Purpose: We report the effect of preoperative balloon aortic valvuloplasty (BAV) in patients with severe aortic valve stenosis (AS) undergoing non-cardiac surgery.
Method: We retrospectively examined the use of preoperative BAV in 27 patients with severe AS undergoing non-cardiac surgery.
Result: Preoperative BAV significantly increased the aortic valve area, and decreased the maximum blood flow velocity and the mean aortic valve pressure gradient. The average period to surgery was 22 days.
Intraoperatively, we monitored only the invasive arterial pressure in all patients. A vasopressor or inotropic agent was administered in 26 of those. All patients survived 30 days after surgery.
Conclusion: Preoperative BAV relieved the severity of AS and may have contributed to good surgical outcome under careful perioperative management.
Objective: This study aimed to evaluate associated factors with postoperative infectious disease in patients undergoing elective open heart surgery, in particular focusing on nutritional conditions and tissue perfusion.
Method: Individuals who were scheduled to undergo open heart surgery in a tertiary-care hospital in Japan between April 2014 and December 2016 were eligible for enrolment in the study. Postoperative infectious disease included catheter infection, wound infection, and pneumonia. A controlling nutritional (CONUT) status score was used as an index of nutritional status, and a difference in CO2 partial pressure of arteriovenous blood (CO2 difference) was used as a tissue perfusion index.
Multiple logistic regression analysis was conducted to determine independent factors associated with postoperative infectious disease.
Results: Ninety-two patients of 157 patients were malnourished and mean CO2 difference was 3.9 mmHg. Twenty-one patients had postoperative infectious disease. Body mass index, duration of surgery, postoperative lactate level, diabetes, glomerular filtration amount, and duration of postoperative artificial respiration were associated with postoperative infectious disease.
Conclusion: Preoperative nutritional status and tissue perfusion index were not significant factors of infectious disease after open heart surgery.
Introduction: Transcatheter aortic valve replacement (TAVR) has become a common treatment for severe aortic stenosis (AS) in patients with prohibitive surgical risks. We aimed to examine the risk factors of postoperative nausea and vomiting (PONV) in patients who underwent TAVR, although the relationship between PONV and TAVR has not been established yet.
Methods: Patients who underwent the transfemoral approach of TAVR between January 2016 and March 2018 were eligible for the present study. A multivariable logistic regression analysis was conducted to determine the association between PONV within 24 hours after the procedure and potential confounders. For all the analyses, a p value of <0.05 was considered statistically significant.
Results: In this study, 110 patients were enrolled, of whom 24 (21%) experienced PONV. The multivariable regression analysis revealed that the significant risk factor of PONV was infusion volume (adjusted odds ratio, 1.08; 95% confidence interval, 1.02-1.14; p<0.01). The other variables were not associated with PONV.
Conclusion: This study suggests that high infusion volume is significantly associated with the development of PONV within 24 hours after TAVR.
Herein, we report a case of an emergency inguinal hernia repair prior to a scheduled transcatheter aortic valve implantation (TAVI) for severe aortic valve stenosis (AS). An 83-year-old woman who developed heart failure secondary to severe AS was scheduled to undergo TAVI. However, before the scheduled TAVI procedure, she developed an acute incarcerated inguinal hernia and required emergency surgery. Anesthesia was induced with extreme caution to avoid systemic hypotension. We controlled her circulation because of the severe AS by maintaining the systemic vascular tone and avoiding tachycardia. She underwent a standard open mesh repair for the inguinal hernia. She recovered well, albeit slowly.
Twenty days after the hernia repair, she underwent TAVI for severe AS without aspiration, circulatory failure, or any other complications.
We treated two patients in whom transesophageal echocardiography was helpful for diagnosis of stenosis of the left coronary artery opening after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). Although their treatment is different, the measurement of coronary artery end-diastolic velocity by the pulse Doppler method in addition to the evaluation of coronary artery perfusion by color Doppler ultrasound before and after both SAVR and TAVI is helpful in investigating the cause of wall motion abnormalities and deciding on treatment.
While performing a modified Blalock-Taussig shunt or unifocalization with a lateral thoracotomy, surgeons need to move the lung using lung spatulas to secure the surgical field. However, the lung sometimes expands, slipping through the spatulas and obstructing the surgical procedure. Although one lung ventilation (OLV) provides better surgical conditions, it is not generally performed when treating infants with cyanotic congenital heart disease due to the risk of severe hypoxia.
We here in report six consecutive cases of general anesthesia with OLV using a bronchial blocker for vascular surgery from February 2016 to April 2017.
It was no longer necessary for surgeons to manipulate the lung on the operation side once it had sufficiently collapsed. No severe hypoxia, hypercapnia or hemodynamic compromise occurred in any of the cases during surgery. OLV can thus be used safely for vascular surgery with a lateral thoracotomy in infants with cyanotic congenital heart disease.
A 50-year-old male with idiopathic dilated cardiomyopathy was scheduled for catheter ablation of refractory ventricular tachycardia (VT). Preoperative ultrasound cardiography revealed severe systolic dysfunction, with a left ventricular ejection fraction of 17% and left ventricular end-diastolic dimension of 100 mm.
General anesthesia with tracheal intubation was planned due to the severely impaired cardiac reserve; further, both epicardial and endocardial approaches to catheter ablation with magnetic navigation system restrict the use of anesthetic equipment within the magnetic field, might have caused increased pain, and resulted in longer immobility to the patient due to the difficulty in predicting the duration of surgery.
On the day of surgery, an arterial line was placed and general anesthesia was induced intravenously with noradrenaline infusion. Temporary hypotension after induction was managed by intermittent boluses of noradrenaline. No serious intraoperative complications occurred. Although pain management was difficult in the immediate postoperative period, VT was successfully treated.
Immediately after the implantation of a drug-eluting stent (DES), the risk of cardiac surgery is relatively high. We describe an aortic valve replacement that was performed 15 days after DES implantation. An 83-year-old woman was admitted because of acute coronary syndrome. Percutaneous coronary intervention was performed, and a DES was implanted into the left anterior descending artery (LAD) at segment 8 (#8). An aortic valve replacement was subsequently required because of heart failure. Despite the postoperative oral administration of warfarin and aspirin, a new stenosis at LAD #7 occurred, and another DES was implanted at LAD #7 on postoperative day 97. Antithrombotic therapy after valve surgery and DES implantation should be administered with one anticoagulant and two antiplatelet drugs or with one anticoagulant and clopidogrel for the first month after DES implantation. Concomitant coronary artery bypass grafting combined with valve replacement should be performed only when a residual significant stenosis of the coronary arteries coexists.
With the increasing number of adult congenital heart disease patients, noncardiac surgeries in this group are expected to increase. We performed general anesthesia during resection of a liver tumor in an adult patient with Fontan circulation. In addition to continuous invasive monitoring of arterial and pulmonary arterial pressure, we also used values measured with a Pulse Contour Cardiac Output (PiCCO) catheter as indicators of circulation. In this patient, there were concerns that Fontan circulation would fail due to positive-pressure ventilation using an artificial respirator and blocking of portal veins during the surgical procedure. The PiCCO catheter was useful for managing circulation.
A 71-year-old male had replacement of the aortic root and ascending aorta for Stanford type A aortic dissection. After the operation, he had liver dysfunction, renal dysfunction, and delayed emergence. Even after liver and kidney function normalized, the delayed emergence continued. Enhanced CT showed a portosystemic shunt, which caused hyperammonemia and was associated with delayed emergence. After he was treated with a branched chain amino acid preparation and lactulose preparation, his consciousness level recovered.
Hepatic encephalopathy due to portosystemic shunt was reported in 1950 as Inose type hepatic encephalopathy, which is relatively rare. When hyperammonemia is prolonged postoperatively, it is necessary to confirm the presence or absence of portosystemic shunt.
We were performing a bypass graft to the celiac, superior mesenteric, and both renal arteries for a thoracoabdominal aortic aneurysm at our hospital when the Great East Japan Earthquake occurred. Although it was difficult to decide whether to continue or cancel the surgery, as we were then bypassing the renal artery, we canceled the surgery, sutured the abdomen, woke the patient up from anesthesia, and exited the operation theatre.
The decision will vary depending on the location of the hospital, damage to the building, and state of progress of the surgery when the disaster occurs. I hope that sharing my experience of this case will aid in improving the response following a disaster.
A leadless pacemaker is a pacemaker that does not have vascular leads. The “Micra” leadless pacemaker (MicraTM, Medtronic Japan Co., Ltd.) was introduced into clinical practice in Japan in 2017. Here, we report perioperative management of a patient with a previously implanted leadless Micra pacemaker. The location of the pacemaker in the body could not be detected from body surface findings since the Micra is implanted in the right ventricle cavity. Successful perioperative management in this case was achieved using the following four steps before induction of general anesthesia: 1) confirmation of the maximum intensity point of communication between the Micra and the controller on the episternum using the color of a light-emitting diode on the controller head, 2) confirmation that the Micra functioned as a ventricular stimulation fixed-rate pacemaker, 3) attachment of transcutaneous pacing/defibrillation pads to the patient to enable emergency electrical therapy for potentially fatal arrhythmia, and 4) continuation of ventricular inhibited pacing.
A 78-year-old man who developed progressive renal dysfunction and discoloration of his change of toes after coronary angiography, was diagnosed with cholesterol crystal embolism. Coronary artery bypass grafting was scheduled for unstable angina pectoris, and he was successfully treated managed with perioperative low-density lipoprotein apheresis.
We experienced the rare case of removal of a giant thrombosis in the right atrium caused by low adherence to direct oral anticoagulant (DOAC) in a patient also diagnosed postoperatively with antiphospholipid syndrome. The patient was first diagnosed with deep vein thrombosis (DVT) and was therefore prescribed a DOAC; however, treatment was self-discontinued owing to decreased DVT symptoms but mainly because of the price of the drug. DOACs, adopted since 2011 in Japan, carry advantages such as no food restriction, fewer brain-bleeding complications, and no need for coagulation monitoring. The main drawback of DOACs, however, is the price, some 20-30 times more expensive than warfarin, often motivating patients to lower their adherence which sometimes leads to severe complications, such as thrombosis as in this case.
A 64-year-old man was scheduled for the removal of a left atrial myxoma. After tracheal intubation, we attempted to insert a pulmonary artery catheter (PAC) from the right internal jugular vein, but there was resistance after the PAC advanced 20 cm. When the PAC was pushed more strongly, the insertion successfully continued to 50 cm, but the right ventricular pressure could not be confirmed. We then pulled the PAC to remove it, but there was a strong resistance at about 40 cm. We performed chest radiography to confirm the location of the PAC, which revealed that the PAC entered from the right internal jugular vein into the right subclavian vein, thus it was bent in the axillary region, with the tip located in the superior vena cava. The PAC was subsequently pulled out of the operation field during cardiopulmonary bypass. Overall, to prevent the PAC from getting stuck, it should not be forcibly pushed during its insertion when resistance is encountered, and fluoroscopic guidance should be considered as an aid.