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Regional cerebral oxygen saturation measured by near-infrared spectroscopy has been used clinically. Its usefulness in cardiac surgery and neurosurgery was also reported. On the other hand, accuracy of rSO2 values has been supposed to be doubtful due to extra-cerebral contamination and unstable mean optical path-length. Therefore, we tried to review issues for accuracy of rSO2 values and clinical usefulness. Our aim is to clarify the issue and clinical usefulness of measuring regional cerebral oxygen saturation.

Despite considerable advances in anesthesia technique, intraoperative aortic dissection remains a potentially lethal complication during on-pump cardiovascular surgery. Intraoperative dissection has been described worldwide, ranging between 0.06% and 0.24%. Here we present 8 patients who had intraoperative dissection during 10-year period with 6,266 on-pump cases (0.13%, 95% confidence interval 0.12% to 0.14%). In-hospital mortality rate of intraoperative dissection was 12.5% (1/8) at our institution, which was exceptionally lower than that reported previously (24% to 43%). Therefore, we also show our treatment strategy for intraoperative dissection with the related-literature review. The original surgical procedures were descending aortic replacement in 3 patients, valve replacement in 4 patients, and aortic-root replacement in 1 patient. Dissection occurred during aortic cannulation in 6 patients and during manipulation of aortic cross-clamping/de-clamping in 2 patients. Three patients had retrograde dissection extending and beyond the arch. Trans-esophageal echocardiography was useful to confirm dissection and ensure proper perfusion of the aortic-branches. Immediately after its diagnosis, all patients were managed with hypotensive strategy and subsequently underwent deep hypothermic circulatory arrest for prevention of dissection propagation. Among patients with intraoperative aortic dissection undergoing on-pump cardiovascular surgery, not only earlier diagnosis but proper anesthetic management may be crucial for the successful outcome.

Hybrid cardiac surgeries combined with catheter intervention and surgical procedure have been performed for infants and neonates in many institutions. Especially, a hybrid operation combining bilateral pulmonary artery banding with arterial duct dilating and stenting for hypoplastic left heart syndrome (HLHS) has achieved similar result compared with Norwood procedure for first stage procedure. Hybrid operation has been selected in a HLHS neonate with risk factors of low weight, intact atrial septum, and severe coexisting issues. In our institution, hybrid operating theater was newly established, and we also experienced the hybrid procedure in a HLHS neonate with high risk factor.

We experienced a patient with severe COPD undergoing OPCAB who showed difficult perioperative respiratory and circulatory management. Since patients with severe COPDs are often complicated with not only respiratory but also circulatory problems such as right heart failure, it is necessary to assess preoperatively the method of intraoperative management including operative procedure.

Pregnant patients with prosthetic valve need anticoagulation therapy during pregnancy to prevent stuck valve. Regarding the thrombosed valve, there is a dilemma between anticoagulation to prevent further thrombus formation and postoperative bleeding after caesarian section until valve replacement surgery. A 35-year-old woman in her 34th weeks of pregnancy with a thrombus on prosthetic mitral valve was scheduled for emergency caesarian section under general anesthesia. Anticoagulation therapy with heparin was started after admission to the intensive care unit targeting the range between 70-100 second of activated partial thromboplastin time to prevent further thrombus formation. Heparin was administered intravenously (25,000 units per day), but APTT was kept over 110 seconds. Abdominal wall hematoma was detected by percutaneous echo next day and surgery for removal of hematoma was performed. Mitral valve replacement surgery was performed on the postoperative third days successfully. Postoperative anticoagulation therapy with heparin should be started carefully in consideration of physiological change of clotting ability after the termination of pregnancy.

We report on a child with moyamoya disease combined with von Gierke's disease. A 7-year-old girl with von Gierke's disease had a stroke associated with moyamoya disease. She had had many episodes of hypoglycemia and severe metabolic acidosis before surgery. General anesthesia was induced with midazolam 3 mg and fentanyl 100 microg followed by rocuronium 12 mg. After tracheal intubation, anesthesia was maintained with sevoflurane 2.5% in 33% oxygen and 66% nitrous oxide. We used mainly mixture of saline and glucose as intraoperative fluid instead of acetated Ringer solution, and controlled administration of glucose according to blood glucose levels. The patient's plasma lactate levels and base excess during operation showed changes compared with those before operation, because sodium bicarbonate was used during the surgery. The duration of anesthesia was 374 minutes. The patient woke up and spontaneous respiration returned, and the trachea was extubated in the operating room. We were able to manage this case safely without any complications.

In Japan, over 50 thousand pulmonary artery catheters (PAC) per year were used for hemodynamic monitoring system perioperatively since 1970s. PAC provides many quantitative circulatory data, such as pulmonary capillary wedge pressure, cardiac output and continuous mixed venous oxygen saturation. On the contrary, several studies pointed out the problems of PAC and advocated the limitations of perioperative PAC monitoring in 2000s. Many randomized controlled studies showed that the use of PAC did not decrease mortality. In addition, aggressive therapy using PAC increased morbidity and complications. Physicians should become proficient in PAC and in obtaining and interpreting information from PAC. It is also important to use PAC in proper patients. I have also discussed other monitoring systems, such as aortic wave form analysis and central venous oxygen saturation, which were less invasive compared with PAC. I think abundant training, correct education and strict management must be employed to increase the benefit of PAC.

The population of children undergoing successful surgery for congenital heart disease (CHD) continues to increase. Increasing number of patients with a Fontan circulation is reaching adulthood and requiring anesthesia for noncardiac surgeries. We anesthetized a patient with a Fontan circulation (9 years old) for giant internal carotid-ophthalmic artery aneurysm trapping. There was a difficulty in cannulating internal jugular vein for measuring central venous pressure because of abnormal collateral arteries around the internal jugular vein. Central venous pressure of around 15 mmHg seemed appropriate to keep good hemodynamic condition during this surgery. In this condition, cerebral cortex was not edematous. Careful management of circulatory volume stabilized hemodynamic state. However, when heart rate decreased below 75, ectopic atrial rhythm occured. Anesthetic time was 13 hr and 40 min. The patient was extubated in the operating room. We have to take into consideration that there are anatomical abnormalities and arrhythmia in the patients with a Fontan circulation.

The advancement of surgical and anesthetic techniques reduced cardiac morbidity and mortality. As a result, the attention has been focused on the perioperative cerebral complication, which contribute to more than 20% of perioperative deaths. Cognitive dysfunction is associated with increased medical costs, decreaged quality of life, and mortality. However, the incidence of cognitive dysfunction has a wide variety due to methodological variations in evaluating cognitive dysfunction, showing the complexity of cognitive dysfunction. The score of cognitive test can include learning effect and natural decline of cognitive dysfunction in elderly population. The research including the control group seems to overcome these issues, but still remains to have problems. Further, patients with cardiac disease have comorbid factors to induce postoperative sequelae compared to healthy population. We describe these issues which require continued researches.

A 14-yr-old boy with hypertrophic obstructive cardiomyopathy, undergoing percutaneous transluminal septal myocardial ablation suffered dissection of the left main coronary artery during the procedure. Sixty minutes after absolute ethanol administration, he was transferred to the operating room for emergency coronary artery bypass grafting, mitral valve replacement and cardiomyectomy. Transesophageal echocardiography (TEE) findings after the induction of anesthesia were: general hypokinesis, mitral regurgitation 1+, left ventricular outflow tract pressure gradient of 11 mmHg and no blood flow in the left anterior descending coronary artery. On aorta declamping, ECG showed ventricular fibrillation and ventricular tachycardia, and the sinus rhythm was restored after 100 mg lidocaine i.v. and DC conversion. TEE revealed severe hypokinesis in antero-septal and hypokinesis in posterolateral wall, respectively. Since supraventricular tachycardia (HR 130 140 bpm) disabled the intraaortic balloon pump (IABP) synchronization, HR was maintained 90-100 bpm with landiolol hydrochloride (10-40 micrograms x kg(-1) min(-1)) and synchronization was obtained. Systolic BP was maintained 90-120 mmHg with norepinephrine (0.2-0.3 micrograms x kg(-1) x min(-1)) and the patient could be successfully weaned from CPB with cardiac index 2.0 and mixed venous oxygen saturation 59%. On the 2nd postoperative day (POD), he was weaned from IABP and ventilator. On the 6 th POD, he was discharged from the ICU.