Cerebral regional oxygen saturation as a predictive parameter for preoperative heart failure and delayed hemodynamic recovery in transcutaneous aortic valve implantation: a retrospective cohort study.

This study aimed to investigate the relationship of perioperative cerebral regional oxygen saturation (rSO2) with various preoperative clinical variables and hemodynamic changes during transfemoral transcatheter aortic valve implantation (TAVI) under general anesthesia. We retrospectively analyzed cerebral rSO2 values from left-hemisphere measurements obtained using near-infrared spectroscopy (O3™ regional oximetry) at five time points: pre-induction, the start of the procedure, the start of valve deployment, time of lowest cerebral rSO2 value during valve deployment, and the end of the procedure. This study included 91 patients (60 with balloon-expandable valves and 31 with self-expandable valves). The baseline cerebral rSO2 values were correlated with B-type natriuretic peptide, hemoglobin, fractional shortening, ejection fraction, left ventricular mass index, left ventricular end-systolic diameter, STS risk of mortality, and STS morbidity or mortality. The patients who took longer to recover their systolic blood pressure to 90 mmHg after valve deployment with a balloon-expandable valve (group B) had lower cerebral rSO2 values during deployment compared to patients with faster recovery with balloon-expandable valve (group A) and with self-expandable valve (group C). Baseline cerebral rSO2 is associated with preoperative variables related to cardiac failure and function, and a significant decline during valve deployment may indicate a risk of prolonged hypotension during TAVI.

Right ventricular perforation, pneumothorax, and a pneumatocele by a pacemaker lead: a case report.

BACKGROUND: Perforation of the right ventricle by a pacemaker lead is a rare and potentially life-threatening complication. We present a patient who developed right ventricular perforation, pneumothorax, and a cyst and underwent partial lung resection. CASE PRESENTATION: A 94-year-old woman was diagnosed with sick sinus syndrome and underwent a dual-chamber permanent pacemaker implantation. The next day, pacing failed and chest radiography showed that the right ventricular lead was outside the cardiac silhouette. Computed tomography revealed that the lead had perforated the right ventricular apex, causing a left-sided pneumothorax and a cystic lesion at the site of pulmonary injury by the pacemaker lead. The patient underwent lung resection and a right ventricular lead extraction. Pathological analysis revealed the cystic lesion to be an acute pneumatocele. CONCLUSIONS: Pneumothorax and pneumatocele associated with right ventricular pacemaker lead perforation is extremely rare. In our case, a radical surgical intervention provided an excellent outcome.

Perpendicular and turbulent flow after aortic valve replacement: paravalvular or transvalvular leakage? - a case report.

BACKGROUND: Perpendicular transvalvular leakage (TVL) is occasionally observed after aortic valve replacement (AVR) in biological valves with a stent post, often originating from the base of the stent post. However, an observed perpendicular jet flow is not always a TVL. In rare cases, paravalvular leakages (PVLs) can be perpendicular and are present behind a TVL. In the present case, both PVL and TVL existed simultaneously as unusual perpendicular jet flows that originated from sites in close proximity to the stent post. CASE PRESENTATION: A 73-year-old man underwent AVR with a biological valve in the supra-annular position using the non-everting mattress suture technique with pledgets. After weaning from cardiopulmonary bypass (CPB), transesophageal echocardiography (TEE) revealed an unfamiliar perpendicular turbulent flow, similar to reported TVL, originating from the anterior stent post. Further TEE examination revealed a PVL had originated from the site between the sewing ring at the anterior stent post and native annulus attached to a pledget. The space between the sewing ring and annular retained native portion caused the perpendicular turbulent jet. Consequently, two types of perpendicular turbulent flows, TVL and PVL, existed adjacent to each other. After reinstitution of CPB, inspection of the prosthesis itself indicated it to be normal, but there was a region adjacent to the anterior stent post near the right coronary ostium where the tip of the curved Pean forceps entered between the sewing ring and the native annulus. The region was consistent with TEE findings. AVR was performed with the same prosthesis again. After weaning from CPB, immediate TEE revealed that the unusual perpendicular turbulent flows had disappeared and only a few small TVLs were observed. Regarding the disappearance of TVL, we considered that the fabric region of the prosthetic valve was covered with cellular elements to prevent the leak, as it was already used in AVR once and soaked in blood. CONCLUSIONS: Perpendicular turbulent flow raises the possibility of both TVL and PVL in the case of AVR with stented bovine pericardial valves. For a differential diagnosis of TVL or PVL, it is important to know the surgical procedures and valve morphology.

Anesthetic management of a patient with a continuous-flow left ventricular assist device for video-assisted thoracoscopic surgery: a case report.

BACKGROUND: As patients with left ventricular assist device (LVAD) have long expected survival, the incidence of noncardiac surgery in this patient population is increasing. Here, we present the anesthetic management of a patient with a continuous-flow LVAD who underwent video-assisted thoracic surgery (VATS). CASE PRESENTATION: A 37-year-old man with LVAD was scheduled to undergo VATS because of repeated spontaneous pneumothorax. Generally, patients with these devices have marginal right heart function; therefore, it is important to avoid factors that worsen pulmonary vascular resistance (PVR). However, VATS requires one-lung ventilation (OLV) and it tends to cause increase in PVR, leading to right heart failure. In the present case, when the patient was set in a lateral decubitus position and progressive hypoxia was observed during OLV, transesophageal echocardiography demonstrated a dilated right ventricle and a temporally flattened interventricular septum, and the central venous pressure increased to approximately 20 mmHg. Because we anticipated deterioration of right heart function, dobutamine and milrinone were administered and/or respirator settings were changed to decrease PVR for maintaining LVAD performance. Finally, resection of a bulla was completed, and the patient was discharged in stable condition on postoperative day 37. CONCLUSIONS: The anesthetic management of a patient with LVAD during VATS is challenging because the possible hemodynamic changes induced by hypoxia associated with OLV affect LVAD performance and right heart function. In our experience, VATS that requires OLV will be well tolerated in a patient with LVAD with preserved right heart function, and a multidisciplinary approach to maintain right heart function will be needed.

Thromboelastometric evaluation of coagulation profiles of cold-stored autologous whole blood: A prospective observational study.

Preoperative autologous blood donation is a well-established procedure to reduce the need for allogeneic blood transfusion. We hypothesized that coagulation activity is maintained in cold-stored whole blood, because the fundamental polymerization properties of fibrin are preserved.Fifty adult patients who underwent elective cardiothoracic surgery were enrolled.Autologous whole blood collected 2 to 4 times at almost 1-week intervals before surgery was stored at approximately 4°C until reinfusion at the time of surgery. Blood samples were drawn just before reinfusion, and rotational thromboelastometry variables and fibrinogen levels were measured.A total of 158 samples were analyzed. The mean duration of cold storage was 16.7 ±â€Š7.4 days (range: 6-33 days). Platelet counts were very low due to collection through a leukoreduction filter. The mean fibrinogen level was 2.3 ±â€Š0.6 g/L. Amplitude at 10 minutes after CT (A10), amplitude at 20 minutes after CT (A20), and maximum clot firmness (MCF) values as determined by FIBTEM analysis were 10.8 ±â€Š3.8, 12.2 ±â€Š4.2, and 13.1 ±â€Š4.7 mm, respectively. Fibrinogen levels were strongly correlated with A10, A20, and FIBTEM-MCF values (ρ = 0.83, P < .0001, ρ = 0.84, P < .0001, ρ = 0.85, P < .0001, respectively). Fibrinogen levels were not correlated with the duration of cold storage (ρ = 0.06, P = .43).The results of the present study demonstrate that fibrin polymerization occurs in cold-stored autologous whole blood, and that such activity is strongly correlated with fibrinogen levels. Furthermore, our data suggest that cold-stored leukoreduced autologous whole blood retains fibrin polymerization properties throughout 33 days.

Falsely high patient state index during cardiopulmonary bypass with intra-aortic balloon pumping: a case report.

BACKGROUND: The patient state index (PSI) is a parameter of a four-channel electroencephalography (EEG)-derived variable used to assess the depth of anesthesia. A PSI value of 25-50 indicates adequate state of hypnosis, and a value of 100 indicates a fully awake state. Due to reduced interference from electronic devices like electrocautery, falsely high intraoperative PSI values are rarely reported. However, this case report cautions about falsely high PSI during cardiopulmonary bypass (CPB) with intra-aortic balloon pumping (IABP). CASE PRESENTATION: A 68-year-old man was scheduled for coronary artery bypass graft surgery with IABP. General anesthesia was maintained using sevoflurane. Initial PSI was between 30 and 50 before CPB. Propofol was administered during CPB, and IABP provided pulsatile flow. IABP was stopped soon after the initiation of CPB, and the ascending aorta was partially clamped to anastomose the saphenous vein graft to the ascending aorta. The PSI value decreased drastically, but with resumption of IABP, the value increased to approximately 80, despite increasing the dose of anesthetics. Meanwhile, the EEG waveform was nearly flat. After discontinuing CPB, the PSI value returned to being extremely low. There was no evidence of intraoperative awareness or instrument trouble. After reviewing the anesthesia record, the high PSI value was almost consistent with ongoing IABP during CPB. We suspect that the oscillation noise created by IABP during CPB erroneously influences the PSI algorithm, resulting in a falsely high PSI. CONCLUSIONS: Anesthesiologists should note that adherence to pEEG-derived values without discretion may cause errors when monitoring the depth of anesthesia.

Esophageal submucosal hematoma developed after endovascular surgery for unruptured cerebral aneurysm under general anesthesia: a case report.

BACKGROUND: Esophageal submucosal hematoma is a rare complication after endovascular surgery. We report a case of an esophageal submucosal hematoma which may have been caused by rigorous cough during extubation. CASE PRESENTATION: A 75-year-old woman underwent endovascular treatment for unruptured cerebral aneurysm under general anesthesia. The patient received aspirin and clopidogrel before surgery and heparin during surgery. Activated clotting time was 316 s at the end of surgery. Protamine was not administered and continuous infusion of argatroban was started after surgery. She had a rigorous cough during removal of the tracheal tube and reported retrosternal discomfort postoperatively. She developed hemorrhagic shock after massive hematemesis. A diagnosis of esophageal submucosal hematoma was made by endoscopic examination and computed tomography. Hemostasis was achieved by compression with a Sengstaken-Blakemore tube and endoscopic cauterization. Blood pressure was recovered by blood transfusion. Endoscopic examination performed 7 days after surgery showed that esophageal submucosal hematoma had almost disappeared and slough had adhered to the mucosal laceration. The patient showed good recovery and was discharged 21 days after surgery. CONCLUSIONS: Careful extubation and postoperative observation are required in patients receiving antiplatelet and anticoagulant therapy.

What range of extra-cardiac conduit flow velocity is detectable intraoperatively following the completion of a total cavo-pulmonary connection?

BACKGROUND: Very few studies have investigated the blood flow velocity from the inferior vena cava (IVC) to the pulmonary artery following the Fontan operation using an extra-cardiac conduit (ECC). No studies at all have investigated the velocity immediately after the circulation is established. The purpose of this retrospective study was to find an acceptable flow velocity at the ECC following the completion of a total cavo-pulmonary connection (TCPC) via transesophageal echocardiography. FINDINGS: We measured the mean velocity (m-V) of the blood flow proximal to the anastomosis between the IVC and ECC in eight patients and compared the results with theoretically predicted values based on assumptions regarding the cardiac output, the ratio of the IVC flow to the superior vena cava flow, and the cross-sectional form of the ECC. Mean velocities ranging from about 15 to 60 cm/s were detected in the absence of any observable stenosis. The measured m-V was significantly faster than the predicted value in our study, both collectively and in every patient individually. The shrinking and compression of the ECC might account for the faster velocities measured in our cases. CONCLUSION: The observed range of m-V at the ECC, about 15-60cm/s, may be acceptable for the establishment of TCPC circulation.

[Perioperative management of a patient with subarachnoid hemorrhage complicated with descending aortic dissection].

A 62-year-old man with descending aortic dissection received general anesthesia for clipping of aneurysm of the cerebral artery. We chose a surgical operation for the aneurysm of the cerebral artery, and conservative therapy for the dissection of the aorta. We gave balanced anesthesia with blood pressure control using calcium channel blocker. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with isoflurane, fentanyl, nitrous oxide and oxygen. Transesophageal echocardiography was useful for checking dissection of the aorta. Perioperative course was uneventful.