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Background Cardiac surgery in frail patients has been reported to be associated with increased mortality and morbidity but may improve functional status of frail patients. Few studies have investigated the impact of cardiac surgery on the trajectory of postoperative frailty. We hypothesized that cardiac surgery in frail patients would improve frailty postoperatively. Method This study included 71 patients over 65 years old who were scheduled for cardiac surgery via sternotomy or thoracotomy. Frailty was prospectively evaluated using the Kihon Checklist (KCL) at 1 and 3 months postoperatively. Patients were divided into three groups based on the preoperative KCL score: nonfrail, prefrail, and frail. The interaction between the degree of preoperative frailty and the trajectory of postoperative KCL scores was assessed. Results The KCL score changed significantly over time (P < 0.001), and the KCL score trajectory differed significantly according to the degree of preoperative frailty (P for interaction = 0.003). In the frail group, the KCL score was significantly lower 3 months postoperatively than preoperatively (median 8, interquartile range [5, 9] versus median 9, interquartile range (9, 13), P = 0.029). Conclusion The trajectory of postoperative KCL scores differed significantly depending on the degree of preoperative frailty. At 3 months after cardiac surgery, the KCL score of frail patients was significantly improved, while that in nonfrail patients was significantly deteriorated., Author(s): Koya Shimakura [sup.1], Kimito Minami [sup.2], Kenji Yoshitani [sup.1], Yoshihiko Ohnishi [sup.1], Hiroki Iida [sup.3] Author Affiliations: (1) grid.410796.d, 0000 0004 0378 8307, Department of Anesthesiology, National Cerebral and [...]

Purpose Fulminant myocarditis is uncommon, but life-threatening, and some patients need mechanical circulatory support. This study was performed to evaluate how different types of mechanical circulatory support-biventricular assist device (BiVAD) or left ventricular assist device (LVAD) placement-affect intraoperative hemodynamic status. Methods From January 2013 to September 2016, the patients who underwent BiVAD or LVAD placement for fulminant myocarditis were analyzed. The mean arterial pressure (MAP), mean pulmonary arterial pressure, central venous pressure (CVP), vasoactive score, and inotropic score were recorded at five time points: after the induction of anesthesia; at weaning, 30 min after weaning, and 60 min after weaning from cardiopulmonary bypass (CPB); and at the end of surgery. The vasoactive and inotropic scores were calculated as follows: vasoactive score = norepinephrine ([micro]g/kg/min) x 100 + milrinone ([micro]g/kg/min) x 10 + olprinone ([micro]g/kg/min) x 25: inotropic score = dopamine ([micro]g/kg/min) x 1 + dobutamine ([micro]g/kg/min) x 1 + epinephrine ([micro]g/kg/min) x 100. Results We enrolled 16 patients of fulminant myocarditis. Ten of them underwent BiVAD placement, and the other underwent LVAD placement. After weaning from CPB, the BiVAD group had a significantly lower MAP but no difference in CVP. The vasoactive score was significantly higher in the BiVAD group at weaning of CPB (p = 0.015), 30 min after weaning (p = 0.004), 60 min after weaning (p = 0.005), and at the end of surgery (p < 0.016). Conclusion Patients with BiVAD placement required more vasoactive support to maintain optimal hemodynamic status compared with those with LVAD placement. This result indicates that BiVAD placement was more associated with vasoplegic syndrome., Author(s): Mariko Ezaka [sup.1] , Takuma Maeda [sup.2] [sup.3] , Yoshihiko Ohnishi [sup.2] Author Affiliations: (Aff1) 0000 0004 0436 8259, grid.459808.8, Department of Anesthesiology, New Tokyo Hospital, , 1271 Wanagaya, [...]

Purpose The aim of this study was to examine the relationship between FFP (fresh frozen plasma)/pRBC (packed red blood cell) transfusion ratio and outcomes in patients undergoing cardiovascular surgery. Methods This is a single center retrospective cohort study performed in a cardiovascular center. Patients undergoing cardiovascular surgery between January 2012 and October 2016 with or without massive transfusion (n = 1453). Patients' outcomes were compared based on FFP/pRBC transfusion ratio (FFP/pRBC > 1 or FFP/pRBC [less than or equal to] 1). Results In hospital mortality and rate of stroke and myocardial infarction was significantly higher in patients with less than 1 of FFP/pRBC transfusion ratio only in patients with massive transfusion (3.0 vs 8.8%, p = 0.001; 0.7 vs 6.4%, p < 0.001; 1.0 vs 3.2%, p = 0.047, respectively). Conclusions Higher FFP/RBC ratio was associated with reduced risk of death, stroke and myocardial infarction only in patients with cardiovascular surgery receiving massive transfusion. Clinicians should be aware that judicious FFP replacement plays a critical role in the successful management of massive transfusion in cardiac surgery., Author(s): Akito Tsukinaga [sup.1] , Takuma Maeda [sup.1] [sup.2] , Shunsuke Takaki [sup.3] , Nobuaki Michihata [sup.4] , Yoshihiko Ohnishi [sup.1] , Takahisa Goto [sup.5] Author Affiliations: (Aff1) 0000 0004 [...]

Purpose The fourth-generation FloTrac/Vigileo[TM] improved its algorithm to follow changes in systemic vascular resistance index (SVRI). This revision may improve the accuracy and trending ability of CI even in patients who undergo abdominal aortic aneurysm (AAA) surgery which cause drastic change of SVRI by aortic clamping. The purpose of this study is to elucidate the accuracy and trending ability of the fourth-generation FloTrac/Vigileo[TM] in patients with AAA surgery by comparing the FloTrac/Vigileo[TM]-derived CI (CI.sub.FT) with that measured by three-dimensional echocardiography (CI.sub.3D). Methods Twenty-six patients undergoing elective AAA surgery were included in this study. CI.sub.FT and CI3.sub.D were determined simultaneously in eight points including before and after aortic clamp. We used CI.sub.3D as the reference method. Results In the Bland-Altman analysis, CI.sub.FT had a wide limit of agreement with CI.sub.3D showing a percentage error of 46.7%. Subgroup analysis showed that the percentage error between CO.sub.3D and CO.sub.FT was 56.3% in patients with cardiac index < 2.5 L/min/m.sup.2 and 28.4% in patients with cardiac index [greater than or equal to] 2.5 L/min/m.sup.2. SVRI was significantly higher in patients with cardiac index < 2.5 L/min/m.sup.2 (1703 ± 330 vs. 2757 ± 798; p < 0.001). The tracking ability of fourth generation of FloTrac/Vigileo[TM] after aortic clamp was not clinically acceptable (26.9%). Conclusions The degree of accuracy of the fourth-generation FloTrac/Vigileo[TM] in patients with AAA surgery was not acceptable. The tracking ability of the fourth-generation FloTrac/Vigileo[TM] after aortic clamp was below the acceptable limit., Author(s): Takuma Maeda [sup.1] [sup.2] , Kohshi Hattori [sup.3] , Miho Sumiyoshi [sup.1] , Hiroko Kanazawa [sup.1] , Yoshihiko Ohnishi [sup.1] Author Affiliations: (Aff1) 0000 0004 0378 8307, grid.410796.d, Department [...]

Background Near-infrared spectroscopy (NIRS)-based cerebral oximetry is a noninvasive technology used to estimate regional cerebral oxygen saturation (rSO.sub.2). Extracranial blood flow is known to substantially affect rSO.sub.2 values measured by most clinically available devices. Several studies have also reported that the Trendelenburg position and upright position have a larger effect on rSO.sub.2 measurements than the supine position. Therefore, we investigated the effect of these two positions (the Trendelenburg position versus the upright position) and extracranial contamination on rSO.sub.2 measurements obtained using two commercially available devices and one prototype device. Methods Twelve healthy volunteers were enrolled in the study. They each had three cerebral oximetry devices applied to their forehead (FORE-SIGHT ELITE[TM], CAS Medical Systems Inc., Branford, CT, USA; INVOS 5100c[TM], Medtronic, Minneapolis, MN, USA; and NIRO-TRS, Hamamatsu Photonics, Hamamatsu, Japan). A circumferential pneumatic head cuff was positioned proximal to the NIRS cerebral oximetry sensors. We measured rSO.sub.2, heart rate (HR), and blood pressure (BP) in six conditions (supine, Trendelenburg and upright positions, with and without scalp ischemia induced by head cuff inflation) every 5 min with each oximetry device. Total hemoglobin (tHb), which is associated with cerebral blood volume (CBV) as measured by positron emission tomography, was measured using the NIRO-TRS device to determine extracranial blood volume in each position. Results Measurements of rSO.sub.2 with all the devices were affected by extracranial contamination. The percentage of extracranial contamination was highest with INVOS 5100c[TM] in the upright position (INVOS, 21.3%; FORE-SIGHT, 14.3%; NIRO-TRS, 3.6%). Measurements of rSO.sub.2 obtained in the upright position were significantly lower than those obtained in the supine position, using INVOS-5100c[TM] and FORE-SIGHT ELITE[TM] (71 vs. 74% and 67 vs. 72%, respectively), but not using NIRO-TRS (62 vs. 64%). A significant decrease in tHb was observed after head cuff inflation in the supine and Trendelenburg positions (supine, 0.132-0.123 [mu]mol/l; Trendelenburg, 0.133-0.125 [mu]mol/l). Conclusions Except when using NIRO-TRS, measurements of rSO.sub.2 in the forehead are significantly lower when measured in the upright position than in the supine position. All devices in this study were affected by extracranial contamination., Author(s): Shinya Kato [sup.1] [sup.2] , Kenji Yoshitani [sup.1] [sup.2] , Yosuke Kubota [sup.1] , Yuzuru Inatomi [sup.1] , Yoshihiko Ohnishi [sup.1] Author Affiliations: (1) 0000 0004 0378 8307grid.410796.dDepartment of [...]

Moyamoya disease is a chronic cerebrovascular occlusive disease, occurring predominantly in young populations, that causes cerebral ischemia and hemorrhage. Patients with moyamoya disease are at high risk of neurological complications during cardiac surgery because of perioperative hemodynamic changes. However, there is no established evidence on temperature management during cardiopulmonary bypass. Previous reports described normothermia or mild to moderate hypothermia during cardiopulmonary bypass in patients with moyamoya disease; however, surgical conditions, such as not having enough space to clamp the aorta or a clean surgical field, sometimes force us to use deep hypothermic circuratory arrest. We report a successful case of a pediatric patient with moyamoya disease who underwent deep hypothermic circulatory arrest (18°C) for hemiarch replacement without neurological complications. Deep hypothermia may be an alternative technique for achieving cerebral protection in the context of moyamoya disease. Keywords Moyamoya disease * Deep hypothermic circulatory arrest * Cardiopulmonary bypass, Introduction Moyamoya disease (MMD) is a chronic progressive cerebrovascular disease involving occlusion of the internal carotid arteries and development of collateral networks [1]. MMD presents predominantly in young populations in [...]

Purpose Thoracic endovascular aortic repair (TEVAR) an emerging less invasive alternative to surgery, is now being increasingly employed, but spinal cord ischemia (SCI) is still a threat with this procedure. Delayed paraplegia has been frequently observed after TEVAR, suggesting there may be different courses of SCI between TEVAR and the conventional open surgical repair (OSR) of thoracic and thoracoabdominal aneurysms. Therefore, we conducted a study to investigate the risk factors for and the course of SCI after TEVAR and OSR. Methods We studied a series of 414 OSR and 94 TEVAR patients prospectively. Postoperative motor function, sensory disturbance, and bladder disturbance were assessed daily to evaluate the course of SCI. Previously reported risk factors for SCI were investigated. Results Spinal cord ischemia occurred in 6 patients (6.4%) in the TEVAR group, and in 18 patients (4.3%) in the OSR group, resulting in no significant difference (p = 0.401). A greater percentage of patients (n = 4, 66.7%) with SCI in the TEVAR group had a delayed onset, compared with 16.7% (n = 3) in the OSR group (p = 0.038). The rate of recovery of walking function after SCI and the incidence of sensory disturbance and bladder dysfunction was similar in the two groups. Multivariate analysis demonstrated that, in the TEVAR group, the stent length of aortic coverage was a significant risk factor for SCI. Conclusion The incidence of SCI was similar in the OSR and TEVAR groups, but delayed SCI occurred more frequently in the TEVAR group. Except for the delayed onset of SCI, SCI showed a similar course of recovery in the two groups. Keywords Spinal cord ischemia * Motor evoked potentials * Thoracic aneurysm surgery, Introduction Spinal cord ischemia (SCI) is one of the most devastating complications of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA) repair. Patients with postoperative SCI have a mortality [...]

Background Paraplegia is a serious complication of descending and thoracoabdominal aortic aneurysms (dTAAs and TAAAs) surgery. Motor evoked potentials (MEPs) enable monitoring the functional integrity of motor pathways during dTAA and TAAA surgery. Although MEPs are sensitive to temperature changes, there are few human data on changes of MEPs during mild and deep hypothermia. Therefore, we investigated changes of MEPs in deep hypothermic circulatory arrest (DHCA) in dTAA and TAAA surgery. Methods Fifteen consecutive patients undergoing dTAA and TAAA surgery using DHCA were enrolled. MEPs were elicited and recorded during each degree Celsius change in nasopharyngeal temperature during both the cooling and rewarming phases. Hand and leg skin temperature were also recorded simultaneously. Results In the cooling phase MEP amplitude decreased lineally in both the hand and leg. The MEP disappeared at ~16°C in both the hand and leg in 10 of 15 patients, but was still elicited in 5 patients. In the rewarming phase MEP in the hand recovered before the temperature reached 20°C for eight patients and 25°C for the other seven patients. In contrast, MEP in the leg recovered below 20°C for two patients and 30°C for three patients. For the other eight patients MEP waves did not recover during the rewarming phase. Conclusion In the cooling phase of DHCA, MEP disappeared at * 16°C in some patients but was still elicited in others. MEP recovered below 25°C in the hand. Recovery of MEP in the leg was, however, extremely variable. Keywords Aortic aneurysm, thoracic * Circulatory arrest, deep hypothermia-induced * Evoked potentials, motor, Introduction Paraplegia is a serious potential complication of the surgical repair of descending thoracic aneurysm (dTAA) and thoracoabdominal aortic aneurysms (TAAAs) and still occurs in a high percentage of patients. [...]