[Anesthetic management of an adult patient with Ebstein's anomaly].

Ebstein's anomaly is a rare congenital heart disease. An adult patient with Ebstein's anomaly was scheduled for Hetzer's procedure (modified tricuspid valve repair). This 36-year-old female had been diagnosed as Ebstein's anomaly and a patent foramen ovale during pregnancy, and Hetzer's repair procedure for tricuspid valve incompetence and closure of the foramen ovale were performed. The surgical techniques were chosen based on preoperative transthoracic echocardiography and intraoperative transesophageal echocardiography. During the operation, maximal attention was paid to prevent hypoxemia and paradoxical embolization. The patient's postoperative course was successful, and she was discharged from the hospital on the 14th postoperative day. Tricuspid valve regurgitation was reduced from IV to I, and New York Heart Association functional class was improved from III to I in the postoperative period. Hetzer's procedure is a useful technique for tricuspid repair of Ebstein's anomaly. Accurate morphological evaluation of the tricuspid valve by preoperative transthoracic and intraoperative transesophageal echocardiography is very important for the surgeon to plan surgery appropriately. Anesthesiologists should understand transesophageal echocardiography for congenital heart disease well.

[A case report of coronary artery fistula in which perioperative transthoracic and transesophageal echocardiography was useful for surgical decision].

Coronary artery fistula is rare in congenital heart diseases but is the major disease among "coronary" congenital diseases. In a coronary artery fistula, the coronary artery tip connects directly or via an unusual blood vessel to unusual parts, such as the inside of the heart chamber, pulmonary artery or superior vena cava. Left ventricular volume overload and coronary steal phenomenon are serious symptoms. The gold standard of diagnosis has been coronary angiography, but echocardiography using Doppler methods is now useful for its diagnosis. This is a case report of coronary artery fistula for which transthoracic echocardiography (TTE) during anesthetic induction and intraoperative transesophageal echocardiography (TEE) by anesthesiologists provided accurate diagnosis of the shunt position. A 62-year-old female was scheduled to undergo surgery for a coronary artery fistula and aneurysm. Two separate shunts from the coronary artery into the pulmonary artery had been suspected by preoperative TTE. Shunt orientation was reexamined by perioperative TTE and TEE. We confirmed that only one shunt was located at the supra pulmonary valve area, and we consulted the diagnosis to surgeons. As a result, one shunt was found in the surgical view at the same position. Perioperative TTE and TEE are useful for surgical decision.

[Anesthetic management of extracorporeal shock wave lithotripsy: case reports of four young patients with epilepsy].

Four young patients, including a 7-year-old girl with Aicardi syndrome, an 11-year-old boy with Lennox-Gastaut syndrome, a 22-year-old man with epilepsy due to childhood encephalitis, and a 17-year-old girl with Rett syndrome, were scheduled to undergo extracorporeal shock wave lithotripsy (ESWL) for urolithiasis. Epilepsy in all of the patients was well controlled by medication. Series of ESWL treatment were safely performed under general anesthesia with tracheal intubation. We recommend that maintenance of anesthesia be performed by sevoflurane and nitrous oxide, which can increase threshold of epileptic stroke, and controlled ventilation with a muscle relaxant should be performed to prevent lung or renal injury by the shock wave of ESWL.

[Effect of landiolol hydrochloride for intraoperative tachycardia--multicenter questionnaire study].

BACKGROUND: The purpose of this study was to evaluate effects of landiolol hydrochloride, which is an ultra-short-acting beta-1 selective blocker, for intraoperative tachycardia and to establish practical methods of administration of the drug. METHODS: We retrospectively examined by multicenter questionnaires the effects and practical methods of administration of landiolol for 100 patients who showed tachycardia needing treatment during anesthesia. The techniques for anesthesia and administration of landiolol were entrusted to each anesthesiologist. RESULTS: One case was excluded because the dose of landiolol hydrochloride was uncertain. Fifty-nine patients received an intravenous bolus injection of landiolol, and continuous injection was performed in 34 patients. Six patients had both bolus and continuous injections. In the 99 patients, heart rate was significantly reduced to desired levels. The time required to reduce heart rate by more than 10% after injection was shorter in the bolus group than in the continuous group. Bolus injection, however, did not reduce blood pressure. Although low-dose continuous administration significantly reduced blood pressure, treatment for increasing blood pressure was not needed in any of the patients. CONCLUSIONS: Information obtained by the questionnaire suggests that bolus injection and/or low-dose continuous administration of landiolol, which are not described in the drug information documents, are effective and safe for treatment of tachycardia during anesthesia.

[Comparison of ultrasound-guided and blindly placed radial artery catheterization].

BACKGROUND: The purpose of this study was to evaluate whether ultrasound (US)-guided radial artery catheterization decreases the number of failed attempts. METHODS: A total of 36 patients requiring an arterial catheter were enrolled. Patients were divided into 3 groups: 1) a blind palpation technique group, 2) an US-guided short-axis group, and 3) an US-guided long-axis group. The vascular access was performed by one anesthesiologist. The number of attempts at catheter placement was compared within the groups. RESULTS: There were no significant differences among the groups in number of attemps (P = 0.268); however, it seems that the deviation of attempts was small in the US groups. CONCLUSIONS: Because the artery and catheter are actually visualized by US, it seems, that US-guided radial artery catheterization is a safe and educational technique.

AP1B plays an important role in intestinal tumorigenesis with the truncating mutation of an APC gene.

Recent evidence has suggested that carcinoma is accompanied by the loss of cell polarity. An epithelial cell-specific form of the AP-1 clathrin adaptor complex, AP1B, is involved in the polarized transport of membrane proteins to the basolateral surface of epithelial cells. In our study, we investigated whether AP1B is involved in intestinal tumorigenesis. The cellular polarity of intestinal tumor cells was examined using APC(Min/+) mice as an in vivo model and SW480 cells with a truncating mutation in the adenomatous polyposis coli (APC) gene as an in vitro model by confocal microscopy. Next, the expression of AP1B in intestinal tumor cells was examined by real-time polymerase chain reaction (PCR) and Western blotting. The localization of ß-catenin and the expression of AP1B in the tumor tissue of patients with colorectal cancer were evaluated by confocal microscopy and real-time PCR, respectively, and the relationships among cell polarity, AP1B expression and intestinal tumorigenesis were examined. Cellular polarity was lost in intestinal tumor cells, and the expression of AP1B was downregulated. In addition, the reduction in the expression level of AP1B correlated with the nuclear localization of ß-catenin in human colorectal cancer. Our study indicates the close associations between AP1B, intestinal tumorigenesis and mutations in the APC gene. This is the first report to reveal the relationships among AP1B, cellular polarity and intestinal tumorigenesis, and achieving a detailed understanding of AP1B will hopefully lead to discovery of therapeutic targets and novel biomarkers for intestinal cancer.

[Successful life saving from brachiocephalic vein injury using cardiopulmonary bypass during video-assited thoracoscopic resection for a mediastinal tumor--a case report].

A 67-year-old man was scheduled for video-assited thoracoscopic resection of a mediastinal tumor under epidural and general anesthesia. During removal of the tumor about an hour 30 minutes after the start of the operation, pulseless electrical activity developed due to uncontrollable massive hemorrhage caused by laceration of the left brachiocephalic vein. After intravenous administration of epinephrine and fluid resuscitation, compatible red cell transfusion with a different ABO group and intraoperative autotransfusion were started. Hemodynamics was unstable although bleeding was stanched. Therefore, cardiopulmonary bypass (CPB) was initiated about 2.5 hours after blanching had started. As a result, bleeding from the laceration was reduced, and the laceration was repaired. The patient recovered uneventfully and had no complications. CPB should be considered for cases of uncontrollable bleeding from a central vein and should be initiated as soon as possible.

[Usefulness of preoperative epidural catheterization under radiographic monitoring in anesthesia for endovascular abdominal aneurysm repair].

In Japan, endovascular abdominal aneurysm repair became one of the standard procedures in 2006. It has been performed in 8 patients at our hospital. We try epidural anesthesia with sedation for treatment because of the good control of blood pressure and immobilization of the patient. We usually perform epidural catheterization one day before the operation to avoid epidural hematoma due to heparinization during the operation. We usually use radiographic monitoring for safe and precise insertion of the catheter into the epidural space. Epidural catheterization with radiographic monitoring is useful for safe and reliable epidural analgesia.

Identification of the lumbar intervertebral level using ultrasound imaging in a post-laminectomy patient.

A spinal block was performed in a post-laminectomy patient, using both ultrasound imaging and X-ray imaging. Ultrasound imaging clearly identified the L3/4 intervertebral level, the spinal canal, the corpus vertebrae, and the dura mater. Using ultrasound imaging, we measured the distance from the skin surface to the dura mater (39 mm). A 25-G needle for the spinal block was accurately advanced into the spinal canal with the use of X-ray imaging (43 mm from the skin to the subarachnoid space). We report here that ultrasound imaging was useful for performing a spinal block in a post-laminectomy patient in whom there was anatomical change around the spine.