Purpose: We aimed to retrospectively investigate whether intraoperative haptoglobin administration is associated with a lower incidence of acute kidney injury (AKI) after cardiac surgery under cardiopulmonary bypass.

　Methods: A review of the medical records identified 142 patients who had undergone cardiac surgery under cardiopulmonary bypass. Using propensity score matching, we compared the incidence of postoperative AKI in the HAPTOGLOBIN cohort to that in the CONTROL cohort. The HAPTOGLOBIN cohort was defined as the patient cohort that was administered haptoglobin in the presence of hemolytic urine and the CONTROL cohort was defined as the patient cohort that was not administered haptoglobin in the absence of hemolytic urine.

　Results: AKI occurred in 37% of the patients. Haptoglobin was administered in 29% of the patients. In the crude cohort, AKI occurred in the HAPTOGLOBIN cohort more frequently than in the CONTROL cohort (53.7% vs 29.7%, P=0.013). However, in the propensity score matched cohort (27 patients in each cohort), the incidence of AKI was not significantly different between the HAPTOGLOBIN and CONTROL cohorts (48.1% vs 40.7%, P=0.78).

　Conclusion: This study suggests that intraoperative haptoglobin administration after the appearance of hemolytic urine may not be associated with postoperative AKI.

　Purpose: The purpose of the present study was to identify the risk factors for postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting.

　Methods: Ninety-eight patients who underwent coronary artery bypass grafting between January 2013 and December 2017 were included. The risk factors for POAF were estimated using a multivariate logistic regression model.

　Results: Twenty-six patients (27%) suffered from POAF. Five risk factors were extracted: (1) age >73 years old, (2) Body Mass Index (BMI)<23 kg/m², (3) non-diabetes mellitus, (4) decrease in the amount of ionized magnesium (ΔiMg) >0.11 mmol/L, (5) the maximum dose of noradrenaline >0.1 μg/kg/min. The risk of POAF increases when patients have more than two factors (sensitivity 65.4%, specificity 78.6%).

　Conclusion: We should be aware of the potential onset of POAF when patients have more than 2 of the five aforementioned factors.

　Background: Previous reports have shown that pulmonary hypertension has negative effects on operative mortality in patients with mitral regurgitation undergoing mitral valve replacement. However, the effect of pulmonary hypertension in patients with mitral stenosis has not been clarified. This retrospective study aimed to determine the effect of preoperative pulmonary hypertension on short- and long-term mortality in patients with severe mitral stenosis undergoing mitral valve replacement.

　Method: Sixty-nine patients with severe mitral stenosis were enrolled. Patients were divided into two groups by preoperative systolic pulmonary artery pressure/systolic blood pressure ratio with a cut-off value of 0.3. Postoperative 30-day mortality and long-term mortality were compared between the groups.

　Result: Forty-nine (71%) patients were in the PH group. Four (5.8%) patients died during the perioperative period. Operative mortality was comparable between the groups (6.1% in the PH group vs. 5% in the non-PH group, p=1.0). Eighteen (26.1%) patients died in the long-term period and mortality was comparable between the groups (30.6% vs. 15%, p=0.24). Neither logistic regression analysis nor Cox regression analysis showed a significant association between the presence of pulmonary hypertension and mortality (adjusted odds ratio: 1.12, 95% confidence interval: 0.08-15.2, p=0.93 and adjusted hazard ratio: 1.91, 0.49-7.44, p=0.35, respectively).

　Conclusion: There is no significant association between pulmonary hypertension and short- and long-term mortality in patients with severe mitral stenosis undergoing mitral valve replacement.

　Purpose: Severe aortic stenosis (AS) is remarkable risk factor of major adverse cardiovascular events (MACE) in non-cardiac surgery. Although surgical aortic valve replacement (SAVR) before non-cardiac surgery is recommended for patients with severe AS, many patients are not appropriate for SAVR from their age, comorbidity and frailty. We considered that Transcatheter aortic valve replacement (TAVR) is alternative pre-treatment for patients with severe AS who was scheduled for non-cardiac surgery. Therefore, we report five cases who were performed TAVR prior to non-cardiac surgery in our hospital.

　Method: Retrospective, case-series study.

　Result: Our patients' median of age was 87 years old, median of days from TAVR to non-cardiac surgery was 78 days, and median of Society of Thoracic Surgery (STS) score was 4.9. After TAVR, 2 of 5 cases improved left ventricle ejection fraction (LVEF), and all cases decreased Brain natriuretic peptide (BNP). In all cases, antiplatelet therapy was introduced following TAVR, 3 of 5 was discontinued antiplatelet therapy and performed heparization until non-cardiac surgery was performed. One case was continued antiplatelet therapy, another case was discontinued antiplatelet therapy unintentionally. All cases had no thrombotic complication. In 4 cases, non-cardiac surgery was performed under general anesthesia. One case was performed under combination of spinal epidural anesthesia (CSEA). In all cases, MACE did not occur during non-cardiac surgery.

　Conclusion: We concluded that in patients with severe AS scheduled for non-cardiac surgery, pre-treatment by TAVR is appropriate therapy for the patients' safety and improving outcome.

　We report a case of left ventricular pseudoaneurysm formation after transapical transcatheter aortic valve implantation (TA-TAVI) in which it was treated with a percutaneous closure. A 82-year-old man. He diagnosed left ventricular pseudoaneurysm after TA-TAVI. The risk of re-operation is very high because he underwent ascending aortic replacement previously. Therefore, a percutaneous closure using AMPLATZER^TM Vascular Plug Ⅱ was selected. It was performed uneventfully under general anesthesia. Transesophageal echocardiography is helpful for the evaluation of the pseudoaneurysm, guidewires and pericardial fluid.

　A 64-year-old man who had complained of abdominal pain and numbness in both legs sought evaluation at another hospital. An aortocaval fistula caused by rupture of an abdominal aortic aneurysm was diagnosed, and he was transferred to our hospital for surgery. We performed abdominal aortic artificial blood vessel replacement emergently. After the induction of general anesthesia, real time echo-guided catheterization of the right internal jugular vein was performed. The central venous blood was red in color because of an arteriovenous shunt. We noted marked hematuria at the time of urethral catheter insertion. The aortocaval fistula was closed with a bovine pericardial patch. The post-operative course was good and he was discharged from our hospital symptom-free 12 days later. We report a case of an aortocaval fistula due to a ruptured abdominal aortic aneurysm that presented with severe hematuria, which was thought to be renal and bladder damage caused by increasing venous pressure.

　Patients with cold agglutinins (CA) are usually asymptomatic. However, hemagglutination can occur at low temperatures, followed by hemolysis upon rewarming. Therefore, a thorough strategy for cardiopulmonary bypass and myocardial protection is essential for patients with CA that are to undergo cardiac surgery that requires cardiopulmonary bypass. Here, we describe a patient who had CA detected incidentally during the preoperative examinations for two valve replacements. Cardiopulmonary bypass was performed at 34℃ using normothermic cardioplegia. There were no complications during or after the operation. When CA are detected in a patient undergoing cardiac surgery that requires cardiopulmonary bypass, individualized planning is necessary, depending on the severity of the condition and operative methods.

　A 2-year-old boy had left ventricular tract obstruction and aortic valve stenosis due to semi-closure of the right coronary cusp after extended aortic arch anastomosis for complex coarctation of the aorta. The semi-closure of the right coronary cusp may have been caused by partial blockage of the left ventricular tract blood flow by a scar obtained during patch closure of a ventricular septal defect. It was difficult to detect this pathology by transthoracic echocardiography before the surgery. The mechanism of aortic valve stenosis was detected by transesophageal echocardiography after induction of anesthesia; subsequently, an appropriate type of surgery—i.e., resection of the scar—was proposed. Therefore, re-evaluation of the pathology by transesophageal echocardiography after induction of anesthesia is important, even for pediatric patients with congenital heart diseases who have been diagnosed mainly by transthoracic echocardiography.

　A 38-year-old woman was scheduled an on-pump coronary artery bypass grafting (ONCAB) for unstable angina pectoris with 3 coronary artery lesions. After induction of anesthesia, we found that intubation was difficult because of subglottic stenosis. The risk of perioperative respiratory complications was high without a properly maintained airway, and the operation was postponed. An approach that would ensure a properly maintained airway was deemed necessary, and therefore a one-stage ONCAB with superior tracheostomy and partial median lower sternotomy was performed at a later date. The patient recovered without any complication.

　Cardiac paraganglioma is a rare tumor. Herein, we report the first case of cardiac paraganglioma in Japan, which was resected by beating-heart surgery under cardiopulmonary bypass.

　A 26-year-old man was referred to our hospital for treatment of a cardiac paraganglioma. Although the tumor adhered to the left atrium and left inferior pulmonary vein, invasion to the adjacent organs was unclear. The blood supply to the tumor was from the right coronary artery and left circumflex artery. Tumor resection under cardiopulmonary bypass via beating-heart surgery was indicated after discussion among the related medical departments. The tumor was resected from the heart and a significant fall in blood pressure due to the decreased blood catecholamine levels after resection occurred, which was managed via continuous noradrenaline administration. The postoperative course was uneventful. To avoid intraoperative crisis, the preparation of anesthesia management in anticipation of hemodynamic changes associated with beating-heart surgery is warranted.

　The patient was a 71-year-old man who was hit by a car from behind while driving a truck. He was diagnosed with blunt aortic injury, right hemopneumothorax, both pulmonary contusions, right 2nd-6th rib fractures, multiple cerebral contusions, facial contusions, and left forearm contusions. We aimed for early surgical intervention for aortic injury, but intervention in acute post-traumatic phase could be avoided by strict circulatory control. Delayed endovascular aortic repair was performed without hemorrhagic complications. Comprehensive judgment is necessary for blunt aortic injury as to timing of treatment, surgical procedure, etc.

　Pulmonary artery embolism during off-pump coronary artery bypass grafting (OPCAB) is rare; however, previous reports have described pulmonary embolism caused by a carbon dioxide blower during repair of the injured right ventricular outflow tract and coronary veins. We describe a rare case of pulmonary artery air embolism during OPCAB without visible tissue injury. After anastomosis of the left internal thoracic to the left anterior descending (LAD) artery, we observed increased pulmonary artery pressure with decreased arterial pressure.

　Transesophageal echocardiography (TEE) revealed gas bubbles in the right heart system; therefore, we diagnosed the patient with pulmonary artery air embolism. The needle inserted for LAD clamping punctured the right ventricle, and air flow observed was attributed to the use of the air blower. It is necessary to manage with TEE carefully to have possibilities to develop air embolism when tissue injury is unclear.

　Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of left atrial appendage (LAA) thrombus. We experienced a case of LAA thrombus which was difficult to evaluate only by TEE. Contrast computed tomography (CT) in the prone position was added for a more accurate diagnosis. A-66-year-old male patient with atrial fibrillation, arterial obstruction in the lower limbs, and LAA thrombus was scheduled for LAA resection by thoracoscopy. Although preoperative early and delayed phase contrast enhanced CT revealed a filling defect of the LAA, a radiologist detected no thrombosis. After general anesthesia induction, the operation was postponed due to our inability to visualize the LAA thrombus accurately by TEE. On the next day, contrast CT was performed to reconfirm the findings. Contrast CT in the prone position was added but revealed no thrombus in the LAA. After a few days, the operation was performed again. TEE revealed the same views of the LAA as in the previous operation, but this time the LAA thrombus was able to be diagnosed clearly and was successfully resected.

　Left ventricular outflow tract obstruction due to retained anterior mitral valve leaflet was detected on transesophageal echocardiography after mitral valve replacement with preservation of both the anterior and posterior mitral valve leaflets. No improvement was attained after medical treatment, thus reoperation was performed on the following day. The A2 portion of the anterior mitral valve leaflet was resected under cardiac arrest, and the left ventricular outflow tract obstruction was resolved. Retaining the native valve leaflet or subvalvular apparatus during mitral valve replacement leads to long-term left ventricular function maintenance but may cause complications, as in this case.

　Based on the poor prognosis of the present case at follow-up, early diagnosis with echocardiography and reoperation are crucial.

　63-year-old man height 165 cm, weigh 55 kg was scheduled to undergo surgery for recurrent aortic and mitral regurgitation. Complete atrioventricular block and hypotension occurred following induction of anesthesia, and temporary chest compression was performed. An increase in airway pressure and systemic erythema was observed, and the patient was diagnosed with anaphylactic shock. Transesophageal echocardiography revealed reduced circumferential wall motion and elevated pulmonary artery pressure. Coronary spasm was suspected, and nitrate was administered, after which the pulmonary artery pressure decreased with improved cardiac contractility and hemodynamic stabilization. Clinicians must consider Kounis syndrome in the differential diagnosis in patients with signs of anaphylaxis or acute coronary syndrome to ensure prompt and appropriate treatment.

　Two women aged 70 and 77 years old underwent aortic valve replacement due to severe aortic valve stenosis. After general anesthesia induction, a central venous catheter was cannulated in the right internal jugular vein with ultrasound guidance in each case. They received median sternotomy with a pillow under their back and their arms were set at bilateral side positions. Although the operations were completed uneventfully, they complained of difficulty in raising their right and left arms and showed proximal muscle weakness in their arms after they woke up. Manual muscle strength tests (right/left) also revealed impaired proximal muscle strength: case 1: triangular muscle 0/5, biceps 3/5, triceps 4/5, case 2: triangular 5/0, biceps 5/5, triceps 5/4. They reported no obvious pain or sensory impairment. Following oral administration of vitamin B12 and physical treatment, their muscle strength gradually improved over several weeks and recovered fully within 1 year after surgery. It should be noted that fifth cervical nerve injury after cardiac surgery could be caused by median sternotomy, intraoperative positioning, internal jugular vein puncture, or cervical spine disease.

　We experienced a case of air embolism as a complication of computed tomography (CT)-guided lung needle biopsy (CTNB), resulting in circulatory collapse and cerebral infarction. A 74-year-old female with a lung tumor underwent CTNB in the left lateral position. As soon as she returned to the supine position after the procedure, she developed circulatory collapse. Chest CT demonstrated an air embolism in the right coronary artery. Cardiopulmonary resuscitation was initiated, followed by insertion of an intra-aortic balloon pump (IABP). Although cardiac function was restored the next day and the IABP was removed, neurological examination revealed left upper limb paralysis. Brain CT showed multiple cerebral infarctions due to air emboli in the cerebral vessels. Fortunately, neurological symptoms improved following cerebral protective treatment and rehabilitation. It is important for medical teams to be aware that since air embolism can be a fatal complication of CTNB, it requires prompt diagnosis and appropriate intervention.

　Pentalogy of Cantrell is a rare congenital syndrome characterized by 5 major malformations: defects involving the abdominal wall, lower sternum, pericardium, and diaphragm; and various congenital cardiovascular anomalies. We herein present the perioperative management of a neonate with Pentalogy of Cantrell, including coarctation complex, subvalvular aortic stenosis, and ectopia cordis. Because of uncontrollable pulmonary overcirculation, the Norwood procedure with a right ventricle-pulmonary artery conduit and internalization of the ectopic heart was performed on the second day after birth. The sternal defect was covered with skin after the completion of the surgery, and subsequently, we had to achieve balanced respiratory and circulatory status by adjusting the ventilator settings. Due to the lack of a pericardial cavity owing to Pentalogy of Cantrell, close monitoring of hemodynamic and ventilatory parameters is essential to control the cardiac and respiratory functions in univentricular parallel circulation.

　Postdural puncture headache is one of the complications of cerebrospinal fluid drainage for spinal cord protection in thoracoabdominal aortic aneurysm surgery. Postdural puncture headache has been reported to occur in 9.7-18.6% of patients with cerebrospinal fluid drainage and to cause postoperative demobilization.

　We report eight cases of postdural puncture headache treated with anhydrous caffeine that occurred after cerebrospinal fluid drainage during thoracoabdominal aortic aneurysm surgery.

　We report a case of total arch replacement and open stent graft (OSG) implantation in a patient with right-sided aortic arch complicated with Kommerell's diverticulum (KD). After separation from cardiopulmonary bypass, a significant pressure gradient between femoral artery pressure and radial artery pressure developed and after sternum closure, ventilation difficulty appeared. The former was due to a kinking in the part of the OSG that does not have a stent framework, and additional endovascular stent-graft treatment improved the pressure gradient. The latter was caused by tracheal stenosis due to physical compression of the trachea by the KD and neighboring soft tissues. In patients with right−sided aortic arch with KD, it is important to evaluate preoperative anatomy, understand anatomical changes and complications that can occur with surgical operation, and manage intraoperative airway and circulation.

　Approximately half of all cases of aortic dissection in young women are related to pregnancy. We report a case of successful perioperative management of a 20-week pregnant woman with Marfan syndrome who developed left-sided heart failure due to Stanford type B aortic dissection. We successfully rescued both the mother and the child by performing the Bentall procedure under a normothermic cardiopulmonary bypass. When cardiac surgery with cardiopulmonary bypass is required for survival during the period when the fetus cannot survive outside the mother's body, both the maternal and fetal status should be considered for better perioperative management.

　We encountered a case of anesthesia of a brain-dead lung transplant for Osler's disease associated with marked polycythemia. We report a case of a 15-year-old man exhibiting polycythemia, with a hemoglobin (Hb) count of 26 g/dL and hematocrit (Ht) of 78%, which was revealed by a preoperative examination. The Ht value should be lowered to perform cardiopulmonary bypass (CPB). Therefore, crystalloid loading was performed before CPB, and blood preservation under CPB was added. In addition, the blood pressure waveform of the radial artery was overdamped from the time of anesthesia induction, and INVOS^® did not display a numerical value. However, when the Ht value decreased, radial artery waveform and INVOS became normalized. It is possible that these monitors were improperly used for treating advanced polycythemia.

　We conducted a cardiac electrophysiologic study in a patient with suspected complete atrioventricular block caused by dexmedetomidine (DEX) to evaluate the effect of DEX treatment on sinus function and atrioventricular conduction. DEX treatment led to a decrease in the sinus node function and atrioventricular conduction in a dose-dependent manner and prolonged the atrio-His interval. In this case, complete atrioventricular block may have possibly developed by the complex participations which were a restraint effect to sinus node and atrioventricular conduction depending on DEX dose, interaction of other drugs including fentanyl and the patient characteristics.

　It is difficult to conclude that the use of DEX induced complete atrioventricular block. In addition, the combination of drugs likely to induce complete atrioventricular block is currently not known. When advanced atrioventricular block develops concurrently with DEX use, the administration of DEX must be terminated, and atropine should be administered.

　Using transesophageal echocardiography after induction of anesthesia for emergency pulmonary embolectomy, we detected a thrombus (9 cm) extending between the right and left atria across a patent foramen ovale. We initially scheduled only pulmonary embolectomy with a beating heart; however, detection of the thrombus necessitated a change in our surgical plan, and we performed intracardiac thrombectomy under cardioplegic arrest. The patient recovered uneventfully and was discharged without any serious complications.

　Intraoperative transesophageal echocardiography is an effective diagnostic tool in patients in whom intracardiac thrombosis might not be detected preoperatively, as observed in our patient.

　In a case of left ventricular reconstruction for left ventricular aneurysm after open heart surgery, retrograde aortic dissection after right femoral artery perfusion was promptly diagnosed based on transesophageal echocardiography, and the perfusion site was changed to the contralateral femoral artery. When the perfusion volume decreased upon withdrawal of the cardiopulmonary bypass, the true lumen was collapsed by the false lumen, and weaning became difficult. Aortography revealed an entry point in the right external iliac artery, and stenting on this entry allowed the patient to be weaned from cardiopulmonary bypass.

　In this report, we describe the case of a patient with a massive primary cardiac malignant lymphoma who underwent anesthetic management for transvenous pacemaker implantation, which was safely performed using combined transesophageal echocardiography (TEE) and fluoroscopy intraoperatively with pacing lead placement guided by echocardiography.

　A 71 year-old male was diagnosed with a massive cardiac malignant lymphoma. The tumor occupied the right atrium and ventricle, as well as the vena cava. Electrocardiography revealed a complete atrioventricular block. Elective pacemaker implantation under general anesthesia was planned. General anesthesia was carefully introduced with extracorporeal circulation on stand-by in case of collapsed circulation.

　Intraoperatively, guiding the pacing lead to the proper position was difficult for the cardiovascular surgeon. The anesthesiologist then suggested the use of TEE for guiding the pacing lead. Subsequently, the pacing lead was successfully placed in the appropriate position by a combination of TEE guidance and fluoroscopy without any cardiovascular complications.

　TEE guidance may be considered feasible and efficient for transvenous pacemaker implantation under general anesthesia.

　A 60-year-old man underwent elective mitral valve replacement, tricuspid annuloplasty, and left atrial appendage occlusion. After cessation of cardiopulmonary bypass, persistent bleeding was noted from the cardioplegia injection site and ascending aortic cannulation site. The patient's blood pressure was decreased, and transesophageal echocardiography revealed dissection of the descending aorta. He was diagnosed with type A aortic dissection extending to the descending aorta based on transesophageal echocardiography and epiaortic echocardiography findings. Aortic dissection of the cardioplegia injection site was detected, and replacement of the ascending aorta was performed under deep hypothermic circulatory arrest. Transesophageal echocardiography and epiaortic echocardiography in combination proved to be an effective diagnostic tool for intraoperative aortic dissection.

　We experienced a case of emergency thoracotomy with hemorrhagic shock due to an aorto-esophageal fistula of a dissecting aortic aneurysm.

　After entering the operating room, insertion of the S-B tube resulted in temporary improvement in circulatory dynamics.

　The patient unfortunately died during the operation, but the use of the S-B tube was considered useful for controlling bleeding in the esophageal rupture of the aortic aneurysm.