Total Intravenous Anesthesia Using Remimazolam for Transcarotid Approach Transcatheter Aortic Valve Replacement: A Case Report.

The transcarotid approach was introduced in Japan in April 2024 as an alternative approach for transcatheter aortic valve replacement (TAVR). Because carotid artery blood flow is reduced on one side during the procedure, there is a risk of intraoperative brain stroke. Therefore, it is crucial to check for cerebral complications immediately after the procedure. We report a case involving an 87-year-old female who underwent transcarotid TAVR under general anesthesia with remimazolam and remifentanil. The operation was completed in a short period. There was no evidence of hypotension during the induction of anesthesia, and intraoperative blood pressure control was easy. However, there was a decrease in local oxygen saturation for approximately nine minutes intraoperatively. Following the administration of flumazenil, the patient was quickly awakened, and neurological findings were confirmed to be normal. The patient was discharged without complications. Our findings suggest that remimazolam, an ultra-short-acting benzodiazepine, is feasible for the transcarotid TAVR procedure due to its minimal circulatory impact and ability to facilitate rapid and reliable arousal.

Retrograde Aortic Valve Migration During Transcatheter Aortic Valve Replacement for Aortic Regurgitation: A Case Report Highlighting the Importance of Prompt Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Initiation.

Surgical aortic valve replacement (SAVR) is the recommended curative treatment for pure native aortic regurgitation (AR). However, some patients are not suitable for SAVR due to comorbidities or frailty. Transcatheter aortic valve replacement (TAVR) has been reported to offer a better prognosis than medical therapy in AR patients; thus, the use of TAVR for AR may increase in the future. However, the reduced calcification and annulus ring stiffness associated with TAVR may increase the risk of valve migration. Accumulating data on rescue measures in the event of valve migration is necessary. An 87-year-old female with a history of hypertension and persistent atrial fibrillation presented to our emergency department with dyspnea. The patient was diagnosed with congestive heart failure class IV, according to the New York Heart Association classification, necessitating urgent admission to our cardiac department. Due to the patient's high surgical risk (Society of Thoracic Surgeons (STS) score 9.17%, Euro2 score 9.55%, frailty 6), the heart team performed TAVR with a right femoral arterial approach. The patient was sedated, and pacing was initiated at 180 bpm. We placed an Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) #23 (-1 mL volume, with attached balloon). During the post-deployment procedure, the aortic valve migrated retrogradely into the left ventricle (LV). Despite the occurrence of severe aortic valve regurgitation, the patient's vital signs remained stable. Five minutes after the migration of the aortic valve, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. A second TAVR valve implantation was then performed. However, after the second valve implantation and the removal of the pre-shaped guidewire (Safari2 pre-shaped guidewire extra small, Boston Scientific, Marlborough, MA, USA), the migrated valve became stuck in the left ventricular outflow tract (LVOT) in a reverse position, resulting in severely limited left ventricular ejection. We increased the support provided by VA-ECMO, and surgical conversion to SAVR was performed without experiencing circulatory collapse. Surgical aortic valve replacement was initiated successfully, and withdrawal of the cardiopulmonary bypass (CPB) was performed without complications. The patient was extubated on the first postoperative day (POD), discharged from the ICU on POD 3, and transferred for rehabilitation on POD 27. In summary, the prompt introduction of VA-ECMO was important for avoiding complications and saving the patient's life following the retrograde migration of the TAVR valve.

Cardiac Arrest Following Torsades de Pointes Caused by Hypokalemia and Catecholamines in a Patient with Congenital Long QT Syndrome Type 1 After Surgical Aortic Valve Replacement: A Case Report.

BACKGROUND Prevention of lethal arrhythmias in congenital long QT syndrome type 1 (LQT1) requires avoidance of sympathoexcitation, drugs that prolong QT, and electrolyte abnormalities. However, it is often difficult to avoid all these risks in the perioperative period of open heart surgery. Herein, we report hypokalemia-induced cardiac arrest in a postoperative cardiac patient with LQT1 on catecholamine. CASE REPORT A 79-year-old woman underwent surgical aortic valve replacement for severe aortic stenosis. Although the initial plan was not to use catecholamine, catecholamine was used in the Postoperative Intensive Care Unit with attention to QT interval and electrolytes due to heart failure caused by postoperative bleeding. Serum potassium levels were controlled above 4.5 mEq/L, and no arrhythmic events occurred. On postoperative day 4, the patient was started on insulin owing to hyperglycemia. Cardiac arrest occurred after the first insulin dose; the implantable cardioverter defibrillator was activated, and the patient's own heartbeat resumed. Subsequent examination revealed that a marked decrease in serum potassium level had occurred after insulin administration. The electrocardiogram showed obvious QT prolongation and ventricular fibrillation following R on T. Thereafter, under strict potassium management, there was no recurrence of cardiac arrest events. CONCLUSIONS A patient with LQT1 who underwent open heart surgery developed ventricular fibrillation after Torsades de Pointes, probably due to hypokalemia after insulin administration in addition to catecholamine. It is important to check serum potassium levels to avoid the onset of Torsades de Pointes in patients with long QT syndrome. In addition, the impact of insulin administration was reaffirmed.

A 32-Year-Old Man Diagnosed with Type II Brugada Syndrome on Preoperative Electrocardiogram 1 Week Before Elective Tympanoplasty.

BACKGROUND Brugada syndrome is a potentially fatal cardiac arrhythmia characterized by incomplete right bundle-branch block (RBB) and characteristic ST-segment elevation in the anterior electrocardiogram (ECG) leads. This report is of a case of type 2 Brugada syndrome, and discusses the importance of preoperative history and ECG evaluation. CASE REPORT A 32-year-old man was scheduled for tympanoplasty. His preoperative ECG revealed saddleback-type J waves in V2 (>2 mm) and ST increase (>1 mm) detected 1 week before elective surgery, but the ECG 1 year before showed normal. He had no notable past history. Anesthesia was induced with remifentanil and propofol, and maintained with sevoflurane in combination with remifentanil. Routine monitoring of vital signs was supplemented with V2 monitoring on the ECG. The heart rate was maintained at above 60 beats/min using ephedrine. The course of the operation was uneventful. CONCLUSIONS We managed anesthesia for a patient with a type 2 Brugada syndrome ECG without events, probably because he had no notable past history such as syncope. Type 2 and type 3 Brugada syndrome ECGs are difficult to recognize, and patients with them are considered to be less risky than a patient with a type I ECG. However, as Brugada syndrome ECG is dynamic and changeable, a type 2 or 3 Brugada syndrome ECG can change to a type I ECG under some conditions, and thus should not be overlooked, and the patient's past history or symptoms, such as syncope, should be carefully investigated.

Can left ventricular hypertrophy on electrocardiography detect severe aortic valve stenosis?

BACKGROUND: Severe aortic stenosis (AS) is increasing in the aging society and is a serious condition for anesthetic management. However, approximately one-third of patients with severe AS are asymptomatic. Echocardiography is the most reliable method to detect AS, but it takes time and is costly. METHODS: Data were obtained retrospectively from patients who underwent surgery and preoperative transthoracic echocardiography (TTE). LVH on ECG was determined by voltage criteria (Sv1 + Rv5 or 6 ≥3.5 mV) and/or the strain pattern in V5 and V6. Severe AS was defined as a mean transaortic pressure gradient ≥40 mmHg or aortic valve area ≤1.0 cm2 by TTE. RESULTS: Data for 470 patients aged 28-94 years old were obtained. One hundred and twenty-six patients had severe AS. LVH on ECG by voltage criteria alone was detected in 182 patients, LVH by strain pattern alone was detected in 80 patients and LVH by both was detected in 55 patients. Multivariable logistic analysis revealed that LVH by the strain pattern or voltage criteria, diabetes mellitus, and age were significantly associated with severe AS. The AUC for the ROC curve for LVH by voltage criteria alone was 0.675 and the cut-off value was 3.84 mm V, and the AUC for the ROC for age was 0.675 and the cut-off value was 74 years old. CONCLUSION: Our study suggests that patients who are 74 years old or over with LVH on ECG, especially those with DM, should undergo preoperative TTE in order to detect severe AS.

Anesthesia management in a patient with very long-chain acyl-Coenzyme A dehydrogenase deficiency.

BACKGROUND: In a patient with very long-chain acyl-Coenzyme A dehydrogenase (VLCAD) deficiency, metabolism of fatty acids is impaired and a supply of alternative energy is limited when glucose level is insufficient on starvation. CASE PRESENTATION: A 37-year-old woman with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Glucose was administered intravenously with the start of fasting. Anesthesia was induced with remifentanil, midazolam, and thiamylal, maintained with desflurane and remifentanil. Body temperature was maintained at 36.2-36.7 °C. During anesthesia, hypoglycemia did not occur, creatine kinase levels were in the normal range, and myoglobinuria was not detected. No shivering was observed after extubation. CONCLUSIONS: Glucose was administered to avoid perioperative hypoglycemia. Body temperature was controlled to avoid shivering, which would otherwise increase skeletal muscle energy needs. Blood creatine kinase did not increase, and myoglobinuria was not detected; thus, rhabdomyolysis was unlikely to develop.

Effectiveness of simplified chest compression-only CPR training program with or without preparatory self-learning video: a randomized controlled trial.

OBJECTIVES: To evaluate the effectiveness of 1-h practical chest compression-only cardiopulmonary resuscitation (CPR) training with or without a preparatory self-learning video. METHODS: Participants were randomly assigned to either a control group or a video group who received a self-learning video before attending the 1-h chest compression-only CPR training program. The primary outcome measure was the total number of chest compressions during a 2-min test period. RESULTS: 214 participants were enrolled, 183 of whom completed this study. In a simulation test just before practical training began, 88 (92.6%) of the video group attempted chest compressions, while only 58 (64.4%) of the control group (p<0.001) did so. The total number of chest compressions was significantly greater in the video group than in the control group (100.5+/-61.5 versus 74.4+/-55.5, p=0.012). The proportion of those who attempted to use an automated external defibrillator (AED) was significantly greater in the video group (74.7% versus 28.7%, p<0.001). After the 1-h practical training, the number of total chest compressions markedly increased regardless of the type of CPR training program and inter-group differences had almost disappeared (161.0+/-31.8 in the video group and 159.0+/-35.7 in the control group, p=0.628). CONCLUSIONS: 1-h chest compression-only CPR training makes it possible for the general public to perform satisfactory chest compressions. Although a self-learning video encouraged people to perform CPR, their performance levels were not sufficient, confirming that practical training as well is essential. (UMIN000001046).