【Objective】To retrospectively investigate the effects of cuffed and uncuffed endotracheal tubes (ETTs) on ETT exchanges in the pediatric intensive care unit (PICU) following a pediatric cardiac surgery.

【Methods】Our study included pediatric patients, aged 6 years or younger, who underwent cardiac surgeries at our hospital between January 2013 and July 2019. We extracted data on ETT exchange rates and postextubation adrenaline inhalation rates in the PICU from electronic medical records and compared the results between the cuffed tracheal tube (Microcuff PET^®) group (M group) and uncuffed tracheal tube group (U group). The primary endpoint was the ETT exchange rate, and the secondary endpoint was the postextubation adrenaline inhalation rate in the PICU between the M and U groups.

【Results】No significant differences in the ETT exchange rate (2/40[5.0%] vs. 8/145[5.5%], P=1.000) and postextubation adrenaline inhalation rate (75.0% vs. 67.5%, P=0.442) were observed between the M and U groups.

【Conclusion】Our findings indicated that the use of Microcuff PET^® did not significantly reduce ETT exchange rates in the PICU following a pediatric cardiac surgery. Further studies are required to demonstrate the usefulness of Microcuff PET^® in enhancing ETT exchanges in the PICU.

【Purpose】Red blood cell distribution width (RDW) serves not only as a diagnostic tool for anemia but also as a biomarker for inflammatory conditions. It also serves as a prognostic factor for chronic diseases and predictor for the outcomes following acute illnesses and surgery involving general anesthesia. This study examines the correlation between preoperative RDW and prognosis for adults undergoing routine cardiac surgery.

【Method】A retrospective investigation involving 211 patients (134 males and 77 females) aged over 20 years who underwent routine cardiac surgery under general anesthesia at our hospital between January 2014 and September 2020 was conducted. The optimal cutoff value for predicting postoperative deaths within 1 year and 30 days through RDW levels measured within 1 week before surgery was determined by receiver operative characteristics (ROCs). Logistic regression analysis was used to assess the link between prognosis and RDW levels thus determined.

【Results】Patients' age range was 42–91 years (mean age: 73.1±9.5 years), with an average preoperative RDW value of 14.4±1.9. The numbers of postoperative deaths within 1 year and 30 days were 10 and 24, respectively. The optimal RDW cutoff value to predict postoperative deaths within 1 year and 30 days from the results of ROC analysis was 15.3. The odds ratio (95% confidence interval) for postoperative deaths within 1 year for patients with high preoperative RDW values was 2.63 (1.05, 6.61). Moreover, the odds ratio for postoperative deaths within 30 days was 4.14 (1.06, 16.19).

【Conclusion】Preoperative RDW is related to both short- and long-term prognosis in adults undergoing routine cardiac surgery.

　Regional cerebral oxygen saturation (rSO₂) is recommended for detecting cerebral blood flow abnormalities during cardiovascular surgery. However, there are cases wherein abnormalities cannot be determined with rSO₂ alone. NPi-200^TM (IM Co., Ltd., Saitama, Japan) is a pupil recorder used to detect abnormalities in cerebral perfusion. It quantitatively measures the Neurological Pupil Index (NPi) with numerical values between 0.0 and 5.0 (<3.0 abnormal). Here, we report a case where the NPi value was useful in determining cerebral perfusion injury. An 83-year-old woman underwent aortic arch replacement for an aortic aneurysm. After arterial cannulation for cardiopulmonary bypass, abnormal cerebral perfusion associated with the onset of aortic dissection was suspected based on low rSO₂ levels. Despite this, a diagnosis could not be made since findings from transesophageal echocardiography, readings of aortic properties, and operation of cardiopulmonary pump were all normal. However, since NPi was 0 at that point, we were convinced that there was a cerebral perfusion injury. Before aortic dissection could be diagnosed, we were able to quickly plan the introduction of hypothermia at 26℃, as well as the start of selective cerebral perfusion. When the ascending aorta was incised, dissection from the right brachiocephalic artery to the ascending arch was observed. However, the planned procedure was performed, and there were no postoperative neurological sequelae. We believe that the NPi monitor is useful for judging intraoperative perfusion injury that occurs during non-hypothermic conditions in cardiac and major blood vessel surgery.

　The incidence of paraplegia in thoracic endovascular aortic repair (TEVAR) is considered to be lower than that in open surgical repair; however, once it occurs, it can be a serious problem affecting the patient's prognosis. Cerebrospinal fluid drainage (CSFD), known as spinal cord protection strategy, is recommended selectively for patients at high risk of paraplegia, such as patients with planned extensive thoracic aorta coverage (>200 mm) or previous abdominal aorta aneurysm repair. Careful management is required because the procedure itself can sometimes cause serious complications. We report a case of acute postoperative paraplegia in a 78-year-old man who underwent TEVAR and fenestrated endovascular aortic repair (F-EVAR) for a Crawford classification II thoracoabdominal aortic aneurysm. Various treatments including CSFD were performed, and the paraplegia improved. However, an epidural hematoma, possibly caused by CSFD, became a problem. This is a case that requires careful consideration regarding spinal cord protection strategies.

　Aortic dissection in young women is rare, and approximately half of the cases are associated with pregnancy. Obstetrical hemorrhage due to heparin use is a problem with aortic replacement after cesarean section and postpartum. We report an experience with anesthetic use in a young woman who developed acute aortic dissection immediately after delivery and underwent aortic root replacement.

　A 38-year-old woman was brought to our hospital with chest and back pain after vaginal delivery. She underwent Bentall and coronary artery bypass surgeries for acute aortic dissection of Stanford type A and suspected coronary artery dissection. Preoperative discussion of the management of obstetrical hemorrhage was done with an obstetrician. It was decided that aortic root replacement was the highest priority due to suspected coronary artery dissection. Hence, a prophylactic total hysterectomy was not performed. Prophylactic administration of uterotonics was avoided because of the possible progression of coronary artery dissection due to elevated blood pressure. Propofol, a weak uterine relaxant, was used as a sedative, and blood loss following delivery was estimated by the operating room staff from sheets soaked with blood and loss of circulating blood volume. Uterotonics, placement of intrauterine balloon tamponade, and total hysterectomy were planned in case of obstetric hemorrhage. The surgery was completed without obstetrical hemorrhage, and she was discharged on the postoperative day 13.

　During the Bentall operation immediately after delivery, it was important to prevent obstetric hemorrhage. We safely manage the patient in collaboration with related departments and operating room staff.

　A 56-year-old man with acute myocardial infarction underwent emergency coronary artery bypass graft surgery. Following the induction of general anesthesia, a central venous catheter was inserted via the right internal jugular vein under ultrasound guidance. Resistance was encountered during guidewire removal, prompting the use of transesophageal echocardiography, which revealed entanglement of the guidewire tip with the Eustachian valve. Attempts to straighten and untangle the guidewire using a longer dilator were unsuccessful. Considering the potential risk of cardiac structure damage, the open-chest procedure was performed, allowing for direct visualization and successful removal of the guidewire.

　When encountering catheter entanglement within the right atrium, the normal structures, such as the tricuspid valve, and the presence of embryonic remnants should be considered for an accurate differential diagnosis. Transesophageal echocardiography serves as a valuable diagnostic tool in identifying this condition. In catheter removal procedures, minimally invasive techniques should be initially employed. If unsuccessful, owing to the potential risk of injury, removal should be attempted in the operating room under the supervision of cardiac surgeons.

　An aortocaval fistula (ACF) is a rare complication of a ruptured aortic aneurysm that presents with various symptoms. High-output cardiac failure, one of the clinical presentations of ACF, has a high mortality rate. This study focused on circulatory management during anesthesia for endovascular aneurysm repair (EVAR) of an ACF associated with high-output cardiac failure. A 70-year-old man was transferred to our department for surgical treatment of an abdominal aortic aneurysm (AAA) with probable rupture. Ultrasound examination showed an infrarenal AAA ruptured into the inferior vena cava (IVC), thereby causing high-output cardiac failure with abnormal liver function parameters and enlargement of the right ventricle. His condition deteriorated so rapidly that emergent surgical treatment for the ACF was indicated. EVAR was chosen because it is less invasive than open surgery. Due to the patient's unstable hemodynamic state, general anesthesia was administered during the procedure, but induction of general anesthesia resulted in persistent hypotension that required large amounts of catecholamines. The EVAR was successfully completed without any catastrophic cardiac event. The hemodynamic instability improved immediately with deployment of a stent-graft in the aorta and exclusion of the communication with the IVC. It should be noted that resuscitative endovascular balloon occlusion of the aorta (REVOA), even though just a palliative treatment for ACF, effectively achieves hemodynamic stabilization in patients who fail to respond to inotropic agents.

　An 88-year-old woman underwent emergency ascending aortic replacement for Stanford type A aortic dissection. Postoperative thoracic contrast computed tomography (CT) and right ventriculography revealed the formation of a pseudoaneurysm in the right ventricular apex, which was suspected to be caused by the insertion of a pulmonary artery catheter. The patient was treated conservatively, and six months after the surgery the pseudoaneurysm had disappeared on contrast CT. Right ventricular pseudoaneurysm formation is an extremely rare and potentially fatal complication of pulmonary artery catheter insertion. When inserting a pulmonary artery catheter, the possibility of myocardial injury, including right ventricular pseudoaneurysm formation, should be considered, and excessive repetition of intraventricular catheter manipulation should be avoided in high-risk patients. Catheter withdrawal should be considered if induction into the pulmonary artery is difficult. In addition, if habitual pulmonary artery catheterization is required, the indication should be reconsidered.

　Significant pulmonary valve regurgitation after congenital heart disease surgery in adults is being observed increasingly. Since 2010, transcatheter pulmonary valve implantation (TPVI) is being performed in the United States in patients with a history of multiple operations, who are considered at high risk for open heart surgery. The Harmony? Transcatheter Pulmonary Valve System (Medtronic Japan, Inc., [Harmony TPV]) was introduced into clinical practice in Japan in March 2023. It is a transcatheter implantation system that uses a porcine pericardial bioprosthetic valve attached to a self-expandable nitinol frame. Transcatheter implantation of the device is performed using a biplane X-ray angiography system. Although TPVI is minimally invasive, the caveats associated with this approach include the need for nonoperating room anesthesia management, complications attributable to poor surgical skill, procedure-related arrhythmias, and circulatory instability during valve deployment.

In this report, we describe our experience with anesthesia management in two cases of TPVI.

　During cardiovascular surgery with cardiopulmonary bypass, abnormal elevation of oxygenator inlet pressure can result in critical situations such as emergency oxygenator changeout. To study cases of abnormally elevated pressure, we herein identified patients who underwent adult cardiovascular surgery with cardiopulmonary bypass at our hospital between April 2015 and March 2021 and experienced an increase in oxygenator inlet pressure of 300 mmHg or higher based on cardiopulmonary bypass records. Five of 463 patients (1.1%) showed an abnormal increase in oxygenator inlet pressure. In only one of the five patients, oxygenator inlet pressure temporarily exceeded 400 mmHg, whereas in the other four patients, it did not increase above 400 mmHg. According to the Japanese Society for Cardiovascular Surgery, emergency oxygenator changeout is not necessary when oxygenator inlet pressure is below 400 mmHg. In this case report, the specified hemodynamic index was maintained for all patients, and oxygenator changeout was not required.

　Pregnant women with congenital heart disease experience significant changes in circulatory dynamics as a result of increased circulating blood volume and cardiac output associated with pregnancy. We report a case of partial anomalous pulmonary venous return during pregnancy that developed into hemoptysis. The patient, a 36-year-old woman, was diagnosed with partial anomalous pulmonary venous return at the age of 19. She had hemoptysis during her last pregnancy and underwent bronchial artery embolization. At 34 weeks of pregnancy, she visited the emergency room due to hemoptysis and dyspneic sensation. At the time of arrival, she was unable to lie supine due to dyspnea. Blood test results indicated anemia, but coagulation was within normal limits. A chest CT scan showed that the right upper pulmonary vein flowed into an odd vein and the right main bronchus had a blood clot that almost completely occluded the lumen. We suspected that hemoptysis occurred due to increased pulmonary blood flow associated with partial anomalous pulmonary venous return in addition to the increased circulating blood volume and cardiac output associated with pregnancy. We judged the patient would have difficulty continuing her pregnancy, and an emergency Cesarean section was performed. Due to the patient's inability to lie supine due to respiratory distress and concerns about respiratory and circulatory changes associated with postoperative pain, general anesthesia with epidural anesthesia was selected as the anesthetic method. Intraoperative circulatory dynamics did not change significantly during the operation, and the surgery was completed successfully.

　We experienced two cases of Stanford type A acute aortic dissection (AoD) in patients with anomalous origin of the right coronary artery (RCA). In these two cases, the RCA originated anterior to the left coronary artery (LCA) on the left coronary cusp (LCC) side, coursed between the aorta and pulmonary artery toward the anterior aorta, and perfused the RCA area. The two patients presented with preoperative or intraoperative ischemic symptoms in the RCA area, although the RCA was not involved in the aortic dissection. AoD in patients with anomalous origin of the RCA can cause ischemic symptoms via unusual mechanisms. It is therefore important to confirm the origin and course of coronary arteries and the presence of dissection in coronary arteries as well as to observe any regional wall motion abnormalities and the treated area when using transesophageal echocardiography.

　Löffler's endocarditis is a cardiac complication of hypereosinophilic syndrome. Herein, we report a case of Löffler's endocarditis associated with severe mitral regurgitation (MR).

　A 74-year-old woman was brought to the emergency department with chest pain and dyspnea and was diagnosed with congestive heart failure. Initial blood investigations revealed an elevated eosinophil count (3,240/μL), and echocardiography revealed thrombus formation in the left ventricle. The suspected diagnosis was Löffler's endocarditis. Medical treatment with an anticoagulant and steroid was ineffective, and severe MR appeared during the disease course. As MR was refractory to medical treatment, surgical correction was planned. As the degree of mitral valve tethering was mild and the possibility of reversible change to the thrombus could not be ruled out, we decided to first perform left ventricular thrombus removal. However, transesophageal echocardiography after thrombus removal and resumption of self-paced heartbeat revealed residual findings of severe MR. Intraoperative findings showed severe degeneration of the papillary muscles and tendon cords; therefore, the mitral valve was replaced. The results suggest that MR associated with Löffler's endocarditis, characterized by fibrosis and other tissue degeneration, may require valve replacement.

　A woman in her twenties (height: 166 cm, weight: 64 kg) underwent inpatient management for congenital absence of the pericardium, which complicated her pregnancy. However, she developed chest pain, and emergency cesarean section was performed at 34 weeks and 4 days of gestation. An antecedent MRI revealed an approximately 3 cm defect in the left ventricular apex epicardium with ECG changes dependent on positioning. Preoperatively, the patient experienced chest pain in the left lateral decubitus position, while being asymptomatic in the supine position. Combined spinal and epidural anesthesia (CSEA) was selected, with the puncture performed in the right lateral decubitus position. There was no subsequent conversion to the supine position perioperatively. Intraoperatively, the patient did not report chest pain and palpitations, and the hemodynamic status remained stable. The pericardial defect at the left ventricular apex may have deviated due to the left lateral decubitus position, resulting in thoracic symptoms. Contributing factors to exacerbating symptoms may include physical factors associated with uterine enlargement throughout the pregnancy and increased pre-load due to augmented circulatory blood volume. Considering the uncertainty surrounding the impact of positive pressure ventilation on the mother and fetus, general anesthesia was avoided, and CSEA, which our institution is most proficient in, was selected for perioperative management for pericardial defect complicating pregnancy. While there is no definitive consensus regarding the selection of anesthetic techniques for cesarean sections in cases of congenital absence of the pericardium during pregnancy, this case demonstrated the feasibility of stable anesthetic management with CSEA.

　A 13-month-old, male infant with pulmonary atresia with an intact ventricular septum underwent a bidirectional Glenn procedure. Elevated superior vena cava (SVC) pressure and facial congestion four minutes after SVC cannulation and snaring around the cannula were observed. After re-positioning of the cannula failed to decrease the SVC pressure, the cannula was removed from the SVC to reveal a thrombus-like object within. A cannula of the identical type and size was placed in the SVC. Thereafter, the venous return normalized, and the surgery proceeded without incident. A pathological analysis of the object from the cannula revealed a white thrombus.

　Luminal white thrombus formation in the cannula was thought to be the cause of the inadequate venous return in the present patient. Although patient-specific factors, qualitative and quantitative deficiency of anticoagulants, and cannula-specific factors were potential causes of the thrombus formation, an activated clotting time >1200 sec and the absence of clot formation in any part of the circuit besides the cannula suggested that a cannula-specific factor was the cause. The affected cannula was returned to the manufacturer for inspection, but no aberration was able to be found.

　Inadequate venous drainage from an SVC cannula may result in neurological sequelae without any change in the mean arterial pressure, flow rate of the cardiopulmonary bypass or mixed venous O₂ saturation. Therefore, it is important to monitor closely for facial congestion and conjunctival edema in addition to SVC pressure and regional cerebral oxygenation as measured by near-infrared spectroscopy.

　A 78-year-old woman with a narrow sino-tubular junction (STJ) was scheduled for surgical aortic valve replacement to treat severe aortic stenosis. The highly calcified STJ had narrowed to a diameter of 17 mm, rendering the passage of a conventional prosthetic valve difficult. Although transcatheter aortic valve replacement was considered to be high risk due to the extreme calcification, we believed the Perceval^® collapsible bioprosthetic valve (Corcym Japan) could pass through the stenotic STJ. Since it was difficult to visualize the position of the implanted valve during surgery as there was almost no gap between the aortic wall and the device in the narrow STJ, we inserted a thoracoscope between the valve and the aortic wall to obtain a field of view. Postimplantation, transesophageal echocardiography (TEE) showed correct valve positioning and no evidence of abnormal opening or closing, or decreased coronary blood flow. A trivial transvalvular regurgitation was observed but was judged amenable to follow-up. Transthoracic echocardiography on postoperative day 8 showed no regurgitation. Thus, after Perceval^® bioprosthetic valve implantation, TEE is useful to evaluate valve deployment, positioning in relation to the coronary artery, and the presence and severity of regurgitation. As with other bioprosthetic valves, the Perceval^® valve ring may be difficult to observe due to high echogenicity. In cases such as this, where it is difficult to visually confirm the position of the valve in the operative field due to STJ stenosis, TEE plays a significant role in confirming a successful procedure.

　We report a case of a 65-year-old man with mitral regurgitation and atrial fibrillation. He underwent mitral valve replacement and left atrial appendage closure with the AtriClip device via robotic-assisted cardiac surgery. It was difficult to wean from the cardiopulmonary bypass due to regional hypokinesis in the inferolateral wall of the left ventricle with transesophageal echocardiography (TEE), resulting in ventricular fibrillation. The surgeon could not find the left circumflex artery (LCX) blood flow by fluorescence imaging of indocyanine green; hence, the AtriClip device was removed considering LCX obstruction. Consequently, we observed no regional wall abnormalities in TEE after device removal, and weaning from cardiopulmonary bypass was uneventful. LCX is near the base of the left atrial appendage. Therefore, the regional wall abnormalities of the left ventricle and LCX blood flow with TEE should be confirmed in case of left atrial appendage closure by the AtriClip device.

　Traumatic tricuspid regurgitation secondary to blunt chest trauma is often missed at initial presentation, which may be attributable to the rarity of this condition, low levels of awareness, difficulty in accurate evaluation owing to the accompanying blunt chest trauma, and nonspecific initial symptoms. A few studies have reported delayed valve injury after blunt chest trauma. In addition, owing to the insidious nature of symptoms, diagnosis is often delayed until progression of right heart failure. Therefore, in cases in which blunt chest trauma or elevated myocardial biomarkers are present, echocardiography and other tests should be performed at the initial visit and repeatedly thereafter to differentiate blunt cardiac injury. Although there is lack of consensus regarding treatment, surgical intervention may be recommended for management of severe primary tricuspid regurgitation. Traumatic tricuspid regurgitation can occur in young individuals, and it is important to avoid missing the time when valve repair is possible. In our case, trauma-induced significant tricuspid regurgitation was not detected during initial transthoracic echocardiography performed urgently prior to emergency surgery for traumatic aortic injury. However, we were able to detect severe traumatic tricuspid regurgitation by transesophageal echocardiography before cardiac arrest during cardiopulmonary bypass, which allowed us to repair the valve in one stage and favorable recovery.