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Background: Chronic postsurgical pain (CPSP) is defined as chronic pain that develops or increases in intensity after a surgical procedure and persists beyond the healing process, defined as at least 3 months postoperatively. However, the rationale behind this time period is weak., Methods: This prospective observational study included a total of 238 consecutive patients who underwent mitral valve repair via thoracotomy. A questionnaire consisting of a numerical rating scale (NRS) to assess the severity of postsurgical pain was mailed to each participant more than 3 months after the operation. The outcomes of interest were current pain, peak pain in the last 4 weeks, and average pain in the last 4 weeks, each assessed using the NRS. The nonlinear associations between the elapsed time after surgery and the intensity of CPSP were evaluated. All statistical analyses were performed with a two-sided significance level of 5%., Results: Two-hundred and ten patients (88.2%) answered the questionnaire. There was a significant nonlinear association between the elapsed time after surgery and each NRS response (all, P < 0.05). The lowest adjusted log odds of current pain, peak pain in the past 4 weeks, and average pain in the past 4 weeks were - 1.49, - 1.13, and - 1.26 at 33, 33, and 33 months postoperatively, respectively., Conclusions: There was a significant U-shaped association between the elapsed time after surgery and intensity of CPSP. The adjusted log odds of each NRS response was lowest at 33 months after cardiac surgery via thoracotomy., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

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., (© 2021. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Objective: Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood., Design: An observational cohort study., Setting: A tertiary care hospital., Participants: Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair., Interventions: A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated., Measurements and Main Results: The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001)., Conclusions: The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Delirium after cardiac surgery affects mortality, but the mechanism remains unclear. Previous studies have reported gut microbiota are associated with brain activity. Systemic inflammation and antibiotics can damage the gut microbiota after cardiac surgery. We aimed to investigate changes in the gut microbiota and the association between the gut microbiota and delirium after cardiac surgery., Methods: Twenty-one patients who underwent cardiac surgery were enrolled. Microbiota counts and fecal organic acid concentrations were measured in fecal samples harvested before surgery, just after surgery, and before discharge. To quantify the microbiota, we extracted total RNA fractions and examined gut microbiota composition using 16S and 23S rRNA-targeted quantitative-reverse Transcription-PCR. Postoperative delirium, insomnia, and pseudopsia were assessed for 1 week. Postoperative total bacterial counts changed significantly from 10.2 ± 0.2 log 10 cells/g of feces to 9.8 ± 0.5 in the first postoperative samples (p = 0.003) and 10.0 ± 0.4 in the samples before discharge (p = 0.039). Fecal pH was 6.9 ± 0.6 before surgery and 7.4 ± 0.7 in the first postoperative samples (p = 0.001). Postoperative Staphylococcus and Pseudomonas counts were significantly higher in patients with postoperative pseudopsia than in patients without pseudopsia (3.2 ± 1.3 vs. 5.4 ± 0.9; p = 0.012 and 1.7 ± 0.8 vs. 4.6 ± 2.7; p = 0.001)., Conclusions: Total bacterial counts were significantly lower after surgery and until discharge. Fecal pH was significantly higher than preoperative levels. Staphylococcus and Pseudomonas counts were significantly higher in patients with postoperative pseudopsia.

Background: Sinus tachycardia coupled with high-dose catecholamine is common after cardiopulmonary bypass (CPB). The present study assessed the hemodynamic efficacy and safety of combination therapy using low-dose β 1 -selective adrenergic blocker (landiolol) and inotropes., Methods: This was a retrospective, single center, self-comparison study at post-anesthesia care unit within a tertiary care center. The study included adults who underwent cardiac surgery with CPB and received landiolol between April 2007 and November 2011. We assessed hemodynamic data prior to and 1 h after initiation of landiolol therapy., Results: We evaluated 11 patients who were administered 2.6 ± 1.3 μg/kg/min (mean ± SD) landiolol with sinus tachycardia and received catecholamine therapy after on-pump cardiovascular surgery. Landiolol administration led to a significant reduction in heart rate (HR; 112.4 ± 5.8 vs 126.0 ± 7.6 beats/min, p < 0.001), and a significant increase in stroke volume index (SVI) assessed by pulmonary artery catheterization (22.4 ± 5.4 vs. 18.9 ± 4.2 mL/m 2 , p = 0.04). Only one patient showed no HR reduction, whereas seven patients showed decreased HR and increased SVI (64, 95% confidence interval: 30-98%). Moreover, all five patients who received high-dose catecholamine support showed improved hemodynamics. In terms of safety, no patients required cessation of landiolol therapy., Conclusions: Low-dose landiolol therapy may safely decrease HR and improve hemodynamics among patients with sinus tachycardia receiving catecholamine treatment after cardiovascular surgery., Trial Registration: This study is retrospective. Registration number: 11. Duration of registration: April 2007~November 2011.

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 ≤ 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.

A 75-year old man with a history of inferior myocardial infarction was admitted with symptoms of progressive heart failure 3 months after undergoing transapical transcatheter aortic valve implantation (TAVI). Echocardiography revealed severe mitral regurgitation (MR) caused by posterior leaflet tethering, without traumatic injury of the mitral valve or chordae. The patient was successfully treated by percutaneous edge-to-edge mitral valve repair (MitraClip ® ). This case highlights the role of MitraClip ® in high-risk patients suffering from MR, and suggests that apical contractile loss or adhesion caused by apical puncture and suturing in transapical TAVI may be one of the mechanisms of worsening MR.

Objectives: The present study aimed to examine the association between tranexamic acid (TXA) use and adverse effects (seizures, thromboembolism, and renal dysfunction) in a pediatric cardiac surgery population using a national inpatient database in Japan. The authors also assessed the association between TXA use and other clinical outcomes (length of hospital stay and in-hospital mortality)., Design: A nationwide, retrospective cohort study using propensity score analyses., Setting: Japanese Diagnosis Procedure Combination inpatient database., Participants: Pediatric patients who underwent cardiac surgery using cardiopulmonary bypass between July 2010 and March 2014 (N = 11,275)., Interventions: None., Measurements and Main Results: Propensity-score matching created 3,739 pairs of patients with and without TXA administration. Propensity-matched analysis showed that the proportion of seizures was significantly higher in the TXA group than in the non-TXA group (1.6% v 0.2%, difference, 1.4%; 95% confidence interval, 1.0-1.9; p<0.001). However, none of the other outcomes was significantly different between the groups., Conclusions: TXA use is associated with a significantly increased risk of seizures. However, there is no difference in any other outcomes between the TXA and non-TXA groups., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to compare cardiac output derived from the FloTrac/Vigileo™ system (CO(FT)) with cardiac output measured by 3-dimensional transesophageal echocardiography (CO3D) in patients with severe heart failure undergoing cardiac resynchronization therapy. The impact of preoperative systemic vascular resistance index on the accuracy of the FloTrac/Vigileo™ system also was investigated., Design: Prospective clinical study., Setting: Cardiac surgery operating room of a single cardiovascular center., Participants: Forty-one patients undergoing elective cardiac resynchronization therapy lead implantation., Interventions: CO3D as the reference method and CO(FT) were determined simultaneously after induction of anesthesia., Measurements and Main Results: Linear regression analysis showed a poor correlation between CO3D and CO(FT) (R² = 0.16). Bland-Altman plots showed wide limits of agreement between CO3D and CO(FT.). Bias was 0.60 ± 0.63 L/min with a high percentage error of 58.2%. Subgroup analysis showed that the percentage error between CO3D and CO(FT) was 74.1% in patients with a cardiac index<2.2 L/min/m(2) and 17.2% in patients with a cardiac index ≥ 2.2 L/min/m(2). Systemic vascular resistance index was significantly higher in patients with a cardiac index<2.2 L/min/m(2) (3,037 ± 820 v 2,461 ± 878; p = 0.039)., Conclusions: The FloTrac/Vigileo™ system is not accurate in patients with low cardiac output, especially those with a cardiac index<2.2 L/min/m(2). A high systemic vascular resistance index in patients with low cardiac index may contribute to this inaccuracy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

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.

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.