Three-step method for transesophageal echocardiography-guided implantation of the frozen elephant trunk: how to prevent spinal cord injury.

Total aortic arch replacement using the frozen elephant trunk (FET) procedure has widely spread all over the world with more sophisticated devices. However, spinal cord injury is one of the most important complications, which limits the use of FET. In our hospital, 80 patients treated with FET had no spinal cord injury. There are three key points to avoid spinal cord injury, (1) The distal end of stent graft should be positioned up to the eighth thoracic vertebrae level; (2) the time for selective left subclavian artery perfusion and distal body circulatory arrest should be shortened within 60 min; and (3) mean blood pressure should be maintained above 70 mmHg. Especially, Key point (1) is the most important. The level of aortic valve, which locates around the seventh thoracic vertebrae level, is an appropriate benchmark. We implanted the stent graft with the use of transesophageal echocardiography guided three-step method.

Coronary ostial stenosis detected by transesophageal echocardiography after aortic valve replacement: a case report.

BACKGROUND: Coronary ostial stenosis is a life-threatening complication of aortic valve replacement (AVR). Clinical symptoms usually appear within the first 6 months after AVR (Funada and Mizuno et al., Circ J 70:1312-7, 2006), and perioperative onset is very rare. CASE PRESENTATION: An 80-year-old woman with severe aortic stenosis was scheduled to undergo AVR. AVR using cardiopulmonary bypass (CPB) was successfully carried out. However, 5 min following AVR, signs of left heart failure appeared, and transesophageal echocardiography (TEE) revealed severe hypokinetic left ventricular wall motion. Left coronary ostial stenosis was diagnosed by TEE, and CPB was immediately resumed and coronary artery bypass grafting (CABG) to the left anterior descending branch was performed. CONCLUSIONS: When circulatory failure presents in the acute phase following AVR, onset of coronary ostial stenosis should be considered.

Phase I clinical trial of olprinone in liver surgery.

PURPOSE: Post-hepatectomy liver failure is one of the most serious complications liver surgeons must overcome. We previously examined olprinone, a selective phosphodiesterase III inhibitor, and demonstrated its hepatoprotective effects in rats and pigs. We herein report the results of a phase I clinical trial of olprinone in liver surgery (UMIN000004975). METHODS: Twenty-three patients who underwent hepatectomy between 2011 and 2015 were prospectively registered. In the first 6 cases, olprinone (0.1 µg/kg/min) was administered for 24 h from the start of surgery. In the remaining 17 cases, olprinone (0.05 µg/kg/min) was administered from the start of surgery until just before the transection of the liver parenchyma. The primary endpoint was safety, and the secondary endpoint was efficacy. For the evaluation of efficacy, the incidence of post-hepatectomy liver failure in 20 hepatocellular carcinoma patients was externally compared with 20 propensity score-matched patients. RESULTS: No intraoperative side effects were observed, and the morbidity rates in the analyzed cohorts were acceptable. The rate of post-hepatectomy liver failure frequency tended to be lower in the olprinone group. CONCLUSIONS: The safety of olprinone in liver surgery was confirmed. The efficacy of olprinone will be re-evaluated in clinical trials.

[Anesthetic Management Using Transesophageal Echocardiography and EV1000 in a Patient with Ebstein's Anomary Undergoing Scoliosis Surgery].

An 18-year-old female patinet with Ebstein anomaly underwent surgical repair of scoliosis under total intravenous anesthesia. In addtition to normal monitors, we used transesophageal echocardiography (TEE) and EV1000 (Edwards Lifesciences, Irvine, USA), which show stroke volume variation and stroke volume index simultaneously in a rectangular coordinates. TEE detected reversal of intracardiac shunt which caused SpO2 decrease during fixing screws at thoracic vertebrae, then manual ventilation with oxygen unproved SpO2. Because of a high venous pressure due to Ebstein anomaly, surgical bleeding seemed to be larger than usual. By using EV1000, volume status and cardiac contractility were estimated and adequate volume loading and inoptrope injection were performed to stabilize circulatory condition. The operation was completed without any cardiac and respiratory complications.

[Early Detection of Iliac Artery Rupture by Sudden Steep Reduction of Regional Saturation of Oxygen at the Ipsilateral Foot during Transcatheter Aortic Valve Implantation--A Case Report].

An 80-year-old woman with severe aortic stenosis was planned to undergo transcatheter aortic valve implantation (TAVI) under general anesthesia. Due to severe stenosis of the femoral arteries, the left iliac artery was cut down and a 16 F Edwards SAPIEN Expandable Sheath (eSheath : Edwards Lifesciences, Irvine, CA) was inserted into the artery smoothly. After balloon aortic valvuloplasty (BAV), an artificial valve was tried to deploy but stuck in the middle of eSheath. Suddenly regional saturation of oxygen (rSO2) at the ipsilateral foot decreased steeply without other significant hemodynamic instabilities. At insertion site of eSheath, the left external iliac artery rupture occurred. To our surprise, there was almost no major bleeding because of the artery spasm and suppression of the large bore sheath. eSheath and the stuck valve were taken out together and TAVI was discontinued. The artery was replaced with a graft, and rSO2 of the foot recovered. Her aortic stenosis improved to moderate by balloon aortic valvuloplasty (BAV) according to transthoracic echocardiography. The patient was discharged on foot without complications. To our knowledge, this is a first report of a silent rupture of the iliac artery during TAVI to be detected by sudden decrease of the foot rSO2 and treated with no fatal events.

[A Case of Lethal Atypical Takotsubo Cardiomyopathy Detected by Sustained Ventricular Arrhythmia Just before Induction of General Anesthesia].

A 73 year-old female patient was scheduled for lumbar peritoneal shunt three weeks after subarachnoid hemorrhage. Before induction of general anesthesia, her ECG showed ventricular tachycardia (VT) without any complaints. Administration of lidocaine and direct current shocks were ineffective and VT continued. Operation was postponed and transthoracic echocardiography revealed diffuse hypokinesis. Emergent angiogram revealed midventricular ballooning with slight hypoki- nesis in basal and apical regions without significant coronary artery lesion. Atypical takotsubo cardiomyopathy was diagnosed. Intra aortic balloon pumping and continuous infusion of amiodaron and catecholamines were started, but her ventricular motion decreased. She died next morning. In this case, the physical/psychological stress before operation was con- sidered to be a trigger of the event. Although tako- tsubo cardiomyopathy is usually a transient disease, it must be kept in mind that an acute and lethal case with no response to any treatment like ours exists.

Fibrin glue on an aortic cusp detected by transesophageal echocardiography after valve-sparing aortic valve replacement: a case report.

INTRODUCTION: Fibrin glue is used commonly during cardiac surgery but can behave as an intracardiac abnormal foreign body following surgery. There have been few such cases reported, and they were typically noticed only because of the resulting catastrophic cardiac conditions, such as valvular malfunction. We report a case where, for the first time, transesophageal echocardiography was used to detected fibrin glue that was adherent to the ventricular side of a patient's aortic valve immediately after aortic declamping. CASE PRESENTATION: A 45-year-old Japanese man with Marfan syndrome underwent an aortic valve-sparing operation to treat moderate aortic valve regurgitation resulting from enlargement of his right coronary cusp. Fibrin glue was lightly applied to the suture line between the previous and new grafts. Transesophageal echocardiography performed prior to weaning from the cardiopulmonary bypass revealed mild aortic valve regurgitation in addition to a mobile membranous structure attached to the ventricular side of his aortic valve. It was identified as fibrin glue. We resolved the regurgitation by removing the fibrin glue and repeating the aortic cusp plication. The patient had no complications during recovery. CONCLUSIONS: Fibrin glue can act as an intracardiac foreign body and lead to a potentially fatal embolism. We demonstrated the use of transesophageal echocardiography to detect a fibrin glue-derived intracardiac abnormal foreign body and to confirm its removal. To the best of our knowledge, this is the first case where fibrin glue adherent to the aortic valve was detected by transesophageal echocardiography. These findings demonstrate the importance of using transesophageal echocardiography during cardiac surgery that involves using biological glues.

[Misplacement of a guidewire into the right vertebral vein through the right internal jugular vein under real-time ultrasound guidance in Trousseau syndrome patient--a case report].

Trousseau syndrome is a venous thromboembolic complication found in abdominal cancer patients. A 46-year-old woman diagnosed with and treated for pulmonary embolism due to Trousseau syndrome with a huge ovalian tumor was planned to undergo oophorectomy. She presented with pulmonary hypertension and her inferior vena cava was compressed by the tumor. After induction of general anesthesia, ultrasound-guided central venous catheterization (CVC) to her right internal jugular vein was tried. The guidewire was misplaced in the vertebral vein through the right internal jugular vein. Her vertebral vein was abnormally dilated. The dilated vertebral vein was supposed to have worked as a venous perfusion route from the lower extremities. When the CVC was performed in patients with restricted venous return due to Trousseau syndrome, deep-seated veins as well as arteries should be checked with ultrasonography.

Continuous carbon dioxide partial pressure monitoring in lung transplant recipients.

BACKGROUND: Living-donor lobar lung transplantation (LDLLT) recipients often have hypercapnia preoperatively, which confers a risk of worsened hypercapnia intraoperatively. We reviewed our experience with continuous carbon dioxide partial pressure (PtcCO2) monitoring in LDLLT to evaluate its accuracy and feasibility. We also assessed preoperative and intraoperative carbon dioxide levels in LDLLT recipients. MATERIAL AND METHODS: Twenty-six LDLLT recipients without pulmonary hypertension underwent preoperative nocturnal and intraoperative PtcCO2 monitoring, determined with a TOSCA-500 monitor. RESULTS: Maximal preoperative nocturnal PtcCO2 (72.7 ± 19.3 mmHg) was significantly correlated with preoperative resting arterial carbon dioxide partial pressure (PaCO2; 55.1 ± 11.6 mmHg, r(2)=0.84). PtcCO2 was more correlated with PaCO2 (range, 39-192 mmHg) during LDLLT (r(2)=0.93) than with end-tidal carbon dioxide partial pressure (r(2)=0.38). Intraoperative continuous PtcCO2 monitoring was useful for evaluating real-time carbon dioxide levels. Intraoperative PtcCO2 did not exceed maximal preoperative nocturnal PtcCO2 in 13 recipients (50%) but temporarily exceeded it in 11 recipients (42%). PtcCO2 was further elevated in 2 recipients (8%) requiring the early establishment of cardiopulmonary bypass. There were no complications related to PtcCO2 monitoring. CONCLUSIONS: PtcCO2 monitoring in LDLLT recipients is useful as a means for determining intraoperative carbon dioxide levels, which increase dramatically and can be predicted preoperatively and assessed in a timely manner.

Cardioprotection with opioids-- trusted old friends -clinical science.

Opioids i.e., compounds with morphine-like actions, and their receptors have been demonstrated to be involved in cardioprotection, at least in scientific studies, which makes sense as cardiomyocytes express most of the known opioid receptors and their agonists. In vitro and in vivo studies have demonstrated that the opioid system plays various important roles in maintaining cardiac function; i.e., it influences cardiac rhythm, cell stress, and even developmental processes. In support of these research findings, there is also good clinical evidence that opioids are effective as cardioprotective drugs. In fact, in the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines for coronary artery bypass graft surgery opioids and volatile halogenated anesthetics are referred to as anti-ischemic or conditioning agents. Although opioids are administered to all patients who undergo surgery as well as patients admitted to the ICU, including those that suffer heart attacks, no recommendations about their use for the preconditioning/management of myocardial ischemia have been included in recent clinical guidelines due to the weak clinical evidence about their effects. Opioids have been used as pain control agents in the clinical setting for a long time. As such, surgical, critical care, and cancer patients routinely receive them. On the other hand, ischemic heart disease continues to be a leading cause of morbidity and mortality in developed countries, and opioid therapy might be useful for treating the condition. This review examines recent clinical trials of the effects of opioids on ischemic heart disease and discusses the barriers to the use of opioids for cardioprotection.

[Appropriate dose of remifentanil to blunt tracheal intubation stress response in patients with severe aortic stenosis].

BACKGROUND: In anesthetic induction of patients with severe aortic stenosis, maintenance of normal heart rate and blood pressure is critical. Remifentanil can blunt cardiovascular responses to tracheal intubation, but may cause circulatory collapse due to potent vasodilating effect. We studied retrospectively the optimal dose of remifentanil, which blunts cardiovascular responses to tracheal intubation and provides the hemodynamic stability to patients with severe aortic stenosis. METHODS: We administerd remifentanil with three different doses (0.3 microg x kg(-1) x min(-1) : n=4, 0.5 microg x kg(-1) x min(-1): n=7, 1 microg x kg(-1) x min(-1): n=7) in anesthetic induction of patients with aortic stenosis. Systolic arterial blood pressure and heart rate before and after the tracheal intubation were recorded. The degree of change of post to pre-intubation of systolic arterial pressure and heart rate was calculated and compared among groups. RESULTS: There were no significant differences in background among the groups. The ratio between before and after tracheal intubation of systolic arterial pressure was significantly lower in the group of 0.5 microg x kg(-1) x min(-1) and 1 microg x kg(-1) x min(-1). There was no significant hypotension or bradycardia which may lead to severe cardiovascular depression. CONCLUSIONS: We found that more than 0.5 microg x kg(-1) x min(-1) of remifentanil can blunt cardiovascular responses to tracheal intubation without severe cardiovascular depression.

Takotsubo cardiomyopathy during ambulatory anesthesia for bladder hydrodistension therapy -A case report-.

Stress-induced cardiomyopathy, also referred to Takotsubo cardiomyopathy or apical ballooning syndrome presents in perioperative period. We demonstrated a case of Takotsubo cardiomyopathy recognized after general anesthesia for bladder hydrodistension therapy as ambulatory surgery, which we surmise was due to inadequate blockage of surgical stress and sympathetic discharge against noxious stimulus during ambulatory anesthesia.

[Monitoring of blood coagulation in perioperative care].

Coagulation disorders often occur perioperatively and monitoring of blood coagulation should be fast and adequate to treat these disorders to protect patients from massive bleeding. Control of hemostasis is one of the main issues in major surgeries. Coagulation test results from a central laboratory may delay making such a perioperative decision. Recently, point-of-care monitoring (POCM), which is able to examine coagulation disorder in an operation theater with short waiting time, has become important. Both prothrombin time (PT) and activated clotting time (ACT) are very useful and popular, but also criticized because they can be monitored only until fibrin formation. On the other hand, viscoelastic monitorings of whole blood, are able to estimate fibrin formation, clot fixation, platelet function and fibrinolysis. In this review article, among variable perioperative POCMs of blood coagulation, three thromboelastographic monitorings, such as TEG ROTEM, and Sonoclot as well as PT and ACT, are described along with their utilities and limits to examine perioperative coagulation.

Stent angioplasty for a kink in the pulmonary artery anastomosis soon after living-donor lobar lung transplantation.

Herein, we report a case of stent angioplasty for a kink in the pulmonary artery (PA) anastomosis soon after living-donor lobar lung transplantation (LDLLT). A 64-year-old man with idiopathic pulmonary fibrosis underwent bilateral LDLLT with lung donations from his daughters. After reperfusion, the left PA anastomosis showed a kink, which could not be corrected completely during surgery. Due to the kink in the left PA, and the relatively small donor grafts, the patient required extracorporeal membrane oxygenation) after LDLLT. Approximately 24 hours after reperfusion, stent angioplasty was performed, resulting in the patient being successfully weaned from extracorporeal membrane oxygenation on postoperative day 4.

Delayed chest closure assessed by transesophageal echocardiogram in single-lobe lung transplantation.

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.

Living-donor lobar lung transplantation with sparing of bilateral native upper lobes: a novel strategy.

A 44-year-old man became wheelchair-bound due to sever bronchiolitis obliterans caused by peripheral blood stem cell transplantation for acute myelogenous leukemia. His lung donors, his sister and his wife, were 17 cm shorter than him. He successfully underwent living-donor lobar lung transplantation with sparing of the bilateral native upper lobes to address the size mismatch. Ten months after the transplantation, the patient has returned to a normal lifestyle without supplemental oxygen.

Living-donor, single-lobe lung transplantation and simultaneous contralateral pneumonectomy in a child.

An 8-year-old girl became ventilator-dependent due to severe bronchiolitis obliterans/interstitial pneumonia caused by cord-blood cell transplantation for neuroblastoma. Her mother's right lower lobe was twice as large as her right chest cavity. She successfully underwent living-donor, right, single-lobe lung transplantation and simultaneous left pneumonectomy under conditions of cardiopulmonary bypass. At 18 months after transplantation, the patient returned to school life and is currently able to carry out daily activities without supplemental oxygen.