Background : We report the current status and future of postoperative pain management after minimally invasive cardiac surgery (MICS) using a questionnaire survey.

　Method : A total of 179 hospitals were included in this survey.

　Findings : A total of 106 hospitals responded, out of which 70 hospitals performed MICS. The majority (41%) of the sites rated continuous peripheral nerve block as the primary method for postoperative analgesia. Single-shot peripheral nerve blocks were found to be performed at 20 sites, while intercostal nerve block was the most commonly practiced method (32 sites). Peripheral nerve block and postoperative pain management were provided by cardiac surgeons in more than half of the cases.

　Conclusions : In most hospitals, cardiac surgeons are the primary providers of peripheral nerve blocks and postoperative pain management in MICS cases. In the future, anesthesiologists would be required to consider and implement more effective postoperative pain management.

　In recent years, the outcomes of Fontan surgery have been improving, and we are increasingly performing anesthesia for malignant disease surgery on post-Fontan patients. However, the postoperative condition of each Fontan patient varies making it difficult to determine surgical tolerance. It is also necessary to consider cardiac function, complications associated with Fontan circulation, surgical site, surgical time, and magnitude of invasion.

　In our case, a left upper lobe resection was planned for a patient with left upper lobe lung cancer after Fontan surgery. We performed the left main pulmonary artery occlusion test for preoperative evaluation under general anesthesia with isolated lung ventilation to help determine the surgical tolerance.

　We report the case of a patient who presented with a thoracic infectious aortic aneurysm after Bacillus Calmette-Guérin (BCG) intravesical instillation therapy with concomitant severe thrombocytopenia. A-64-year-old man was transferred to our hospital for the treatment of a thoracic aortic aneurysm impending rupture. He was diagnosed with an infectious aortic aneurysm and was treated previously in another hospital. We performed thoracic endovascular aortic repair on the day of admission. The first laboratory examination at our hospital showed low blood platelet count, and thrombocytopenia persisted even after surgery.

　We diagnosed immune thrombocytopenia (ITP) because bone marrow examination showed increased giant cell count. Immunoglobulin therapy, Helicobacter pylori removal therapy, and thrombopoiesis-stimulating protein therapy were administered, and the platelet count increased post treatment. He was discharged on postoperative day 84. Five months later, mycobacteria were detected in his bloody sputum specimen, and further investigation revealed a tuberculous aortic aneurysm caused by BCG intravesical instillation therapy.

　A 9-month-old female infant was diagnosed with incomplete Cantrell syndrome with complete ectopia cordis accompanied by congenital heart defects including tetralogy of Fallot, cor triatriatum, and an unroofed coronary sinus. She was provided coverage for her heart with split thickness skin grafts after birth, and she underwent intracardiac repair and chest wall reconstruction using musculocutaneous flaps 9 months later. The long-term use of cardiopulmonary bypass for dissecting adhesions of the heart to the chest wall and repairing the complex congenital heart defects in the malposition contributed to coagulopathy and myocardial edema. The latter caused cardiac ventricular diastolic dysfunction, leading to decreased cardiac output on covering the sternal defect with a polytetrafluoroethylene sheet. Continuous epinephrine infusion and release of a part of the coverage preserved the cardiac output. Reconstruction of the chest wall was accomplished postoperatively using musculocutaneous flaps on day 11 after improving the myocardial edema with continuous hemodiafiltration.

　We report two cases of 10-month-old and 2-year-old girls with hypoplastic left heart syndrome (HLHS) who have a history of Norwood and bidirectional Glenn operations.

　They both underwent bidirectional Glenn operation and laparotomy cholecystectomy, and their electrocardiograms (ECGs) showed giant negative T-waves with QT prolongation during postoperative management in the intensive care unit (ICU). HLHS patients have a risk of coronary ischemia. However, the ECG changes did not lead to any vital changes, so we treated the patients conservatively. Transthoracic echocardiography (TTE) performed on the 2-year-old patient showed global hypocardia. For both cases, the N-terminal pro b-type natriuretic peptide (NTproBNP) levels were elevated, but creatine kinase levels were within the reference value. The ECG changes improved tendency within a few days, and TTE performed after that showed no reduction of ventricle ejection fraction. We surmise that the observed giant negative T-waves may be stress-induced.

　Left atrial intramural hematoma is a very rare condition that creates a gap in the left atrial wall or atrial septum and forms a false cavity.

　We encountered a case of acute heart failure due to left atrial intramural hematoma, which was managed with anesthesia. The case involved a 79-year-old man. The coronary artery was injured by percutaneous coronary angioplasty; the following day, transthoracic echocardiography was performed, revealing a hematoma in the left atrial wall. We removed the hematoma under cardiopulmonary bypass and subsequently embolized the injured coronary artery. The large left atrial intramural hematoma impaired blood inflow in the mitral valve and caused hemodynamic instability; thus, we avoided a sudden decrease in preload or tachycardia, and we managed the case safely. Multimodal therapy with a surgical and transcatheter approach is useful for iatrogenic left atrial hematoma.

　A 70's male patient underwent revision surgery for pseudoaneurysm at the anastomotic site of the ascending aorta graft. During the surgery, we experienced a drop in his blood pressure that did not respond to catecholamines. Transesophageal echocardiography (TEE) revealed regional wall motion abnormality (RWMA) on the anterior and anterolateral wall. We judged that myocardial ischemia requiring immediate revascularization was occurring. Furthermore, based on TEE, it was suspected that the cause of the myocardial ischemia was a blood flow disruption due to a thrombotic obstruction in the left main coronary trunk. Percutaneous coronary angioplasty (PCI) was performed to save his life. When RWMA occurs during surgery, TEE is useful for evaluating its distribution, estimating the culprit coronary artery and the cause of the RWMA, and evaluating the therapeutic effects, meaning that TEE plays an important role in saving the life of patients and their prognosis.

　Primary cardiac tumors are quite rare. The frequency of right ventricular tumor is especially low, and thus there are few opportunities to perform anesthetic management in these patients. It is necessary to be fully aware that right ventricular outflow tract obstruction due to tumor embolism can cause cardiovascular collapse during surgical removal of a right ventricular tumor. Here, we report a case of anesthetic management that was safely performed during surgical removal of a cardiac tumor that caused severe right ventricular outflow tract stenosis. Surgical removal of the tumor extending from the right ventricular outflow tract to the pulmonary valve was scheduled. Based on preoperative discussion on preventing cardiovascular collapse due to tumor embolism, induction of anesthesia was initiated while the extracorporeal circulation system was ready for immediate use. In this case, multidisciplinary collaboration was essential and the adoption of appropriate measures was crucial considering the risks associated with anesthesia induction.

　Patients with Eisenmenger syndrome are at high risk of perioperative complications in non-cardiac surgery, with a mortality rate of 3.8-24%. In perioperative management, consideration should be given to the balance of systematic and pulmonary vascular resistance and maintenance of cardiac output without increasing the right-to-left shunt. We report a case of successful anesthetic management by a combination of analgesia with peripheral nerve blocks and sedation with dexmedetomidine for femoral fracture surgery in a patient in his fifties with Down syndrome who had severe pulmonary hypertension secondary to an unrepaired atrioventricular septal defect.

　We report a patient with a deep neck abscess resulting from pharyngeal injury caused by transesophageal echocardiography (TEE). A 72-year-old male underwent TEE before radiofrequency catheter ablation for atrial fibrillation. A few hours after the examination, he developed a severe sore throat and bloody sputum. Laryngeal endoscopy revealed a laceration from the arytenoid region to the pyriform fossa, and a pharyngeal injury caused by TEE was diagnosed. He had a fever on the third day after the injury, and plain computed tomography showed fluid collection with emphysematous changes in his right neck. An emergency operation was performed under a suspicion of a deep neck abscess, and drainage and tracheostomy were carried out under general anesthesia. The patient's postoperative course was uneventful, and he was discharged. After TEE, it is necessary to pay attention to the appearance of symptoms so that the diagnosis of complications is not delayed.

　We report the case of a 69-year-old woman with blood group AB Rh-negative who underwent emergency ascending aorta and partial arch replacement for acute type A aortic dissection. Since we could not obtain the necessary amount of ABO- and Rh-matched blood products during preoperative preparation for the surgery, we transfused 2000 ml of group A RhD-negative red blood cell concentrate and 250 ml of group AB RhD-positive platelet concentrate, which had been cross-match tested, during the surgery. Postoperatively, although transient mild worsening of biochemical parameters of hepatorenal function was observed, a clinically significant hemolytic reaction did not occur. Her subsequent hospital course was fairly uncomplicated, and she was discharged home on the 31st postoperative day. In the case of transfusion of otherwise compatible blood of a different ABO group to patients with blood group AB, group O blood cell concentrates tend to be selected. The current guidelines for critical bleeding in Japan recommend using group A or group B blood cell concentrates in such cases. In this case, the planned transfusion of ABO- and RhD- different but compatible blood products based on the guidelines was effective and safe for emergency cardiovascular surgery in a patient with the rare AB Rh-negative blood group.

　Perioperative bleeding control is particularly important in patients with idiopathic thrombocytopenic purpura undergoing cardiac and major vascular surgery. In this case, the patient was started on 10 mg prednisolone and 12.5 mg eltrombopag 6 weeks before surgery. As the platelet count increased from 28,000/μl to 127,000/μl, preoperative gamma globulin therapy or platelet transfusion was not performed. In order to avoid extracorporeal circulation, she underwent off-pump coronary artery bypass grafting. Intraoperative hemostasis was achieved by transfusion of 20 units of concentrated platelets. However, postoperative graft occlusion occurred. The present case suggests that thrombopoietin receptor agonists can effectively increase platelet counts in patients with idiopathic thrombocytopenic purpura undergoing coronary artery bypass surgery, but their use should be considered with caution because of possible thrombotic complications.

　In 41 patients, anesthetic management was performed during transcatheter aortic valve implantation under non-intubation general anesthesia with remimazolam and remifentanil. We retrospectively investigated all patients within 6 months after introduction. Anesthesia with remimazolam, involving the use of flumazenil, provided prompt awakening, facilitating an immobile surgical field and stable circulatory kinetics.

　Furthermore, it was possible to achieve a stable respiratory state to most patients even in the absence of high-level airway control.

　Remimazolam is a new benzodiazepine sedative used for total intravenous anesthesia (TIVA) because of its short-acting property. However, clinical experience in children is limited, and the efficacy and safety of remimazolam have not been reported, particularly in pediatric cardiac surgery with cardiopulmonary bypass (CPB). We report a case of TIVA using remimazolam in a pediatric cardiac surgery with CPB, wherein the possibility of developing malignant hyperthermia could not be ruled out.

　We experienced multiple anesthesia in two patients with Loeys-Dietz syndrome within the same family. Case 1: 50-year-old female. She underwent emergency surgeries for two aortic dissections. In both surgeries, it was difficult to intubate and secure the arterial line, and there was significant blood loss for the patient. After discharge, she died of aortic rupture at the distal end of the replacement. Case 2: 30-year-old female, eldest daughter of the patient in Case 1. She underwent a standby basal to thoracoabdominal aortic replacement for an enlarged aorta, which was performed in triplicate. Based on our previous experience with Case 1, intubation and securing of the arterial line went smoothly, and the patient is currently doing well. This patient has an analog of Marfan syndrome, which can result in aortic dissection or rupture at a younger age. The patient is also prone to vascular tortuosity, premature skull fusion, congenital heart disease, joint contractures, and characteristic facial features and requires careful perioperative management accordingly.

　At the transition from the non-coronary cusp of the aortic valve to the anterior mitral leaflet, there is the avascular region called the mitral-aortic intervalvular fibrosa (MAIVF), and pseudoaneurysms can form due to various factors.

　In this report, two patients who were scheduled for revision aortic surgery for a pseudoaneurysm of the MAIVF (P-MAIVF) after aortic valve root replacement. The patients were found to have P-MAIVF, which could not be diagnosed by contrast enhanced CT and transthoracic echocardiography before surgery. The P-MAIVF was confirmed by intraoperative transesophageal echocardiography, which contributed to the accurate location of the MAIVF and the selection of the procedure.

　When P-MAIVF is suspected based on surgical and medical history, a transesophageal echocardiography evaluation can provide information about the lesion to the surgeon and contribute to the selection of an appropriate operative method.