A number of anesthetics, including volatile halogenated and intravenous alkylphenol anesthetics, can affect the heart rate in the clinical setting, but their mechanisms of action have yet to be fully elucidated. The heart rate is determined by the intrinsic electrical activity of the primary cardiac pacemaker sinoatrial (SA) node in the right atrium and modulated by the sympathetic and parasympathetic branches of the autonomic nervous system. Anesthetics can affect the heart rate by modifying not only the function of the autonomic nervous system, but also the spontaneous electrical activity of SA node in the heart. Some general anesthetics directly suppress SA node automaticity by inhibiting the ionic current involved in the SA node cells independently of the autonomic nervous system. Under the pathological conditions of SA node dysfunction, such as sick sinus syndrome, in the clinical setting, the inhibitory action of anesthetics on the SA node function can thus become exaggerated and thereby induce bradycardia. Understanding the molecular, electrophysiological and neuronal mechanisms underlying the regulation of the heart rate by anesthetics is therefore essential to properly control the heart rate during the perioperative period.

　Objective: We examined early postoperative cognitive dysfunction (POCD) in abdominal aortic aneurysm (AAA) surgery.

　Methods: Data were collected on 96 AAA patients. POCD was compared between endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR). 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: The incidence of POCD was 9% in the EVAR group and 37% in the OAR group. Level of education, risk factors of arteriosclerosis and history of cerebrovascular disease were similar for both groups. The EVAR group was older than the OAR group (81±6 vs. 73±7 years) and had lower preoperative cognitive scores. On the other hand, the OAR group had longer procedures, higher rates of blood transfusion and needed more opioids and sevoflurane. Multivariate analysis revealed that the 5 factors most correlated with POCD were OAR, low preoperative cognitive score, age, amount of opioids and sevoflurane, and peripheral vascular disease.

　Conclusions: EVAR reduced POCD, especially in elderly patients with mild cognitive impairment.

　Objective: There is no protocol to decide an adequate perfusion pressure during cardiopulmonary bypass (CPB). The aim of this study was to investigate the relationships between hypertension observed just before anesthesia, CPB-related factors and postoperative lactate levels to determine the benefit of adjusting the perfusion pressure depending on pre-operative hypertension.

　Methods: We have reviewed patients who underwent cardiac surgery under CPB and divided them into hypertension (HTN) and non-hypertension (No HTN) groups, depending on the blood pressure just before anesthesia. We have analyzed the relationship between the maximum lactate levels within 10 hours following the operation and pre-operative and intra-operative factors, including CPB-related factors in both groups, using univariate and multivariate analysis.

　Results: Ninety-one patients (HTN group; n=45, Non HTN group; n=46) were involved in this study and there was no significant difference in post-operative maximum lactate levels between the two groups. We found a significant association between the duration of CPB and postoperative lactate levels in both groups, and a significant association between the ratio of mean arterial blood pressure before anesthesia and mean perfusion pressure during CPB with postoperative lactate levels in HTN group.

　Conclusion: It was suggested that not only short duration of CPB but also an adjustment of perfusion pressure during CPB, depending on the hypertensive state before anesthesia, was important to reduce postoperative lactate levels.

　Objectives: Over-insertion of the pulmonary artery catheter can cause serious complications. This study investigated the difference in estimated recommended-site insertion length of the pulmonary artery catheter in the immediately postoperative period versus the insertion length on postoperative day 1.

　Methods: After approval by the Ethics Committee of Osaka Medical College, we performed a retrospective observational study in 46 patients who had undergone on-pump coronary artery bypass grafting. The recommended-site insertion length of the pulmonary artery catheter was defined as the length from the sixth thoracic vertebra to the right hilum, as measured on thoracic radiographs. The insertion length of the pulmonary artery catheter on a thoracic radiograph taken immediately postoperatively was compared with the insertion length on a thoracic radiograph taken in the intensive care unit on postoperative day 1. The correlation between the change in the insertion length and the change in the cardiothoracic ratio was calculated.

　Results: The insertion length of the pulmonary artery catheter on postoperative day 1 was significantly greater than that in the immediately postoperative period. There was no correlation between the change in the insertion length and the change in the cardiothoracic ratio.

　Conclusion: The recommended-site insertion length of the pulmonary catheter was greater on postoperative day 1 than on the day of surgery. This change was not caused by the increased cardiothoracic ratio.

　Introduction : A decrease in oxygen content and/or low blood flow during cardiopulmonary bypass (CPB) can lead to inadequate oxygen delivery (DO₂) and subsequently cause anaerobic metabolism in cells. This deficiency is considered a main cause of hyperlactemia, referred to as type A hyperlactemia. Yet, some reports have indicated that if DO₂ does not decrease below a threshold termed the “critical level”, oxygen consumption (VO₂) remains unchanged. Given that the critical level is well defined and that hyperlactemia during CPB results from DO₂ under this threshold, oxygen supply above the critical DO₂ level can be the target value for CPB management. We conducted a prospective observational study to determine whether the critical DO₂ level correlated with hypoxic blood lactate increase. Method : We studied 52 consecutive patients who underwent cardiac surgery with CPB. Indexed DO₂ (DO₂I), indexed VO₂ (VO₂I), and lactate were measured every 30 min during CPB. To evaluate any correlations between the parameters, univariate and regression analyses were applied. Results: There was a weak correlation between DO₂I and VO₂I, and the critical level of DO₂ was 303 ml/min/m². Blood lactate levels increased with CPB time, but did not correlate with DO₂I.

　Conclusion : We identified a critical level of DO₂ during CPB. However, there was no significant correlation between DO₂I and blood lactate levels.

　We experienced a case of neonatal total anomalous pulmonary venous return and severe pulmonary venous obstruction identified by fetal echocardiography that was treated by pulmonary vein repair surgery immediately after delivery by elective caesarean section. Because the safety time margin after delivery was difficult to predict, we had created a protocol at a preoperative multidisciplinary conference, assuming the worst case-scenario. Anesthesiologists were in charge of the anesthetic management and overall supervision of the medical team. The parents were able to meet the neonate after delivery, as planned, after which the patient was swiftly moved to another operating room and intubated at 9 minutes of gestation. Due to the smooth cooperation within the team based on the pre-planning, the operation was successful and the patient was transported to the intensive care unit without any accidents throughout the anesthesia and surgical procedure. Similar urgent cases are expected to increase in the future due to the improved accuracy of fetal echocardiographic diagnosis. Regular multidisciplinary simulation trainings for neonatal urgent surgery seem to be useful based on this experience.

　A 1-month-old hypoplastic left heart syndrome (HLHS) baby who had successfully undergone Norwood surgery with RV-PA conduit at 1 month after birth developed oxygen desaturation at three weeks after Norwood surgery and was diagnosed with left pulmonary artery (PA) stenosis. PA plasty was performed, but it was difficult to wean him from cardiopulmonary bypass because of severe desaturation. Evaluation of pulmonary venous (PV) flow by intraoperative transesophageal echocardiography (TEE) helped us to identify the cause of the desaturation as right PA stenosis and to decide the operative procedure. Evaluation of PV flow by TEE is relatively easy and useful in rapidly estimating pulmonary circulation during surgery for congenital heart disease, in which the balance of pulmonary and systemic circulation is important.

　A 71-year-old man was scheduled for lumbar spine surgery. Preoperative transthoracic echocardiography showed a calcified aortic valve with a valve area of 0.96 cm², and a mean pressure gradient of 27 mmHg. He diagnosed with asymptomatic, moderate aortic stenosis. The intraoperative course was uneventful, but the postoperative course was complicated by intractable heart failure. Aortic valve replacement was performed. Although he had ischemic heart disease, his intractable heart failure seemed to have been caused mainly by myocardial ischemia due to low-flow low-gradient severe aortic stenosis. The operative findings of severely calcified aortic leaflets were compatible with severe aortic stenosis. He had hemodialysis-dependent end-stage renal disease, chronic atrial fibrillation, and mitral regurgitation, and these comorbidities appeared to be associated with the underestimation of the severity of aortic stenosis on echocardiographic assessment. In addition, his cardiac symptoms could have been underestimated because of his limited activity, attributed to the pain from spinal stenosis.

　Anesthesiologists frequently observe gastric contents on transesophageal echocardiography (TEE) after fasting. We report on a case of aspiration pneumonia after TEE in a patient with dysfunction of the esophagogastric junction (EGJ). Anesthesiologists need to pay attention to aspiration during TEE, because TEE may impair the function of EGJ.

　We encountered an 11-year-old male patient who presented with rhabdomyolysis after intracardiac repair for a ventricular septal defect.

　We considered the administration of propofol in the intraoperative period as the cause of rhabdomyolysis because a correlation was noted between creatine kinase and acylcarnitine, indicating a disturbance in fatty acid oxidation in the postoperative period. The mechanism responsible for rhabdomyolysis may be an energy supply imbalance caused by the combination of a disturbance in fatty acid oxidation and increased demand for fatty acid oxidation with cardiopulmonary bypass.

　We used propofol only in the intraoperative period, and the patient was discharged without organ failure.

　A patient transported to our center due to ruptured abdominal aortic aneurysm (rAAA) went into shock immediately after endovascular aortic repair (EVAR). Enhanced computed tomography revealed type-2 endoleak (T2EL) that improved after transcatheter arterial embolization. The retroperitoneal hematoma was removed because of significant abdominal swelling. The reduction of pressure caused a T2EL and re-rupture of the aneurysm.These issues made hemostasis difficult. Artificial blood vessel replacement surgery was performed. EVAR for rAAA can cause T2EL just after surgery, leading to re-rupture of the aneurysm. This can make it very difficult to control the patient's condition.

　One of the possible reasons for postoperative biological valve replacement is suture loop jamming. Suture loop jamming is caused by jamming of the strings around the stent of the bioprosthesis, which results in severe regurgitation through the valve, and requiring another immediate valve replacement. We herein report a case of a patient with a history of mitral valve replacement and coronary artery bypass grafting. During weaning from cardiopulmonary bypass after the second mitral valve replacement with a bioprosthesis, transesophageal echocardiography revealed transvalvular and paravalvular leaks, and rigidity in the tip of the cusps. Suture loop jamming was suspected, and another mitral valve replacement was immediately performed.

　Corrected transposition of the great arteries (cTGA) is a very rare congenital heart defect that accounts for <1% of all congenital heart disorders; only a few case reports describe general anesthesia in patients with this condition. We report a case of general anesthesia in an adult patient with cTGA who underwent successful tricuspid valve replacement due to severe tricuspid regurgitation. Since the right ventricle supports systemic circulation in cTGA, such patients have a low tolerance for increasing preload and afterload. In the anesthetic care of these patients, personalized hemodynamic management is required, which is based on comprehensive evaluation of the right ventricle with transesophageal echocardiography, pulmonary artery catheterization, and intraoperative findings.

　Transesophageal echocardiography (TEE) may be used during cardiovascular surgery to provide direct visualization of cardiac structures. It is considered both a diagnostic and monitoring tool to improve surgical safety and clinical outcomes. While complications, such as gastric injury, after manipulating the TEE probe are rare, such complications can be severe and fatal. In this case series, three cases of gastric injury after TEE utilization for cardiac surgeries are reported. Case 1 was a patient with bleeding from a gastric ulcer and represented days after postoperative anticoagulant therapy, which was complicated with undiagnosed gastric antral vascular ectasia (GAVE). Case 2 was a patient with esophageal injury which was detected when the mouth filled with blood immediately after insertion of the TEE probe. Case 3 was a patient with a gastric laceration following TEE without symptoms which progressed to severe gastric damage because of anaphylactic shock at postoperative day 12. Even if successful TEE manipulation was performed during operation, every clinician must consider that undiagnosed gastric injury may exist in all cases and be prepared to respond appropriately to mitigate risk.

　Reexpansion pulmonary edema is rare in patients undergoing open heart surgery other than minimally invasive cardiac surgery. We herein report our experience with a case of unilateral pulmonary edema after reinflation of a collapsed lung that had been compressed by surgical bleeding in a patient undergoing valve replacement. This case illustrates that preoperative chronic pulmonary hypertension can lead to postoperative reexpansion pulmonary edema. Thus, surgeons, perfusionists, and anesthesiologists should focus on preoperative pulmonary hypertension and collaborate with one another to prevent the development of reexpansion pulmonary edema.

　Thoracoabdominal aortic surgery for an aneurysm was performed on a woman aged 60 years. On the first postoperative day, obstructive shock due to cardiac tamponade was diagnosed by bedside ultrasonography immediately after extubation of a tracheal tube and removal of a pulmonary artery catheter (PAC). The hemodynamics recovered immediately after pericardial drainage. Intraoperative transesophageal echocardiography revealed no pericardial effusion. The postoperative hemodynamics being so stable, cardiac tamponade was unexpected. Complications arising on removal of a PAC are rare. This report, however, shows the importance of being aware of the possibility of such life-threatening events occurring and indicate that removal of a PAC should be performed under careful observation.

　Aortic valve replacement (AVR) after coronary artery bypass surgery (CABG) has a high mortality rate and high degree of difficulty. Especially When living graft is present, there is a particularly increased risk of injury, providing sufficient myocardial protection is challenging, and operation and anesthesia management are often hard to manage. We experienced two cases of anesthesia for the patients who had undergone Minimally Invasive Cardiac Surgery (MICS) for aortic valve stenosis after CABG without blocking living graft. Re-thoracotomy and AVR after CABG are high risk, but application of MICS anesthesia made it possible to perform the operation safely.

　Interventricular septal hematoma (IVSH) is a very rare complication of congenital heart surgery. We report a case of IVSH after a patch closure of a ventricular septal defect (VSD) in a 1-year-old patient with tetralogy of Fallot. After weaning the patient off of cardiopulmonary bypass, an intra-operative transesophageal echocardiography (TEE) showed severe hypo-echogenic thickening of the interventricular septum beneath the VSD, with ventricular dysfunction that was diagnosed as IVSH. However, the hematoma did not obstruct the right or left ventricular outflow tracts based on visualization during the TEE, and the patient was hemodynamically stable. Therefore, we chose conservative therapy and did not proceed with surgical revision. The patient recovered well without any complications.

　Intra-operative TEE monitoring allowed for the immediate detection of IVSH and contributed to the selection of conservative therapy. We conclude that intra-operative TEE plays an important role in congenital heart surgery.

　We herein present a 56-year-old male who developed malignant hyperthermia during on-pump beating-heart coronary artery bypass surgery under general anesthesia with sevoflurane against ischemic cardiomyopathy. The patient developed tachycardia, hypotension, and increase in end- tidal carbon dioxide concentration immediately after withdrawal of the cardiopulmonary bypass. A sudden increase in body temperature with a maximum central blood temperature of 39.6℃ was observed. Dantrolene (40 mg) was administered in the operating room in consideration of possible malignant hyperthermia, which achieved resolution of the symptoms. A similar episode occurred after the patient was admitted to the intensive care unit, which was successfully resolved with dantrolene (60 mg). The patient was discharged on postoperative day 16 without no sequelae. Evaluation of skeletal biopsy conducted at a later date revealed that the patient was predisposed for malignant hyperthermia.

　A 76-year-old woman with an ovarian tumor underwent elective laparoscopic salpingo-oophorectomy under general anesthesia. Although she showed an elevated level of N-terminal pro-brain natriuretic peptide and left ventricular diastolic dysfunction, she had no apparent symptoms of heart failure in the preoperative period. Immediately after surgery, rapid-onset pulmonary edema developed. Administration of a diuretic resolved the pulmonary edema, and she had an uneventful course without any other complications. This case was considered to be preclinical heart failure with a preserved ejection fraction. Because there were no apparent symptoms of heart failure in the preoperative period, we underestimated the risk of perioperative pulmonary edema and failed to prevent it. In patients who have heart failure with a preserved ejection fraction, increases in load can lead to rapid-onset pulmonary edema even without symptoms of heart failure. This case indicates that detailed preoperative evaluation, treatment of volume overload in advance, and perioperative management under the condition of appropriate monitoring may be important for the prevention of perioperative pulmonary edema in patients who have suspected heart failure with a preserved ejection fraction.

　Endovascular aortic repair (EVAR) is a less invasive technique than open surgical repair. However, late open conversion (LOC), occurring at least 30 days after initial EVAR, can result in high mortality rates. In particular, LOC-related perioperative mortality is high in patients with secondary aortoenteric fistula following EVAR. In this study, we report the anaesthetic management of two cases of LOC because of secondary aortoenteric fistula after EVAR. Case 1 was that of a 60-year-old man, and case 2 was that of a 75-year-old man; both men were diagnosed with secondary aortoenteric fistula with melaena before operation. They underwent operation in the emergent setting and elective setting, respectively. Both patients were discharged without neurological sequelae despite intraoperative massive haemorrhage.

　We report successful transcatheter aortic valve replacement (TAVR) that saved the life of a patient with severe aortic stenosis after resuscitation for cardiac arrest. Percutaneous cardiopulmonary support was used during resuscitation and it was also used during TAVR, enabling maintenance of stable circulation. For patients with a high risk of sudden changes, preoperative examinations and TAVR should be performed as early as possible.

　We report a case of a patient with successful resuscitation following ascending aortic rupture and subsequent cardiac arrest during thoracic endovascular aortic repair (TEVAR). An 86-year-old male with thoracic aortic aneurysm developed sudden cardiac arrest following a series of stent graft balloon expansion during TEVAR. Resuscitative transesophageal echocardiogram revealed a large circumferential pericardial effusion with findings consistent with cardiac tamponade. Ruptured ascending aorta was soon identified after emergent median sternotomy and pericardiotomy. Active bleeding from the lesser curvature of the ascending aorta was eventually controlled by manual application of pressure, and it took longer than 25 minutes until spontaneous circulation returned. Ascending aorta replacement was performed under cardiopulmonary bypass with hypothermia and the patient was transferred to an intensive care unit for 48 hours of therapeutic hypothermia. Contrary to our dismal expectation on poor neurological outcome due to prolonged cardiac arrest, the patient regained fully conscious and discharged without any noticeable neurological deficit. We speculate that an induction of hypothermia under cardiopulmonary bypass immediately following ischemic insult could effectively alleviate ischemic brain damages.