery.
Method: Patients were separated into long group (L group; ICU stay >14 days) and short group (S group; ICU stay ≤14 days). The intensity of rSO2 decline was calculated from rSO2 values for each minute and then combined. We measured both absolute values and relative values from baseline.
Result: Of 259 cases (S group: 233, L group: 26), the intensity of rSO2 decline was lower in the S group when absolute value measurements were examined; However, there was no difference in decline intensity using relative values.
Conclusion: The lengths of postoperative ICU stay were moderately associated with intraoperative rSO2 reduction.
In cardiovascular surgery cases using cardiopulmonary bypass (CPB), severe inflammation is generated as an effect of the disease itself, as well as a reaction to the presence of a foreign-body during CPB, which creates tissue damage that may also lead to multiple-organ failure. To counter this, we implemented and examined the effects of continuous hemodiafiltration (HDF) during surgery with the aim of inhibiting inflammation.
We retrospectively compared a concurrent HDF group to a non-HDF group.
In the concurrent HDF group, cardiac, pulmonary, and renal functions were all well-maintained. Electrolyte management during CBP was also simple.
These results suggest that concurrent HDF mitigates the effect of the underlying disease, as well as the reaction to a biologically invasive surgical procedure and CPB. It may also lead to a good postoperative course.
Background: The optimal transfusion strategy in the perioperative management for cardiac surgery has not been established yet. We investigated whether HES 130/0.4 can be safely used as an alternative to 5% albumin.
Methods and results: Among non-dialysis patients scheduled to undergo cardiac surgery who were admitted to the intensive care unit (ICU) between April 1, 2014, and March 31, 2015, 88 who required non-infusion load, HES 130/0.4, and 5% albumin were included in this retrospective study. In terms of water balance on the day of surgery, the presence of acute kidney injury, lengths of ICU and hospital stay, no significant differences were found among the three groups.
Conclusion: In the perioperative management of cardiac surgery, HES 130/0.4 can be used as an alternative to 5% albumin.