[Show abstract][Hide abstract] ABSTRACT: Epicardial pacemaker wire insertion is standard following cardiothoracic surgery. However, undersensing of pacing wires may cause the R-on-T phenomenon, which induces ventricular fibrillation. We report a case of a male patient with severe mitral regurgitation scheduled for mitral valve replacement who experienced two ventricular fibrillation episodes related to the R-on-T phenomenon caused by undersensing of the epicardial pacing wire. Both undersensing events happened despite an appropriately low sensing threshold. Notably, the stimulated T wave followed the QRS of the premature ventricular contraction (PVC). This case suggests that a PVC’s R wave may be undersensed despite a low sensing threshold. This critical complication may have occurred because pacemakers sense R waves using a slew rate, which is the quotient of voltage over time. As a result, pacemakers may undersense wide QRS waves such as PVCs. Avoiding this dangerous phenomenon completely is not possible using epicardial pacemakers; therefore we recommend carefully adapting epicardial pacing especially when PVC waves occur frequently.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to elucidate the difference in inotrope use between patients who underwent left ventricular assist device (LVAD) implantation with preoperative extracorporeal membrane oxygenation (ECMO) and those who underwent LVAD implantation without preoperative ECMO. One hundred and eight patients who underwent LVAD implantation were enrolled in this study. Prior to LVAD implantation, 27 patients received ECMO support (ECMO group) and the other 81 patients did not (non-ECMO group). Cardiac index (CI), mean arterial pressure (MAP), mixed venous oxygen saturation (SvO2), and the vasoactive inotropic score (VIS) were recorded at weaning from cardiopulmonary bypass (CPB), 30 min after weaning from CPB (min after CPB), 60 min after CPB, and at the end of surgery. MAP and VIS were also recorded before induction of anesthesia (baseline). The modified VIS was defined as: (dopamine µg/kg/min × 1 + dobutamine µg/kg/min × 1 + epinephrine µg/kg/min × 100 + noradrenaline µg/kg/min × 100 + milrinone µg/kg/min × 10 + olprinone µg/kg/min × 25). There were no significant differences between the ECMO group and the non-ECMO group in terms of hemodynamic parameters such as MAP, CI, and SvO 2 . However, the ECMO group had higher VIS and noradrenaline doses than that of non-ECMO group (p = 0.030 and p = 0.044, respectively). VIS was significantly higher in ECMO group at 30 min after CPB (p = 0.03), 60 min after CPB (p = 0.003), and at the end of the surgery (p < 0.001). The doses of noradrenaline were significantly higher in ECMO group at 60 min after CPB (p = 0.013), and at the end of surgery (p = 0.002). Patients who received ECMO support prior to LVAD implantation required significantly more noradrenaline to maintain normal levels of hemodynamic parameters compared with patients without ECMO.
[Show abstract][Hide abstract] ABSTRACT: The patient was a 67-year-old woman with a history of worsening dyspnea over several months. Cardiac echocardiography showed a large, mobile left atrial myxoma. Emergency surgery was performed. Cardiac arrest occurred during repositioning of the heart to cannulate the inferior vena cava and transesophageal echocardiography revealed the large myxoma obstructing the left ventricle. Cardiopulmonary bypass was initiated and spontaneous heartbeat returned shortly afterward. Changing myxoma position and sudden mitral orifice obstruction must be considered in these cases and once the diagnosis is made, patients should be operated on as early as possible.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
First, to examine the perioperative association between increased cardiac index (CI) measured using three-dimensional echocardiography (CI3D), two-dimensional echocardiography (CI2D), and FloTrac/Vigileo (CIFT) (Edwards Lifesciences, Irvine, CA) after cardiac resynchronization therapy (CRT) and decreased brain natriuretic peptide (BNP) 6 months after CRT. Second, to evaluate the accuracy and tracking ability of CI2D and CIFT.
A prospective clinical study.
A cardiac surgery operating room in a single cardiovascular center.
Forty-five patients undergoing elective CRT lead implantation.
CIFT and CI2D were determined simultaneously before and after CRT using CI3D as the reference method.
Measurements and main results:
BNP was measured before CRT and 6 months after CRT. Areas under the receiver operator characteristic curves (AUCs) were calculated for each method of measurement to predict BNP decrease. AUC was largest for CI3D (AUC = 0.735, p = 0.017). Bland-Altman analysis revealed that the percentage error was 58% for CIFT and 28% for CI2D. A polar plot analysis showed that the mean angular bias was -7.26° and 0.64°, the radial limits of agreement were 70° and 29.4°, and the concordance rate was 67.7% and 93.8% for CIFT and CI2D, respectively.
CI significantly increased after CRT in patients whose BNP level decreased 6 months after CRT. However, only CI3D could predict decreases in BNP 6 months after CRT. Although CI2D was acceptable compared with CI3D, the tracking ability of CI changes was just below acceptable. CIFT has a wide limit of agreement with CI3D, with a poor tracking ability.
No preview · Article · Sep 2015 · Journal of cardiothoracic and vascular anesthesia
[Show abstract][Hide abstract] ABSTRACT: It is crucial to evaluate cerebral blood flow (CBF) during carotid endarterectomy (CEA). However, it is difficult to measure CBF in the operating room. The recent development of high-accuracy near-infrared spectroscopy (NIRS) has enabled the measurement of regional CBF following injection of indocyanine green (ICG). We aimed to measure changes in regional CBF by clamping the carotid artery during CEA and to analyze factors affecting the blood flow index (BFI) in CEA.
Patients undergoing elective CEA were enrolled in this study after it was approved by the institutional ethical board. All patients underwent CEA under general anesthesia. Intraoperative blood pressure was controlled about 30% higher than the precarotid cross-clamping during carotid cross-clamping. ICG (0.5 mg/kg) was injected before, during, and after carotid cross-clamping. The kinetics of an intravenous bolus of ICG were monitored by a NIRS oximeter (NIRO200NX) and the BFI was calculated using the slope of the ICG concentration. The impact of carotid cross-clamping on the BFI was evaluated, along with factors influencing changes in the BFI.
A total of 50 patients were enrolled. The BFI significantly decreased during carotid cross-clamping compared with baseline values (from 0.077±0.019 to 0.0054±0.0019 μmol/L/s) (P<0.01). After unclamping the common carotid artery, the BFI recovered to the preclamping level (0.0073±0.0023 μmol/L/s) (P<0.01). Multiple logistic regression analysis revealed that abnormalities of the circle of Willis correlated significantly with reduced BFI (odds ratio=12.07, P=0.036).
The BFI was significantly reduced by carotid artery clamping during CEA. Abnormalities of the circle of Willis were a significant factor contributing to reduced BFI.
No preview · Article · Aug 2015 · Journal of neurosurgical anesthesiology
[Show abstract][Hide abstract] ABSTRACT: Regional cerebral oxygen saturation measured by near-infrared spectroscopy has been used clinically. Its usefulness in cardiac surgery and neurosurgery was also reported. On the other hand, accuracy of rSO2 values has been supposed to be doubtful due to extracerebral contamination and unstable mean optical pathlength. Therefore, we tried to review issues for accuracy of rSO2 values and clinical usefulness. Our aim is to clarify the issue and clinical usefulness of measuring regional cerebral oxygen saturation.
No preview · Article · May 2015 · Masui. The Japanese journal of anesthesiology
[Show abstract][Hide abstract] ABSTRACT: Delirium after cardiac surgery is a serious complication, increasing morbidity and mortality. Despite its high expectations, off-pump coronary artery bypass grafting (OPCAB) has largely failed to reduce the incidence of postoperative neurological complications. To further investigate the reasons for this failure, we used perioperative brain magnetic resonance imaging (MRI) to determine the relation between MRI findings and postoperative delirium.
Altogether, 98 patients undergoing elective OPCAB were enrolled in this prospective observational study. Patients underwent brain MRI and magnetic resonance angiography (MRA) before and after surgery to identify cerebral infarction, white matter lesions, and intracranial artery stenosis. Postoperative delirium in the intensive care unit was measured using the delirium rating scale. The relation between postoperative delirium and MRI findings was examined using logistic regression.
Magnetic resonance imaging and MRA was completed in 88 (90%) of the patients. New ischemic lesions were present in seven (7.9%) patients. Delirium rating scale scores of 0, 1-7, and ≥ 8 were found in 25 (31%), 48 (60%), and seven (9%) patients, respectively. Multivariate logistic regression analysis revealed that new ischemic lesions (odds ratio [OR] 11.07, 95% confidence interval [CI]: 1.53 to 80.03; P = 0.017), carotid artery stenosis (OR 7.06, 95% CI: 1.59 to 31.13; P = 0.010), history of myocardial infarction (OR 3.78, 95% CI: 1.05 to 13.65; P = 0.043), and deep subcortical white matter hyperintensity (OR 3.04, 95% CI: 1.14 to 8.12; P = 0.027) were significantly associated with postoperative delirium.
Magnetic resonance imaging findings of new cerebral ischemic lesions, carotid stenosis, and deep subcortical white matter hyperintensity correlated significantly with postoperative delirium in patients who had undergone OPCAB surgery.
No preview · Article · Feb 2015 · Canadian Journal of Anaesthesia
[Show abstract][Hide abstract] ABSTRACT: Bleeding in cardiac surgery carries a high mortality and is more frequent in case of coagulopathy. Goal-directed hemostatic therapy is widely accepted to be associated with reduced bleeding volume and allogeneic blood transfusion requirements, possibly thereby improving outcomes in cardiac surgery. We performed a prospective, single-center, observational study investigating the analytical accuracy and feasibility of the coagulation device "CoaguCheck" (COGC) for point-of-care monitoring of blood coagulation profiles in the operating room in patients undergoing on-pump cardiovascular surgery. With ethical committee approval, 31 consecutive patients were recruited for the study. At 3 operative-time-points before and after cardiopulmonary bypass (CPB), international normalized ratio of prothrombin time (PT-INR) and activated partial thromboplastin time (APTT) were measured in parallel using the COGC and central laboratory tests, which served as reference standards. The bias and dispersion of the two assays were calculated to assess systematic error and random error, respectively. For PT-INR, the COGC showed acceptable to good results in terms of accuracy and feasibility. However, the Bland-Altman analysis revealed that the COGC tended to overestimate APTT values, particularly after CPB. Among patients undergoing on-pump cardiovascular surgery, the COGC is a feasible and relatively accurate analyzer for assessing PT-INR but not APTT values.
Preview · Article · Jan 2015 · Japanese Journal of Transfusion and Cell Therapy
[Show abstract][Hide abstract] ABSTRACT: Objectives: The goal of this study was to compare cardiac output derived from the FloTrac/Vigileo (TM) system (COFT) with cardiac output measured by 3-dimensional transesophageal echocardiography (CO3D) in patients with severe heart failure undergoing cardiac resynchronization therapy. The impact of preoperative systemic vascular resistance index on the accuracy of the FloTrac/Vigileo (TM) system also was investigated. Design: Prospective clinical study. Setting: Cardiac surgery operating room of a single cardiovascular center. Participants: Forty-one patients undergoing elective cardiac resynchronization therapy lead implantation. Interventions: CO3D as the reference method and COFT were determined simultaneously after induction of anesthesia. Measurements and Main Results: Linear regression analysis showed a poor correlation between CO3D and COFT(R-2 = 0.16). Bland-Altman plots showed wide limits of agreement between CO3D and COFT. Bias was 0.60 +/- 0.63 L/min with a high percentage error of 58.2%. Subgroup analysis showed that the percentage error between CO3D and COFT was 74.1% in patients with a cardiac index <2.2 L/min/m(2) and 17.2% in patients with a cardiac index >= 2.2 L/min/m(2). Systemic vascular resistance index was significantly higher in patients with a cardiac index <2.2 L/min/m(2) (3,037 +/- 820 v 2,461 +/- 878; p = 0.039). Conclusions: The FloTrac/Vigileo (TM) system is not accurate in patients with low cardiac output, especially those with a cardiac index <2.2 L/min/m(2). A high systemic vascular resistance index in patients with low cardiac index may contribute to this inaccuracy.
No preview · Article · Oct 2014 · Journal of Cardiothoracic and Vascular Anesthesia
[Show abstract][Hide abstract] ABSTRACT: 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.
No preview · Article · Feb 2014 · Masui. The Japanese journal of anesthesiology
[Show abstract][Hide abstract] ABSTRACT: Moyamoya disease is a chronic cerebrovascular occlusive disease, occurring predominantly in young populations, that causes cerebral ischemia and hemorrhage. Patients with moyamoya disease are at high risk of neurological complications during cardiac surgery because of perioperative hemodynamic changes. However, there is no established evidence on temperature management during cardiopulmonary bypass. Previous reports described normothermia or mild to moderate hypothermia during cardiopulmonary bypass in patients with moyamoya disease; however, surgical conditions, such as not having enough space to clamp the aorta or a clean surgical field, sometimes force us to use deep hypothermic circuratory arrest. We report a successful case of a pediatric patient with moyamoya disease who underwent deep hypothermic circulatory arrest (18 °C) for hemiarch replacement without neurological complications. Deep hypothermia may be an alternative technique for achieving cerebral protection in the context of moyamoya disease.
No preview · Article · Jan 2014 · Journal of Anesthesia
[Show abstract][Hide abstract] ABSTRACT: Regional cerebral oxygen saturation measured by near infrared spectroscopy has often been used clinically due to its non-invasiveness and continuous measurement. However, rSO2 values have a wide individual variation compared to SpO2 measured by pulse oximeter. We need to consider why there is a wide variation individually and what kind of errors rSO2 is associated with. Further, we would like to discuss the usefulness of rSO2 in the future.
Preview · Article · Jan 2014 · THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA
[Show abstract][Hide abstract] ABSTRACT: Stroke during pregnancy is rare, but after occurring, most patients develop serious neurological conditions. Hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, often requires emergency surgical intervention. In addition to significant maternal physiological changes, the potential for fetal harm should be considered during anesthetic management of these patients. Whether cesarean section or neurosurgical intervention should be prioritized or performed simultaneously in pregnant women with stroke is an important issue. Whether the patients receive general or spinal and epidural anesthesia is another clinically significant issue. Finally neurosurgeons, anesthesiologists, and obstetricians should cooperate to manage pregnant women with stroke.
No preview · Article · Aug 2013 · Neurologia medico-chirurgica
[Show abstract][Hide abstract] ABSTRACT: Background:
Near-infrared spectroscopy has been used clinically to continuously and noninvasively monitor cerebral oxygen saturation (ScO2). However, there is no gold standard for measuring absolute values of ScO2. Although time-resolved spectroscopy (TRS) is one of the most reliable algorithms that reliably calculate absolute values of ScO2, there are very few clinical studies available. To evaluate the clinical relevance of ScO2 measurements using TRS, we compared ScO2 with jugular venous oxygen saturation (SjO2) during carotid endarterectomy. We also investigated factors associated with cerebral oxygen desaturation during clamping of the carotid artery.
Sixty patients who underwent carotid endarterectomy were enrolled. ScO2 was measured by TRS-20 using TRS at 10 minutes before and after clamping of the carotid artery and 10 minutes after unclamping. SjO2 was measured simultaneously. The relationship between ScO2, SjO2, and estimated ScO2 (0.75×SjO2+0.25×SaO2) were examined by simple regression and the Bland-Altman analysis. Factors related to ScO2<60% were investigated by logistic regression analysis.
There was a significant correlation between ScO2 and SjO2 (r=0.49, P<0.002). Bland-Altman analysis revealed narrow limits of agreement between ScO2 and SjO2 (bias, 9.2%; precision, 12.6%), as well as ScO2 and estimated ScO2 (bias, -1.3%; precision, 9.7%). Impaired cerebral hemodynamics (Powers stage 2 or Kuroda type 3) was significantly associated with ScO2<60%.
ScO2 measured by TRS and SjO2 showed narrow limits of agreement. Reduced ScO2 was significantly associated with impaired cerebral hemodynamics.
No preview · Article · Dec 2012 · Journal of neurosurgical anesthesiology
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
No preview · Article · Jul 2012 · Journal of Anesthesia
[Show abstract][Hide abstract] ABSTRACT: We experienced a patient with severe COPD undergoing OPCAB who showed difficult perioperative respiratory and circulatory management. Since patients with severe COPDs are often complicated with not only respiratory but also circulatory problems such as right heart failure, it is necessary to assess preoperatively the method of intraoperative management including operative procedure.
No preview · Article · Apr 2012 · Masui. The Japanese journal of anesthesiology
[Show abstract][Hide abstract] ABSTRACT: Paraplegia is a serious complication of descending and thoracoabdominal aortic aneurysms (dTAAs and TAAAs) surgery. Motor evoked potentials (MEPs) enable monitoring the functional integrity of motor pathways during dTAA and TAAA surgery. Although MEPs are sensitive to temperature changes, there are few human data on changes of MEPs during mild and deep hypothermia. Therefore, we investigated changes of MEPs in deep hypothermic circulatory arrest (DHCA) in dTAA and TAAA surgery.
Fifteen consecutive patients undergoing dTAA and TAAA surgery using DHCA were enrolled. MEPs were elicited and recorded during each degree Celsius change in nasopharyngeal temperature during both the cooling and rewarming phases. Hand and leg skin temperature were also recorded simultaneously.
In the cooling phase MEP amplitude decreased lineally in both the hand and leg. The MEP disappeared at ~16°C in both the hand and leg in 10 of 15 patients, but was still elicited in 5 patients. In the rewarming phase MEP in the hand recovered before the temperature reached 20°C for eight patients and 25°C for the other seven patients. In contrast, MEP in the leg recovered below 20°C for two patients and 30°C for three patients. For the other eight patients MEP waves did not recover during the rewarming phase.
In the cooling phase of DHCA, MEP disappeared at ~16°C in some patients but was still elicited in others. MEP recovered below 25°C in the hand. Recovery of MEP in the leg was, however, extremely variable.
No preview · Article · Dec 2011 · Journal of Anesthesia
[Show abstract][Hide abstract] ABSTRACT: To compare cardiac output (CO) measurements acquired using the Flotrac/Vigileo system (Edwards Lifesciences, Irvine, CA) and CO measured by transesophageal echocardiography using the product of the aortic valve area, the time integral of flow at the same site, and the heart rate during abdominal aortic aneurysm (AAA) surgery.
A prospective clinical study.
Cardiac surgery operating room of 1 heart center hospital.
Twenty patients undergoing elective AAA surgery.
CO was determined simultaneously using the Flotrac/Vigileo system (CO(AP)) and transesophageal echocardiography (CO(TEE)) as the reference method at 8 time points during AAA surgery.
One hundred sixty simultaneous datasets were obtained. The authors observed a significant correlation between CO(AP) and CO(TEE) values (R = 0.56, p < 0.001). Bland-Altman analysis of CO(AP) and CO(TEE) showed a bias of 0.12 L/min and limits of agreement from -1.66 to 1.90 L/min, with a percentage error of 41%. Just after aortic clamping, CO(AP) significantly increased, but CO(TEE) decreased in comparison with previous measurements. There was a significant association among changes in CO(AP) and pulse pressure, heart rate, and central venous pressure (CVP). However, changes in CO(TEE) were only associated with variations in heart rate.
CO(AP) values were not clinically acceptable for use in AAA surgery because of wide variations during aortic clamping and declamping. Changes in pulse pressure, heart rate, and CVP were associated with significant changes in CO(AP), whereas only changes in heart rate showed associated changes in CO(TEE).
No preview · Article · Sep 2011 · Journal of cardiothoracic and vascular anesthesia