[Anesthetic management of intraoperative aortic dissection during cardiovascular surgery].

Despite considerable advances in anesthesia technique, intraoperative aortic dissection remains a potentially lethal complication during on-pump cardiovascular surgery. Intraoperative dissection has been described worldwide, ranging between 0.06% and 0.24%. Here we present 8 patients who had intraoperative dissection during 10-year period with 6,266 on-pump cases (0.13%, 95% confidence interval 0.12% to 0.14%). In-hospital mortality rate of intraoperative dissection was 12.5% (1/8) at our institution, which was exceptionally lower than that reported previously (24% to 43%). Therefore, we also show our treatment strategy for intraoperative dissection with the related-literature review. The original surgical procedures were descending aortic replacement in 3 patients, valve replacement in 4 patients, and aortic-root replacement in 1 patient. Dissection occurred during aortic cannulation in 6 patients and during manipulation of aortic cross-clamping/de-clamping in 2 patients. Three patients had retrograde dissection extending and beyond the arch. Trans-esophageal echocardiography was useful to confirm dissection and ensure proper perfusion of the aortic-branches. Immediately after its diagnosis, all patients were managed with hypotensive strategy and subsequently underwent deep hypothermic circulatory arrest for prevention of dissection propagation. Among patients with intraoperative aortic dissection undergoing on-pump cardiovascular surgery, not only earlier diagnosis but proper anesthetic management may be crucial for the successful outcome.

Spinal cord ischemia after endovascular aortic repair versus open surgical repair for descending thoracic and thoracoabdominal aortic aneurism.

PURPOSE: Thoracic endovascular aortic repair (TEVAR) an emerging less invasive alternative to surgery, is now being increasingly employed, but spinal cord ischemia (SCI) is still a threat with this procedure. Delayed paraplegia has been frequently observed after TEVAR, suggesting there may be different courses of SCI between TEVAR and the conventional open surgical repair (OSR) of thoracic and thoracoabdominal aneurysms. Therefore, we conducted a study to investigate the risk factors for and the course of SCI after TEVAR and OSR. METHODS: We studied a series of 414 OSR and 94 TEVAR patients prospectively. Postoperative motor function, sensory disturbance, and bladder disturbance were assessed daily to evaluate the course of SCI. Previously reported risk factors for SCI were investigated. RESULTS: Spinal cord ischemia occurred in 6 patients (6.4 %) in the TEVAR group, and in 18 patients (4.3 %) in the OSR group, resulting in no significant difference (p = 0.401). A greater percentage of patients (n = 4, 66.7 %) with SCI in the TEVAR group had a delayed onset, compared with 16.7 % (n = 3) in the OSR group (p = 0.038). The rate of recovery of walking function after SCI and the incidence of sensory disturbance and bladder dysfunction was similar in the two groups. Multivariate analysis demonstrated that, in the TEVAR group, the stent length of aortic coverage was a significant risk factor for SCI. CONCLUSION: The incidence of SCI was similar in the OSR and TEVAR groups, but delayed SCI occurred more frequently in the TEVAR group. Except for the delayed onset of SCI, SCI showed a similar course of recovery in the two groups.

[Undiagnosed hereditary angioedema in a patient undergoing emergency caesarean section].

Hereditary angioedema (HAE) is characterized by acute, recurrent attacks of localized edema. Surgical procedures, trauma, and infections have been considered as potential triggers of HAE. Although HAE is a rare genetic disorder, approximately 50-60% of all HAE patients are involved with at least one occurrence of upper airway obstruction. The airway trouble is the most life-threating complication in HAE patients because HAE-related edema does not respond to typical treatment, such as administration of epinephrine, antihistamines, or glucocorticoids. Indeed, mortality rates of laryngeal attack are estimated around 25% to 40%. Here we describe a case of undiagnosed HAE patient undergoing emergency caesarean section under neuraxial blockade. A 31-year-old woman showed multiple regions at her lip margin during surgery and rapidly developed lip swelling after admission to the ward. Neither respiratory nor hemodynamic instability was found during and after surgery. Immediately, in order to assess whether HAE caused these dermatological manifestations, we measured values of both complement component 4 (C4) and functional activity of C1-esterase inhibitor (C1-inh), a protein of the complement system. These laboratory data showed low levels, which were compatible with HAE definition. After commencement of C1-inhibitor replacement therapy, her lip swelling and erythema gradually disappeared without adverse drug reactions. The patient was finally discharged from our institution 10 days after surgery.

[Bladder temperature versus tympanic temperature in patients undergoing abdominal aortic aneurysm surgery].

BACKGROUND: Inaccurate measurements of body temperature might be associated with complications during the perioperative period. We conducted a retrospective cohort study to compare the bladder temperature and the tympanic membrane temperature in patients undergoing open repair of abdominal aortic aneurysm. METHODS: Fifteen adult patients who had undergone general anesthesia with/without epidural anesthesia were included in the present cohort. The bladder and the tympanic temperatures were simultaneously recorded at 6 points during surgery. One-way repeated measures ANOVA and Bland-Altman analysis were performed to assess statistical significance. The two-tailed P values less than 0.05 were considered statistically significant. RESULTS: No difference was found between the bladder and the tympanic temperatures before abdominal aortic cross-clamping. However, during and after cross-clamping, the bladder temperature values were likely to be lower compared with the tympanic values. The average temperature difference (+/- 2 SD) was 0.4 degrees C (+/- 1.1 degrees C) (95% CI: -1.21-0.78). CONCLUSIONS: The tympanic membrane might be a reliable site for core body temperature measurement in abdominal aortic aneurysm surgery patients.

[Case of awake intubation in semi-sitting position for a patient with myasthenia gravis combined with cervical disc hernia utilizing Pentax-AWS Airwayscope].

We report a case of awake intubation utilizing Pentax-AWS Airwayscope in semi-sitting position. A 74-year-old man with myasthenia gravis and cervical disc hernia was scheduled for distal gastrectomy under general anesthesia. He could not move his head due to severe cervical disc hernia and also could not sufficiently breathe due to the fatigue of respiratory muscles by myasthenia gravis in supine position. With fentanyl bolus administration and lidocaine spray for laryngotracheal anesthesia, we performed awake intubation in semi-sitting position with AWS from cranial side. The patient did not buck during intubation and no hemodynamic change was observed.

[Efficacy of cryoprecipitate transfusion for coagulopathy after cardiopulmonary bypass in thoracic aortic surgery].

BACKGROUND: Excessive bleeding after cardiopulmonary bypass remains a major complication for cardiac surgery. The principal causes of hemostatic bleeding are related to inadequate surgical hemostasis or diluted coagulopathy. We investigated the efficacy of cryoprecipitate (Cryo) transfusion in thoracic aortic surgery with cardiopulmonary bypass. METHODS: We divided 30 patients undergoing thoracic aortic surgery into two groups retrospectively. Fifteen patients transfused with cryoprecipitate and fresh frozen plasma (FFP) were defined as Group Cryo, and the other 15 patients transfused with FFP only were defined as Group FFP We compared the amount of blood products administered and the blood loss during the perioperative period between the two groups with P <0.05 to be significant. RESULTS: There were no significant differences in the clinical background between the two groups. There were significant differences in the volume of blood loss (Group Cryo 544 +/- 233 ml, Group FFP 888 +/- 339 ml), requirements of FFP (Group Cryo 0.6 +/- 1.7 unit, Group FFP 4.3 +/- 6.0 unit) in ICU. CONCLUSIONS: Cryoprecipitate transfusion is an effective treatment for coagulopathy caused by dilution of coagulation factors after cardiopulmonary bypass.

[Anesthetic management for pneumonectomy in a patient with cardiac amyloidosis].

Cardiac amyloidosis may cause restrictive cardiomyopathy associated with heart failure, conduction disorder and ischemic heart disease. Therefore, patients with amyloidosis require careful hemodynamic monitoring in perioperative period. A 63-year-old man with cardiac amyloidosis was scheduled for pneumonectomy. His transthoracic echocardiography assessment showed a hypertrophic interventricular septum and slight decreased ejection fraction of 55%, but left ventricular (LV) diastolic function was decreased. Pulse Doppler for mitral valve inflow showed that the early peak velocity/atrial peak velocity (E/A) ratio was 0.9, the deceleration time (DT) was 163 msec and the early diastolic mitral annular tissue velocity (E') was 4 cm x sec(-1). These data suggested a pseudonormalization state. We performed careful monitoring using arterial pressure-based cardiac output (APCO), central venous oxygen saturation (ScvO2) and transesophageal echocardiography. There were no severe complications such as circulatory collapse and arrhythmia in the perioperative period.

A case of infective endocarditis associated with atopic dermatitis perioperatively treated with dupilumab.

Background: Several case reports and reviews support a relationship between atopic dermatitis (AD) and infective endocarditis (IE). Here, we present a case of severe AD suspected of causing IE. Case presentation: A 21-year-old man with severe AD was admitted to our hospital due to unidentified fever, syncope, and headache. He was diagnosed with IE with cerebral embolism and mitral regurgitation. Before elective cardiac surgery, he was subcutaneously administered dupilumab for 2 months to control AD. Dupilumab improved AD, and cardiac surgery was performed without complications. Conclusions: Dupilumab may be effective in AD cases as preparation for cardiac surgery.

[Inflammatory myofibroblastic tumor of the bladder: a case report].

A 15-year-old girl presented to a clinic with an asymptomatic macrohematuria. Cystoscopy revealed a bladder tumor. The next day she was admitted to our hospital because of preshock status with macrohematuria. Abdominal computed tomography (CT) revealed a solid tumor in the left anterior to lateral wall. Urinary cytology was negative. She received a transfusion and transurethral resection of bladder tumor as an emergent operation. Histopathological examination revealed inflammatory myofibroblastic tumor. Anaplastic lymphoma kinase immunohistopathological studies revealed cytoplasmic staining of the myofibroblasts. To our knowledge, this is the 35th reported case of inflammatory myofibroblastic tumor of the bladder in Japan. She has been followed up for 13 months without any evidence of local recurrence.

Emergency cardiac surgery and heparin resistance in a patient with essential thrombocythemia.

A 66-year-old man with thrombocytosis was brought to our hospital to undergo removal of a left ventricular thrombus. He had developed cerebral infarction 6 days before presenting to the hospital and suffered from right incomplete hemiparalysis. Blood tests on admission revealed his platelet count to be 124.3 × 104/µl. The urgent removal operation was performed under general anesthesia. For carrying out extracorporeal circulation (ECC), approximately three times as much heparin as expected was needed, as well as antithrombin III (AT III) administration. This met the definition of heparin resistance. The thrombus was removed and surgical left ventricular reconstruction was performed. Aspirin and warfarin were initiated on postoperative day 5. A bone marrow biopsy was performed on postoperative day 8, which revealed hypercellular marrow with megakaryocyte proliferation, and the patient was diagnosed as having essential thrombocythemia (ET). Although hydroxycarbamide administration started on postoperative day 10, his platelet count increased to 290.7 × 104/µl on postoperative day 13. The counts descended gradually, and on postoperative day 34, his platelet count reached the normal range and he was discharged from the hospital. In the perioperative period, his new neurologic abnormality did not appear. Addition of heparin, administration of AT III, and coating the cardiopulmonary bypass circuit with heparin or macromolecular polymer prevented clot formation and enabled safe ECC in a patient with ET and a high platelet count.