Search

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Conjoined twins are an extremely rare congenital occurrence, and anesthetic management for surgical separation presents unique challenges for anesthesiologists., Case Presentation: Five-month-old male pygopagus conjoined twins underwent separation surgery. We performed anesthesia induction in the supine position and surgery in the prone position. This presented a challenge because the transition from supine to prone position reversed the positional relationship between the two babies, resulting in crossing of the respiratory circuits and monitors. To solve the problem, we used anesthesia machines and monitors on the opposite side of each baby during anesthesia induction. The positional relationship between the twins and anesthesia machines and monitors normalized after the change to the prone position. Following the separation surgery, the twins were discharged without any complications., Conclusions: Our method of using opposite side anesthetic machines and monitors for anesthesia induction was useful for the safe anesthetic management of pygopagus conjoined twins.

Background: Amniotic fluid embolism (AFE) is a life-threatening obstetric emergency. Because the maternal mortality associated with AFE is very high, early recognition and prompt treatment are important for improving the prognosis. We report a case of amniotic fluid embolism successfully treated by multidisciplinary treatment., Case Presentation: A 39-year-old woman with fetal congenital heart anomaly and polyhydramnios was scheduled for induction of delivery at 37 weeks of gestation with labor epidural analgesia. Uncontrollable bleeding occurred 30 min after vaginal delivery. Based on the clinical diagnosis of AFE, massive blood transfusion, insertion of an aortic occlusion balloon catheter, and hysterectomy was performed. Total blood loss was 12,000 mL. The diagnosis of AFE was confirmed by pathological examination. She was discharged with no complications., Conclusion: We report a case of AFE who were rescued by prompt diagnosis and treatment.

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.

Purpose: Regional anesthesia is more favorable than general anesthesia in patients with severe comorbidity; however, data on the superiority of peripheral nerve blocks over general anesthesia in patients with severe cardiac dysfunction are lacking. We aimed to demonstrate that peripheral nerve blocks reduce perioperative analgesic requirements and promote faster recovery compared to general anesthesia., Methods: We retrospectively evaluated intraoperative blood pressure, perioperative medications, and postoperative recovery in patients who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation. We compared patients who received general anesthesia (group G, n = 27) to those who received femoral nerve block with propofol sedation (group B, n = 22)., Results: Left ventricular ejection fraction was 24% on average, with no significant difference between groups. Compared with group G, a lower dose of propofol was used intraoperatively (1.25 versus 2.0 µg/mL, respectively; P < 0.001) and fewer patients required opioids (13.6 versus 100%, P < 0.01) in group B. Additionally, the lowest intraoperative mean blood pressure was higher (54 versus 48 mmHg, respectively; P = 0.02) in group B. More patients received postoperative analgesic drugs (51.9 versus 13.6%, P = 0.01) and they received them more frequently (1 [0-3] versus 0 [0-1], P = 0.02) in group G. The length of heart care unit stay was shorter in group B than group G (0 [0-18.5] versus 17 [0-47] h, respectively; P < 0.0001)., Conclusions: Femoral nerve block with sedation was more beneficial than general anesthesia in patients with severe cardiac dysfunction who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation.

Rapid ventricular pacing (RVP) is used during transcatheter aortic valve implantation (TAVI). RVP disturbs myocardial oxygen balance, and when prolonged, it may cause procedure-related myocardial injury (PMI). This study investigated whether a longer duration of RVP increased the occurrence of PMI or worsened long-term mortality after TAVI. We retrospectively analyzed data from 188 patients who underwent TAVI in our institute from January 2013 to July 2015. Myocardial injury was represented by the peak value of creatine kinase-myocardial band (CK-MB) within 72 h after the procedure; an increase greater than 5 times the upper reference limit was regarded as PMI. There was no difference in RVP time (RVPT) between patients with and without PMI (median [range]: 57 [9-189] s vs. 54 [0-159] s, p = 0.9). A higher peak CK-MB was significantly correlated with the apical approach for the procedure (p < 0.001) but not with total RVPT (p = 0.22). A subanalysis of 133 patients whose troponin I was tested within 72 h postprocedurally showed no correlation between the peak value and RVPT (p = 0.40). Shortening RVPT did not result in myocardial protection; thus, RVPT during TAVI should be sufficient to optimize valve placement.

Background: Arytenoid cartilage dislocation/subluxation is one of the rare complications following tracheal intubation, and there have been no reports about risk factors leading this complication. From our clinical experience, we have an impression that patients undergoing cardiovascular operations tend to be associated with this complication., Aims: We designed a large retrospective study to reveal the incidence and risk factors predicting the occurrence and to examine whether our impression is true., Settings and Designs: This was a retrospective study., Methods: We retrospectively studied 19,437 adult patients who were intubated by an anesthesiologist in our operation theater from 2002 to 2008. The tracheal intubation was performed by a resident anesthesiologist managing the patients. Only patients whose postoperative voice was disturbed more than 7 days were referred to the Department of Otorhinolaryngology-Head and Neck Surgery and examined using laryngostroboscopy by a laryngologist to diagnose arytenoid cartilage dislocation/subluxation. We evaluated age, sex, weight, height, duration of intubation, difficult intubation, and major cardiovascular operation as risk factors to lead this complication., Statistical Analysis: The data were analyzed by logistic regression analysis to assess factors for arytenoid cartilage dislocation/subluxation after univariate analyses using logistic regression analysis., Results: Our analysis indicated that difficult intubation (odds ratio: 12.1, P = 0.018) and cardiovascular operation (odds ratio: 9.9, P < 0.001) were significant risk factors of arytenoid cartilage dislocation/subluxation., Conclusion: The present study demonstrated that major cardiovascular operation is one of the significant risk factors leading this complication.

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.

Left ventricular assist device (LVAD) implantation is increasingly being used as a bridging therapy to heart transplantation. Infection is a major complication in patients with implanted LVADs, and it is associated with short- and long-term mortality. Surgical management for infection control is sometimes necessary; however, providing pain management during the surgical procedures is challenging. Anesthesiologists may be able to contribute to better pain management during surgical interventions to treat LVAD infections. We successfully performed a continuous thoracic paravertebral block (TPVB) for perioperative pain relief during invasive surgical procedures on three patients with infections of implanted LVADs. Despite several limitations that need to be addressed in the future, TPVB was able to relieve surgical pain in these patients without obvious complications.

Objective: This study aimed to determine the risk of hematoma associated with thoracic paravertebral block (TPVB) in patients undergoing cardiovascular surgery., Design: Retrospective analysis., Setting: Single university hospital., Participants: The study comprised 141 patients who underwent cardiovascular surgery with TPVB to relieve postoperative pain., Interventions: None., Measurements and Main Results: Three patients were excluded and of the remaining 138, TPVB was performed in 135, ages 11 to 96 years, who either had a clotting abnormality or were on anticoagulant or antiplatelet therapy. No paravertebral, epidural, or spinal hematoma was detected, and only 1 case of superficial bleeding was observed. The frequency of hematoma associated with TPVB in patients with a risk of bleeding undergoing cardiovascular surgery was calculated as 0% (95% confidence interval 0-2.7)., Conclusion: Hematoma did not occur in patients at risk of bleeding who underwent cardiovascular surgery with TPVB for postoperative pain management. However, the risk and benefit in each case still must be considered carefully to determine whether TPVB is indicated., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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.

We describe a patient with biventricular assist devices who had systemic inflammation because of cholecystitis that required open cholecystectomy, and we discuss the anesthetics and monitors that should be used in unstable patients with ventricular assist devices (VADs) who are undergoing major surgery. The patient was a 40-year-old man in the dilated phase of hypertrophic obstructive cardiomyopathy, who was implanted with an internal left VAD and external right VAD. We anesthetized the patient with a combination of a low dose of sevoflurane and ketamine to minimize vasodilation. We chose ketamine because we expected it to have a postoperative analgesic effect. An INVOS™ (Medtronic) monitor was beneficial, especially since the pulse oximeter did not work because of a pulse deficit. The FloTrach™ (Edwards Lifesciences) failed to measure the stroke volume and its variability. The left VAD, the Jarvik2000, did not show its flow rate. However, we were able to estimate that the flow was stabilized, because the flow rate of the right VAD was stable, and there was no significant change in both ventricles and septa, as shown on transesophageal echocardiography.

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.

Paravertebral block (PVB) is feasible for postoperative analgesia in patients who undergo cardiac surgery with unilateral thoracotomy. Postoperative continuous PVB is as effective as thoracic epidural anesthesia and is less likely to cause hypotension. However, the intraoperative utility and safety of PVB remains unclear. Therefore, the present study was conducted to determine the efficacy and hemodynamic influence of intraoperative paravertebral bolus injection during cardiac surgery. We retrospectively compared intraoperative medication use and blood pressure measurements between patients who underwent transapical transcatheter aortic valve implantation (TA-TAVI) with (PVB group, n = 46) or without (non-PVB group, n = 15) intraoperative PVB. Remifentanil administration was lower by more than 40 % in the PVB group compared with that in the non-PVB group (728 ± 319 µg vs. 1240 ± 488 µg, P < 0.001). The average and variability of intraoperative blood pressure showed no significant differences between groups. The duration of hypotension (blood pressure less than 80 % of baseline) was 25.1 ± 21.5 % and 25.4 ± 18.1 % of the entire anesthesia time in the non-PVB and PVB groups, respectively (P = 0.74). The use of inotropic and vasopressor agents was comparable between groups. Intraoperative paravertebral bolus injection decreased remifentanil administration without causing hypotension during TA-TAVI in hemodynamically unstable patients. This result suggests the intraoperative utility of PVB in cardiac surgery.

Objective: Intraoperative two-dimensional echocardiography is technically challenging, given the unique geometry of the right ventricle (RV). It was hypothesized that the RV fractional area change (RVFAC) could be used as a simple method to evaluate RV function during surgery. Therefore, the correlation between the intraoperative RVFAC and the true right ventricular ejection fraction (RVEF), as measured using newly developed three-dimensional (3D) analysis software, was evaluated., Design: Retrospective study., Setting: University hospital., Participants: Patients who underwent cardiac surgery with transesophageal echocardiography monitoring between March 2014 and June 2014., Interventions: None., Measurements and Main Results: Sixty-two patients were included in this study. After the exclusion of poor imaging data and patients with arrhythmias, 54 data sets were analyzed. RVFAC was measured by one anesthesiologist during surgery, and full-volume 3D echocardiographic data were recorded simultaneously. The 3D data were analyzed postoperatively using off-line 3D analysis software by a second anesthesiologist, who was blinded to the RVFAC results. The mean RVFAC was 38.8% ± 8.7%, the mean RVEF was 41.4% ± 8.3%, and there was a good correlation between the RVFAC and the RVEF (r(2) = 0.638; p<0.0001)., Conclusions: The RVFAC was well-correlated with the RVEF calculated using 3D echocardiography; therefore, RVFAC provides a simple and useful method for anesthesiologists to evaluate intraoperative RV function., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To identify the risk factors of prolonged hemodynamic compromise caused by rapid pacing for valve deployment during transcatheter aortic valve implantation., Design: A retrospective study., Setting: Academic hospital., Participants: Forty-seven patients with severe aortic stenosis who underwent transcatheter aortic valve implantation., Interventions: The time after the end of rapid pacing until systolic arterial pressure and SvO2 recovery (systolic arterial pressure>90 mmHg and SvO2>65%) was defined as "the hemodynamic recovery time" and was measured from online anesthetic charts. The total study population was divided into 2 groups according to the recovery time (third quartile in all patients; 33 and 14 patients in the early and delayed recovery groups, respectively). Subsequently, the factors associated with prolonged hemodynamic compromise after rapid pacing for valve deployment were identified by univariate and multivariate analyses., Measurements and Main Results: Multivariate analysis identified left ventricular end-diastolic diameter (odds ratio, 0.774; 95% confidence interval, 0.608-0.915) and SvO2 (odds ratio, 0.748; 95% confidence interval, 0.590-0.868) as independent factors associated with prolonged hemodynamic compromise after rapid pacing for valve deployment., Conclusions: SvO2 and left ventricular end-diastolic diameter were found to be significant independent predictors of prolonged hemodynamic compromise immediately after rapid pacing for valve deployment during transcatheter aortic valve implantation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Non-cardiac surgery should only be performed in patients with Eisenmenger's syndrome if absolutely mandatory because these patients are at high risk of perioperative mortality. Proper anesthetic and perioperative pain management in these patients remains a controversial topic. Transversus abdominis plane (TAP) block provides safe and beneficial perioperative analgesia in adults and children; however, no report has described the performance of TAP block in a child with Eisenmenger's syndrome. Herein, we describe the performance of bilateral orchiopexy for cryptorchidism in an 8-year-old boy with Eisenmenger's syndrome due to an uncorrected muscular ventricular septal defect (mVSD). Anesthesia induction and maintenance were uneventful. Subsequently, the patient received ultrasound-guided bilateral TAP block by using 10 mL of 0.25 % levobupivacaine shortly before recovery from anesthesia. The TAP block provided pain relief and maintenance of stable hemodynamics during the postoperative period. We successfully used a TAP block in a child with Eisenmenger's syndrome to provide postoperative analgesia. No side effects were apparent during the perioperative period. TAP block can be considered a beneficial pain management technique for analgesia in children with Eisenmenger's syndrome.

Moyamoya disease (MMD) is a rare disease characterized by occlusive intracranial arteriopathy with formation of abnormal cerebrovascular collateral networks. Conventional cardiovascular surgical procedures using cardiopulmonary bypass for patients with MMD is challenging because low cerebral perfusion pressure and nonpulsatile (continuous) flow during cardiopulmonary bypass can cause severe cerebral ischemia. We successfully performed transcatheter aortic valve replacement in 3 women with severe aortic valve stenosis complicated with MMD. Transcatheter aortic valve replacement may be useful for patients with severe aortic valve stenosis complicated with severe cerebral ischemia, including MMD., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical aortic valve replacement (SAVR) which requires cardiopulmonary bypass (CPB) is still the gold standard for treatment of aortic stenosis (AS). But for elderly patients with severe AS and coexisting conditions, invasive surgery with CPB may lead to organ dysfunction and life-threatening complications. Transcatheter aortic valve replacement (TAVR) is a novel treatment for AS. TAVR is performed by catheter techniques, which do not require sternotomy, CPB, and cardiac arrest, and are less invasive than SAVR. That is why TAVR is considered quite suitable for such patients at high risk. Anesthesiologists managing TAVR should aim at fast-track anesthesia in order to make the most of the minimal invasiveness of TAVR by stabilizing circulations and respiratory conditions, keeping body temperature, and controlling postoperative pain.

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.

Background: The incidence of perioperative pulmonary thromboembolism (PTE) has increased in Japan. As the mortality rate of PE is very high, its prophylaxis is important., Methods: From January 1998 to December 1999 no prophylactic strategies were employed. From May 2000 to December 2004, elastic stockings (ES) for prevention of perioperative deep vein thrombosis were worn from the morning of the operation until the beginning of ambulation. Intermittent pneumatic compression (IPC) apparatuses were used in combination with ES right after the induction of anesthesia until leaving ICU. Sixty percent of patients stayed in ICU until the next morning after the operation and the other patients for a few hours after the end of surgery., Results: We managed 4,511 patients without any preventing method and 11,688 patients with the combination of ES and IPC. Seven patients developed PTE without any prophylaxis and one with preventative methods. The incidence of PTE was significantly decreased from 15.51 persons/10,000 cases to 0.86 person/10,000 cases. Symptomatic deep vein thrombosis occurred in 3 cases in spite of preventative methods., Conclusions: Our preventive strategies with the combination of ES and IPC seem to be useful to decrease the incidence and severity of perioperative PTE.

A 68-year-old woman with anti-phospholipid antigen syndrome (APS) was proposed to undergo partial pulmonary resection for lung cancer. She suffered from mild cerebellar ataxia. Exercised 201Tl myocardial scintigraphy was performed due to abnormal Q wave in preoperative electrocardiography and showed old myocardial infarction in inferior-to-posterior area without myocardial ischemia. Cardiac function was marginally decreased in cardiac echographic evaluation. Arterial thrombosis by APS might cause cerebellar ataxia and myocardial infarction. Low molecular weight heparin (LMWH) was continuously infused from 1 hour prior to arrival in an operation room. Elastic stockings (ES) were worn from the morning of the operation in combination with the use of intermittent pneumatic compression apparatus (IPC). Significant bleeding was not observed perioperatively. Hypothermia was avoided by forced-air-warming therapy. She was transferred to ICU after the end of the operation. She was returned to her ward without IPC on the first postoperative day. Warfarin was given with the beginning of ambulation on the second postoperative day to keep PT-INR about 2. On the third postoperative day LMWH was discontinued and ES were taken off. The postoperative course was uneventful.