【OBJECTIVE】

　To determine the effect of differences in accommodated beds after endovascular aortic repair (EVAR) on the development of postoperative delirium.

【METHODS】

　We investigated the incidence of delirium in patients who underwent EVAR at Hiroshima University Hospital between October 2013 and April 2019. The patients were separated into intensive care unit (ICU) and general ward (GW) groups during postoperative admissions. We also examined factors associated with the development of delirium using multivariate analysis.

【RESULTS】

　Of 141 subjects (ICU group, n=30; GW group, n=111), 10 patients (7.1%) had delirium: 3 in the ICU group (10.0%) and 7 in the GW group (6.3%). There was no significant difference in the frequency of delirium between the two groups (p=0.48). In addition, ICU admission was not a significant factor associated with delirium in the multivariate analysis (P=0.71).

【CONCLUSIONS】

　Short-term admission to the ICU after EVAR does not affect the development of postoperative delirium.

【Purpose】 We retrospectively investigated the effect of administering ketamine as an anesthetic adjuvant on postoperative acute pain after thoracoabdominal aortic replacement.

【Method】 The participants were 42 patients who underwent thoracoabdominal or descending thoracic aortic replacement at our institution between 2015 and 2019. Postoperative fentanyl doses were compared between the intraoperative ketamine use and non-use groups, using the inverse probability of treatment weighting.

【Result】 The mean postoperative fentanyl dose was not significantly different between the ketamine use (28.0 μg/kg) and non-use (21.7 μg/kg) groups (p=0.20).

【Conclusion】 Our results suggest that intraoperative ketamine use during thoracoabdominal aorta replacement may not reduce the postoperative fentanyl dose.

【Objective】 This study aimed to determine the relationship between aortic cross clamp (ACC) time, surgical factors, management of weaning from cardiopulmonary bypass (CPB), and prognosis of patients who underwent cardiac surgery.

【Method】 A total of 508 patients who received cardiac surgery with CPB at Tohoku University Hospital from 2017 to 2019 were included. The surgical factors, use of inotropes, vasopressors, and circulatory assist devices during the CPB weaning, and the mortality rate at 30 and 180 days after surgery were retrospectively examined. The patients were divided into the group with ACC time equal to or longer than 240 minutes (long ACC group) and the group with ACC time less than 240 minutes (short ACC group), and the factors mentioned were compared between the groups.

【Results】 There were 105 patients in the long ACC group and 403 in the short ACC group. The total amount of intraoperative bleeding and blood transfusion was significantly higher in the long ACC group. There was no significant difference found in the use of inotropes, vasopressors and circulatory assist devices between the two groups. Patients who required a circulatory assist device at the CPB weaning had a significantly higher mortality rate in both groups.

【Conclusion】 In the patients with long ACC, it is important to manage increased blood loss and prevent the lowering of cardiac function at the time of CPB weaning.

【Purpose】FibCare^® (ATOM MEDICAL) is a device that can measure fibrinogen concentration in about 2 minutes. We retrospectively examined its accuracy in cardiovascular surgery.

【Methods】In 63 patients undergoing cardiovascular surgery using cardiopulmonary bypass, fibrinogen concentrations were measured in the central laboratory and by FibCare^® before weaning of the cardiopulmonary bypass and the measurements were compared.

【Results.】Bland-Altman analysis showed a bias of 15.2 mg/dL and 95% limits of agreement of −21.5 to 51.9 mg/dL.

　Spearman's rank correlation coefficient was 0.92, indicating a strong positive correlation.

【Conclusion.】Fibrinogen concentration in cardiovascular surgery with cardiopulmonary bypass can be accurately measured by FibCare^® as well as in a central laboratory.

　A 43-day-old girl had been diagnosed with scimitar syndrome with right pulmonary hypoplasia and scimitar veins, atrial septal defect, and aortopulmonary collateral artery during the neonatal period. Pulmonary hypertension due to a high pulmonary blood flow was difficult to control, and after coil embolization of the aortopulmonary collateral artery, atrial septal defect closure and ductus arteriosus ligation were performed. Intraoperatively, the patient's blood pressure was markedly reduced after displacement of the heart, making cannulation into the ascending and descending vena cava difficult. Pulmonary artery cannulation was performed instead, and cardiopulmonary bypass was done to complete the operation. In cases of scimitar syndrome, which requires treatment intervention in early infancy, pulmonary hypoplasia and multiple left-to-right shunts affect the right ventricular volume and pressure overload. Unexpected intraoperative circulatory collapse and postoperative pulmonary hypertension crises may occur.

　Bronchial stenting was performed under general anesthesia in a patient who received veno-venous extracorporeal membrane oxygenation (V-V ECMO) for severe stenoses in the left main bronchus and right pulmonary artery owing to mediastinal lung cancer. When the left main bronchus was open, oxygen saturation (SpO₂) was maintained within 90%~100%. However, when the left bronchus was occluded, SpO₂ decreased to 80%~90%. After the flow volume of the V-V ECMO was increased, SpO2 was maintained within 90%~100%. When severe bronchial stenosis is unilateral, the instability of pulmonary circulation in the ventilable lung may worsen the ventilation-perfusion imbalance, making it difficult to maintain oxygenation. V-V ECMO may be useful in maintaining oxygenation during bronchial stenting in patients with unstable pulmonary circulation.

　Ventricular septal defects (VSDs) that progress to Eisenmenger's syndrome are not usually an indication for surgical repair. However, some patients with atrial septal defects (ASDs) and severe pulmonary hypertension (PH) can be curatively treated with transcatheter ASD closure combined with pulmonary vasodilatation.

　A 65-year-old man presented with a double-outlet right ventricle. He had been diagnosed with Eisenmenger's syndrome in childhood and subjected to a long-term treatment with pulmonary vasodilators. We performed a surgical closure of the VSD accompanied by ASD creation with fenestration. Consequently, his PH ameliorated, and we performed ASD closure with a transcatheter device 12 months later.

　The present case indicates a possible comprehensive treatment strategy for patients with adult congenital heart disease despite progression to Eisenmenger's syndrome, placed on long-term medications for PH.

　Perioperative management of antiphospholipid syndrome (APS) in patients undergoing cardiac surgery is challenging as an anticoagulation strategy for cardiac surgery with cardiopulmonary bypass (CPB) has not been established. Reports of difficulty in managing perioperative APS are increasing, and coagulation analyzers may help in the management of APS during cardiac surgery involving CPB. Here, we report a case of anticoagulation management using a heparin-activated clotting time (heparin-ACT) titration curve and Sonoclot^® in a patient with APS undergoing cardiac valvular surgery.

　We report a patient with Fontan circulation who experienced delayed emergence from anesthesia after scoliosis surgery.

　Before the surgery, serum makers for developing liver fibrosis were slightly elevated, but transaminase levels were within normal range.

　She underwent surgery in the prone position. Despite stable hemodynamics with 10-13 mmHg of central venous pressure and adequate urine output, delayed emergence from anesthesia was observed. We thought that the cause was delayed drug metabolism because of postoperative liver damage.

　This patient likely suffered from a Fontan associated liver disease as she was a long-term Fontan patient. Therefore, it was considered that latent hepatic dysfunction and hepatic artery dominance on her hepatic circulation were the factors that contributed to the postoperative liver damage.

　We need to evaluate liver function carefully, and give an anesthetic management and circulation management based on the characteristic hepatic circulation of FALD in noncardiac surgery for patients with long-term Fontan circulation.

　We used transesophageal echocardiography (TEE) for intraoperative management of pneumoperitoneum gas embolism because it can occur during laparoscopic hepatectomy. Here, we report the influx of pneumoperitoneum gas into the left heart system in three cases. Case 1 was a 78-year-old man who was planned for post-hepatic segmentectomy. The patient's bubble test was negative. During hepatic transection, an air embolus in the atrium and ventricle was observed. A few minutes later, pneumoperitoneum had to be interrupted because the patient's blood pressure decreased. At that time, we observed the influx of the air embolus into the left heart system. Case 2 was a 76-year-old woman who was planned for partial hepatectomy. The patient's bubble test was positive. A small air embolus was observed during hepatic transection and flowed into the left heart system. Case 3 was a 59-year-old man who was planned for partial hepatectomy. The patient's bubble test was positive. A small air embolus was observed during hepatic transection and flowed into the left heart system. Since an air embolus derived from pneumoperitoneum gas flowing into the left heart system is potentially dangerous, evaluation by TEE may be useful in preventing complications.

　Pulmonary artery catheters (PACs) are widely used to monitor cardiac surgical procedures. We experienced a case of accidental PAC damage in surgery that caused inadequate pulmonary artery pressure (PAP) waveform after cardiopulmonary bypass (CPB). In most clinical cases, we notice that the intraoperative catheter is entrapped or damaged when the catheter is withdrawn after surgery. In our case, the anesthesiologists and the cardiologists observed abnormal change in the PAP waveform after the CPB, which alerted us to the fact that the PAC might be damaged. Consequently, we avoided a catheter -related accident by carefully removing of the PAC.

　The patient was a man in his eighties, who had undergone mitral valve replacement and coronary artery bypass for mitral valve prolapse and myocardial infarction 5 years previously. He had been receiving anticoagulation therapy with warfarin, which had been switched to edoxaban about 10 months previously. He was scheduled to undergo a mitral valve re-replacement for prosthetic valve stenosis. The surgery was performed through a midline skin incision and a cardiopulmonary bypass was established with inflow via the ascending aorta and with venous drainage via the superior vena cava and inferior vena cava. On removal, a thrombus and pannus were observed on the prosthetic valve, and he underwent re-replacement with a bioprosthetic valve. Postoperative anticoagulation therapy is required for patients who undergo valve replacement with mechanical valves, owing to the risk of thrombus formation, and the guidelines recommend warfarin therapy. Although it has not been confirmed that patients being treated with edoxaban are more prone to thromboembolism than those being treated with warfarin, more careful management is needed for these patients.

　We report a case of a cardiac blood cyst, the attachment site of which could not be identified by preoperative transthoracic echocardiography (TTE) and intraoperative transesophageal echocardiography (TEE). Preoperative TTE and CT showed the tumor near the entry of the right atrium in the inferior vena cava but we could not identify the tumor attachment site. Identifying the attachment site is critical for tumor resection. However, intraoperative TEE showed only a part of the tumor. Surgical site echocardiography revealed tumor attachment at the right side of the atrial septum, which allowed tumor resection during cardiopulmonary bypass. Thus, surgical site echocardiography was useful in identifying the attachment site of an atrial blood cyst.

　Purpose: We investigated intraoperative and postoperative management of branched artery ligation and stent graft-conserving aneurysmorrhaphy, a type 2 endoleak repair surgery after endovascular aortic repair (EVAR).

Method: We retrospectively examined the intraoperative and postoperative course of four patients who underwent this procedure at our hospital. The results are expressed as median [interquartile range].

Result: The elapsed time since EVAR was 42 [29~58] months, operation time was 161 [150~174] minutes, anesthesia time was 235 [226~257] minutes, and bleeding volume was 167 [141~233] mL. In one case, the amount of bleeding during surgery was 3069 mL; hence, operative blood salvage and blood transfusion were performed. The postoperative length of hospital stay was 13 [11~15] days. None of the patients developed postoperative infection.

Conclusion: The postoperative course of all patients was uneventful. However, massive bleeding during surgery should be considered during anesthesia management.

　A 71-year-old woman visited her family doctor with complaints of general malaise and hemoptysis. Computed tomography (CT) showed an impending rupture of an arch aortic aneurysm, and she was transferred to our hospital for surgery. CT showed a large aneurysm of the aortic arch that compressed the left pulmonary artery and left bronchus and a right cardiac overload. The pulmonary artery pressure was above 50 mmHg after anesthesia induction. When the chest was opened, further elevation of pulmonary artery pressure and hypotension were observed, and total cardiopulmonary bypass was initiated. However, the pulmonary artery pressure did not decrease after the initiation of total cardiopulmonary bypass, and it remained at the same level as the arterial pressure. An aortic pulmonary fistula was suspected, and transesophageal echocardiography confirmed the flow from the arch aneurysm to the pulmonary artery. The fistula was detected within the operative field, and it could be weaned from the cardiopulmonary bypass without any problems by direct closure.

　Infective endocarditis (IE) during pregnancy is a rare condition, with an incidence of only 0.006%; however, the maternal mortality rate ranges from 11 to 33% and the fetal mortality rate ranges from 14 to 29%, indicating a poor prognosis. Here, we discuss the case and report the subsequent findings of a pregnant patient who underwent a two-stage surgery including a cesarean section followed by an open heart surgery to treat IE which developed during pregnancy.

　The patient was a 34-year-old woman with a period of gestation of 38 weeks and 2 days and having mobile vegetation exceeding 10 mm on the mitral valve. There were no signs of heart failure; therefore, the cesarean section was performed first, followed by open heart surgery seven days later. The patient was at the risk of a hemorrhage from placental abruption due to the use of heparin, but this did not become a problem. When deciding on the treatment strategies for IE during pregnancy, it is important to plan the surgery giving due consideration to the condition of both the mother and the fetus.

　Antiphospholipid antibody syndrome (APS) is a group of diseases that cause thromboembolism of veins and arteries, thrombocytopenia, and pregnancy complications associated with autoantibodies against phospholipids. Since antiphospholipid antibodies inhibit phospholipid-dependent coagulation reactions, the activated coagulation time (ACT) is prolonged, and evaluating anticoagulation by heparin becomes difficult in cardiac surgery under cardiopulmonary bypass. Herein, we report a case of anesthesia management of a patient with APS undergoing valve replacement. After entering the operating room, a heparin dose sensitivity test using the patient's blood was performed, and ACT corresponding to the target heparin blood concentration of 3 U/L under cardiopulmonary bypass was calculated to be 699 s. The patient could be safely managed by setting this value as the target value of anticoagulation.

　Oximetry central venous catheter (CVC), which can measure central venous oxygen saturation (ScvO₂), has an optical fiber inside its shaft to receive infrared light. We report the case of a patient whose catheter had fractured inside his body with the tip of the catheter bound to the optical fiber but having escaped from internal remnants. Although we were not able to measure the ScvO₂ on the 2^nd-day post-cardiotomy, the catheter had been in use for 6 days after the intervention, and we could not locate the fracture of the catheter. Thus, if abnormalities are observed in the parameters, such as ScvO₂, when using Oximetry CVC, the catheter should be removed and checked for damage.

　There are a few reports of the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in patients with difficult airway management. However, VV-ECMO using the subclavian vein under spontaneous breathing in cervical surgery has not been reported thus far.

　A 69-year-old woman was scheduled to undergo surgery under general anesthesia for thyroid cancer with tracheoesophageal infiltration; however, it was predicted that both tracheal intubation and tracheostomy would be difficult due to cancer. Therefore, we planned to introduce VV-ECMO for the purpose of airway management for airway stenosis in cervical surgery. VV-ECMO was introduced under sedation to facilitate femoral vein blood removal and subclavian vein blood supply for preventing recirculation and allowing safe and efficient airway management.

　A 69-year-old woman underwent redo-mitral valve replacement for severe mitral regurgitation 4 years after her initial aortic and mitral valve replacement. Before the cessation of cardiopulmonary bypass, transesophageal echocardiography revealed newly imaged perivalvular leakage and rocking motion of the aortic prosthesis. Redo aortic valve replacement was consequently performed. Since the retained anterior leaflet that had been preserved in the previous operation had fused to the aortic annulus, the mitral prosthesis was removed in conjunction with part of the aortic annulus, presumably resulting in aortic regurgitation. During the mitral replacement procedure, it is important to carefully examine not only the mitral apparatus but also the aortic one in order to detect adverse complications as early as possible.

　We encountered a case of asthma attack during cardiac surgery using an extracorporeal circulation. The patient had a history of asthma, but was in symptom-free remission at the time of surgery. When artificial respiration resumed after the aortic declamp, an increase in inspiratory pressure and wheezing were observed, making it difficult to withdraw from the extracorporeal circulation. After inhalation of sevoflurane and salbutamol, and intravenous administration of methylprednisolone, wheezing disappeared and extracorporeal circulation was successfully withdrawn. Continuous administration of a small quantity of adrenaline was started, and sevoflurane was discontinued. Asthma did not recur, and hemodynamics became stable. Asthma attacks induced by an extracorporeal circulation are thought to be caused by inflammatory substances such as complement and cytokines that are released after the contact of blood cells with the circuit and artificial lung. When using an extracorporeal circulation, attention should be paid to patients in asthma remission because of the risk of having an asthma attack.

　Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder characterized by dilated mucosal and skin capillaries and arteriovenous fistulas in the lungs, brain, and liver. Perioperative management of open heart surgery complicated by HHT has rarely been reported. In this case report, we describe anesthetic management in a patient with HTT, who underwent mitral valve replacement for infective endocarditis.

　A 66-year-old woman (height 159 cm, weight 56.4 kg) revealed a history of anemia, hereditary pulmonary arterial hypertension, hepatic arteriovenous fistula, oral hemangioma, gastric vasodilatation, and atrial fibrillation. She underwent mitral valve replacement with annulus reconstruction, tricuspid annuloplasty, and left ventriculoperitoneal closure for infective endocarditis and mitral regurgitation secondary to cholecystitis. Transesophageal echocardiography was not performed owing to the patient's bleeding tendency, and epicardial echocardiography and pulmonary artery catheterization were used for cardiac function evaluation.

　Thromboelastography TEGR6s was used for prompt hemostasis and efficient use of blood products. Nitric oxide (NO) inhalation was initiated for management of pulmonary hypertension from the time she was weaned off cardiopulmonary bypass (CPB). The patient received noradrenaline (0.2 μg/kg/min), adrenaline (0.2 μg/kg/min), nitroglycerin (0.3 μg/kg/min), and continuous inhalational NO (20 ppm) and was successfully weaned off CPB. She was extubated on postoperative day (POD) 2 and discharged from the intensive care unit on POD 14.

　Few studies have reported open heart surgery complicated by HHT; we describe safe anesthetic management with optimal monitoring and anesthetic strategies in a rare case of HTT in a patient who underwent cardiac surgery.

　A 67-year-old man underwent surgery for combined valvular disease. We did not identify the coronary sinus on transesophageal echocardiography (TEE) performed before cardiopulmonary bypass. Intraoperatively, following the insertion of a cannula for retrograde cardioplegia, we observed coronary sinus orifice atresia together with an unroofed coronary sinus. Preoperative contrast-enhanced computed tomography (CT) revealed that the coronary sinus opened into the left atrium. We cut the left atrium to insert the cannula for retrograde cardioplegia, and successfully performed cardioplegic perfusion. We did not modify the surgical procedure and did not repair the coronary sinus because we did not detect any other cardiovascular deformities. TEE performed after cardiopulmonary bypass revealed that the coronary sinus opened into the left atrium. However, it did not significantly affect the method and convalescence from the disorder. This case report highlights the importance of accurate preoperative CT and perioperative TEE.

　Herein, we present a case of oxygenator circuit thrombo-occlusion with rapid thrombocytopenia occurring during an emergency partial ascending aortic arch replacement for acute aortic dissection after the initiation of extracorporeal circulation. However, in addition to circuit exchange, extracorporeal circulation was continued with anticoagulation management by the combined use of argatroban and nafamostat mesilate. Consequently, the patient was rescued without neurological complications. Although there was no history of heparin administration, the patient tested positive for antiplatelet factor 4-heparin complex antibodies submitted during the operation. We therefore conclude that rapid thrombogenesis after heparinization should be addressed in light of heparin-induced thrombocytopenia in patients with and without prior heparinization.