Search

Author(s): Kenta Okitsu [sup.1] , Takeshi Iritakenishi [sup.1] , Tatsuyuki Imada [sup.1] , Michioki Kuri [sup.1] , Sho Carl Shibata [sup.1] , Yuji Fujino [sup.1] Author Affiliations: (1) Department of [...], Purpose This study aimed to reveal whether the occurrence of periprocedural myocardial damage (PMD) decreases in patients who received volatile anesthetics to maintain general anesthesia compared with those who received propofol during transcatheter aortic valve implantation (TAVI). Methods We included one hundred and forty adult patients who underwent transfemoral TAVI under general anesthesia from January 2015 to March 2017 in this single-center retrospective review. We compared the rate of patients who developed PMD between those who received desflurane (Group D, n = 72) and propofol (Group P, n = 68) for anesthetic maintenance. PMD was represented by the peak levels of creatine kinase myocardial band (CK-MB) and troponin I within 72 h following the procedure and defined as an increase >5 times in CK-MB or >15 times in troponin I compared with the institutional upper reference limits. Further analysis was performed to identify the independent predictors of PMD. Results There was no significant difference in the rate of PMD between groups (Group D 72.2% to Group P 70.6%, P = 0.85) or levels of CK-MB (Group D 7.85 [1.3-72.7] ng/mL to Group P 8.45 [1.8-49.7] ng/mL; P = 0.59) and troponin I (Group D 1.061 [0.050-10.8] ng/mL to Group P 1.214 [0.036-29.0] ng/mL; P = 0.97). The risk of PMD was higher in patients with more intraprocedural blood loss (odds ratio 1.49 per 100 mL, P = 0.048) and lower in those with an implanted permanent pacemaker (odds ratio 0.17; P = 0.02). Conclusions Desflurane does not appear to be more cardioprotective than propofol when used for anesthetic maintenance in patients undergoing transfemoral TAVI.

Introduction PHACE syndrome (1) is a coined acronym consisting of the initial letters of the following features: posterior fossa brain malformations, hemangiomas on face, anomaly of the cerebral arteries, coarctation [...], PHACE syndrome is a neurocutaneous syndrome characterized by the association of large cutaneous hemangiomas and the cardiac and cerebral vascular anomalies. We report a 6-year-old female with PHACE syndrome presented with left facial hemangiomas, cystic lesion in the cerebral posterior fossa, coarctation of the aorta, aplasia of the left vertebral artery and stenosis of the left internal carotid artery. Surgical repair of the aorta with left heart bypass under beating heart was scheduled. We monitored regional cerebral oxygen saturation (rS[O.sub.2]) with infrared spectroscopy in order to detect cerebral hypoperfusion. A decrease of rS[O.sub.2] ipsilateral to the cerebrovascular anomalies occurred during anastomosis of the aorta, which was treated by reducing the flow rate of left heart bypass and by increasing the inhalational oxygen concentration. As children with PHACE syndrome are frequently accompanied with cerebrovascular anomalies and at a risk of cerebral hypoperfusion, prevention of cerebral hypoperfusion is crucially important during general anesthesia. Keywords Coarctation of the aorta * Dandy-Walker syndrome * Left heart bypass * PHACE syndrome * Regional cerebral oxygen saturation

Background: Vocal cord paralysis (VCP) is a rare complication of thoracic cardiovascular surgery. In severe cases, life-threatening airway obstruction may occur.Objective: To evaluate the incidence and severity of VCP among patients who underwent thoracic cardiovascular surgery and to identify possible risk factors.Design: Single-centre retrospective review of adult patients.Setting: Osaka University Hospital, Suita, Japan, from January 2013 to August 2015.Patients: We included 688 patients in the final analysis. Preoperative, intraoperative and postoperative data were collected from medical records. Patients with preoperative VCP or tracheostomy prior to extubation were excluded. The VCP severity in relation to functional recovery was graded using the following categories: absent; mild, remission at 6 months; moderate, partial or persistent VCP at 6 months; or severe, airway obstruction after extubation requiring reintubation. An otolaryngologist diagnosed all VCP cases.Main Outcome Measures: The incidence and severity of VCP after extubation.Results: The incidence (number) of VCP was 4.7% (32), with those of mild, moderate and severe VCP being 1.7% (12), 1.5% (10) and 1.5% (10), respectively. The ICU stay was significantly longer in patients with severe VCP than in patients without VCP [12.5 days (interquartile range 5.5 to 25.5) vs. 3 days (interquartile range 2 to 5), P = 0.0002]. In our multivariable analysis, type 2 diabetes mellitus [odds ratio (OR) 1.853, P = 0.009], intubation period (OR per 24 h 1.136, P = 0.014), ascending aortic arch surgery with brachiocephalic artery reconstruction (OR 8.708, P < 0.001) and ventricular assist device implantation (OR 3.460, P = 0.005) were independent predictors for VCP.Conclusion: The identification of these risk factors may facilitate screening for VCP before extubation and possibly help anaesthesia personnel to be prepared to treat VCP-related airway obstruction should it occur. [ABSTRACT FROM AUTHOR]

Objective: We report a case of perioperative management of a single-ventricle patient with Fontan-associated liver disease undergoing hepatectomy.Case Report: A 12-year-old boy with Fontan circulation was scheduled for partial hepatectomy to remove a liver mass in segment 6. He received stent implantation to relieve conduit stenosis 6 months before the operation. The operation was performed under general anesthesia and with a bilateral thoracic paravertebral block (PVB). A continuous paravertebral infusion of levobupivacaine was administered via right and left catheters postoperatively. He was hemodynamically stable throughout the perioperative period, extubated soon after surgery, and had an uncomplicated postoperative course.Conclusions: An analgesic regimen including thoracic PVB resulted in a rapid recovery without opioid-related side effects and early reinitiation of anticoagulation therapy. Our case illustrates the effective application of thoracic PVB in congenital heart disease patients for non-cardiac-related surgery. [ABSTRACT FROM AUTHOR]

We present a case of massive air inflow into the left ventricle from the right ventricle through a small intraventricular shunt detected by transesophageal echocardiography (TEE). This case suggests that TEE plays an important role in the right ventricle-pulmo- nary artery conduit re-replacement.

Background: The purpose of this study was to compare the perioperative management of aortic valve replacement combined with coronary artery bypass grafting (AVR+CABG) and transcatheter aortic valve implantation combined with off-pump coronary artery bypass grafting (TAVI+OPCAB)., Methods: A retrospective analysis was performed on patients who had undergone either AVR+CABG or TAVI+OPCAB for AS and CAD in Osaka Univer- sity Medical Hospital from January to October, 2014., Results: AVR+CABG was performed in 11 pa- tients (group A) and TAVI+OPCAB was performed in 4 patients (group T) in this period. The patients in group T was significantly older than the patients in group A. There were no significant differences in other background factors. Procedure time and postoperative mechanical ventilation time were shorter in group T than in group A. Postoperative recovery was signifi- cantly faster in group T than in group A., Conclusions: TAVI+OPCAB is less invasive than AVR+CABG and an effective treatment for high risk patient with AS and CAD.

A 64-year-old male patient with pheochromocytoma underwent an off-pump coronary artery bypass graft- ing. Determination of order of surgeries, preoperative medical management and intraoperative hemodynamic management are important in these cases. Al- though bolus administration of phenylephrine showed poor response, the surgery was uneventful and the patient remained hemodynamically stable throughout the procedure and perioperative period.

Primary cardiac tumors are extremely rare. We experienced the management of anesthesia for removal of right atrial tumors in two cases. The removal of cardiac tumors is associated with various risks such as embolism, obstructive symptoms of organs and ar- rhythmia. It is necessary to predict such risks from the characteristics of the tumor and to make plans for safe anesthetic management.

Heart and lung transplantation (HLT) is the surgical procedure for congenital heart disease and cardiomy- opathy with pulmonary hypertension. HLT is rare in the world and has been performed only twice until October, 2014 at our hospital in Japan. We report the anesthetic management for HLT.

Transcatheter aortic valve implantation (TAVI) is a novel treatment option for inoperative high-risk pa- tients with severe aortic stenosis (AS). However, there is a risk of cerebral ischemia by the two times of rapid ventricular pacing (RVP) procedure during valvulo- plasty and prosthesis implantation. An 86-year-old man was diagnosed with old myocardial infarction and severe AS, and was scheduled to undergo TAVI and off-pump coronary artery bypass grafting (OPCAB). He had the risk of cerebral ischemia due to total occlu- sion of the right common carotid artery, and was monitored with bilateral bispectral index (BIS) and cerebral regional saturation of oxygen (rSO2). In order to maintain his cerebral blood flow, we used low dose catecholamine during OPCAB. During prosthesis implantation, RVP was performed as quickly as pos- sible to maintain cerebral perfusion. Hemodynamics of the patient was restored with no reduction of either bilateral BIS or rSO2 values after RVP. He did not develop neurological complications and was discharged on postoperative day 15. Rapid ventricular pacing followed by unstable hemo- dynamics during valvuloplasty and prosthesis implan- tation is challenging to the anesthesiologists.

A 40-year-old man (168 cm tall and weighing 71 kg) with intractable pneumothorax was operated for resection of a bulla in the left lung. After insertion of epidural catheter via T 5-6 interspace, general anesthesia was induced and maintained with propofol, remifentanil and rocuronium. The duration of surgery was 1h 48 min and rocuronium given during surgery was 110 mg. After completion of surgery, the double-lumen tube was replaced with laryngeal mask airway to prevent cough reflex. However, infusion of sugammadex 200 mg induced mild cough reflex, resulting in air leakage from thoracic drainage. Because air leakage still continued after extubation, reoperation must be done and re-intubation was required. Since rocuronium 50 mg did not provide satisfactory muscle relaxation measured by train of four, additional dose of rocuronium 40 mg was administered and re-intubation was successfully performed without cough reflex. Reoperation lasted for 43 minutes and rocuronium infused was 100 mg. Nasal airway was inserted to prevent airway obstruction by the tongue and extubation was performed under muscle relaxation with infusion of rocuronium 10 mg. And then, immediate administration of sugammadex 400 mg could elicit spontaneous respiration without cough reflex.

We report a case of acute subdural hematoma which occurred following cerebrospinal fluid (CSF) drainage during thoracic endovascular aortic repair (TEVAR) surgery. A 63-year-old woman was scheduled to receive TEVAR for thoracic-abdominal aneurysm extending from the descending aorta (T10) to 15 mm above the celiac trunk. Before the TEVAR operation, a lumbar cerebrospinal drain was inserted at L4-5. CSF pressure was maintained at 10cmH2O throughout the operation. The surgical procedure was completed uneventfully. At the end of the surgery, the attending anesthesiologist recognized an inequality in the patient's pupil size. Emergency CT scan reviewed left acute subdural hematoma. The patient underwent emergency external decompression surgery. The benefits of CSF drainage for spinal cord protection is well established, and ischemia of Adamkiewicz artery is prevented by careful control of CSF pressure. However, the use of CSF drainage has been associated with the risk of acute subdural hematoma. Careful observation for amount of CSF drainage is necessary during thoracoabdominal aortic aneurysm repair.