Masataka Kuroda

Difficult cannulation of the coronary sinus due to a large Thebesian valve.

• Volume 116 • Number 3 www.anesthesia-analgesia.org 563 A 59-year-old man with a history of diabetes mellitus and renal dysfunction was scheduled for aortic valve replacement via a full median sternotomy, to treat moderate aortic stenosis due to a bicuspid aortic valve. After anesthetic induction and tracheal intubation, a transesophageal echocardiography (TEE) probe (X7-2t transducer, Philips Healthcare, Andover, MA) was inserted into the esophagus to intraoperatively assess cardiac function, guide the placement of cannulae, and assess the competency of the aortic valve prosthesis. The surgical plan was to administer the cardioplegic solution via a combination of anterograde and retrograde methods. TEE was used to guide cannulation of the coronary sinus (CS) for retrograde coronary perfusion. After scanning in the midesophageal 4-chamber view with the multiplane angle at 0°, the probe was turned slightly clockwise, while slowly advancing and slightly retroflexing it, and the CS was visualized at a sector depth of 7 cm. A large, dynamically moving Thebesian valve was noticed at the ostium of the CS (Fig. 1A, Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A509), with echogenecity similar to the surrounding walls. It was imaged to originate from the atrial wall, posterior (dorsal) to the site of the CS ostium. Its dynamic motion obstructed the ostium of the CS in diastole. With color Doppler, flow from the CS into the right atrium (RA) was seen in systole (Fig. 1B, Video 1, see Supplemental Digital Content 1, http://links. lww.com/AA/A509), but not in diastole (Fig. 1C, Video 1, see Supplemental Digital Content 1, http://links.lww. com/AA/A509). Orthogonal views scanned using the X-plane mode (Philips, Healthcare, Inc.), which scans and displays 2 independent 2-dimensional scanning planes, simultaneously demonstrated that the Thebesian valve was partly attached to the interatrial septum, superior (cranial) to the site of the CS ostium at the multiplane 90° angle (Fig. 2, Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A510). Although the surgeon attempted to place the CS cannula (Retro-Self Inflate for cardio-protection; Edwards Lifesciences, Inc., Irvine, CA) under direct echocardiographic guidance, the cannula Difficult Cannulation of the Coronary Sinus Due to a Large Thebesian Valve

Regurgitant leak from the area between the stent post and the sewing ring of a stented bovine pericardial valve implanted in the aortic valve position

Biologic valves can sometimes have a small closure or leakage backflow jet originating from the central coaptation point. This is physiologic regurgitation that usually only requires monitoring, and not treatment.Another non-central transvalvular leakage is occasionally seen in both porcine and pericardial valves and originates from the base of the stent post. Typically, it spontaneously decreases or even disappears by the end of the surgery, after administration of protamine. This leak, however, needs to be distinguished from abnormal paravalvular leakages, especially if the regurgitation is relatively large, as this may require an extra cardio-pulmonary bypass (CPB) run.In our case with stented bovine pericardial valves, detailed transesophageal echocardiography (TEE) examination immediately after CPB showed oblique and turbulent flow, which originated from the base of the stent post and flowed toward the anterior mitral leaflet. An extra CPB run, assessment of the cause of the leakage, and restoration if necessary, might have been required if the leakage did not improve or was exacerbated, because contact of the anterior mitral valve leaflet by the oblique flow is associated with the risks of infective endocarditis and hemolysis. Detailed TEE examination accurately delineated the site of the leak, which was subsequently found to originate from the site between the anterior stent post and the sewing ring. The leakage in this case was classified as non-paravalvular, non-central leakage within the sewing ring. Accurate diagnosis of the leakage by intra-operative TEE led to the decision to administer protamine and to adopt a wait-and-watch approach.

The effects of volatile anesthetics on nonadrenergic, noncholinergic depressor responses in rats.

UNLABELLED The effects of volatile anesthetics on nonadrenergic, noncholinergic (NANC) transmission mediated by calcitonin gene-related peptide (CGRP) are unclear. We studied the effects of isoflurane, halothane, and sevoflurane on NANC depressor responses to electrical spinal cord stimulation in pithed rats whose mean arterial blood pressure was maintained near 120 mm Hg by continuous infusion of methoxamine. Autonomic outflow was blocked by hexamethonium. After 30 min of inhalation of different concentrations of anesthetics, spinal cord stimulation at the lower thoracic level (10 V at 4 Hz; duration, 1 ms) was applied for 30 s to induce a NANC depressor response. Isoflurane at 2% and halothane at 1.5% attenuated NANC depressor responses significantly, whereas isoflurane at 1%, halothane at 0.75%, and sevoflurane at 2% or 4% did not. Volatile anesthetics did not attenuate the release of CGRP after spinal cord stimulation, whereas isoflurane at 2% and halothane at 1.5% significantly inhibited depressor responses to exogenously administered CGRP. Sevoflurane at 4% did not significantly affect CGRP-induced depressor responses. Thus, isoflurane and halothane at large concentrations attenuate NANC depressor responses by attenuating the depressor action of CGRP, not CGRP release. IMPLICATIONS The anesthetics isoflurane and halothane attenuate nonadrenergic, noncholinergic depressor responses mediated by calcitonin gene-related peptide in the rat without affecting the release of the peptide.

Vecuronium dose requirement and pupillary response in a patient with olivopontocerebellar atrophy (OPCA).

PurposeOlivopontocerebellar atrophy (OPCA), a variant of spinocerebellar degeneration (Shy-Drager syndrome), is a systemic degenerative disorder affecting the neurons of multiple nuclei. We investigated the sensitivity to vecuronium and the pupillary responses to various stresses in a patient with OPCA.Clinical featuresA 65-yr-old woman with a six-month history of OPCA underwent a left upper lobectomy for lung cancer under propofol-N2O anaesthesia. She had symptoms of dysarthria, bulbar palsy, cerebellar ataxia, Parkinsonism, myosis, pyramidal signs and muscular atrophy of the distal extremities. A cumulative dose-response curve for vecuronium was constructed, and pupillary changes in response to various noxious stimuli were evaluated with concomitant recording of the Spectral-Edge-Frequency 90% (SEF90; the frequency below which 90 percent of the EEG power is located). The dose-response curve for vecuronium and the estimated ED50 value (the 50% blocking dose of vecuronium) in this patient with OPCA were almost identical with those of five ASA 1–11 patients (27 μg·kg−1vs 31 μg·kg−1). The pupil size and the SEF90 did not change after tracheal intubation or surgical stimulation in this patient, while in the control subjects (n = 3), these measures increased in response to both stresses.ConclusionsThe absence of pupillary and SEF90 responses to noxious stimuli suggests a sensitivity to propofol and/or central autonomic dysfunction in patients with OPCA. Although the dose requirement of vecuronium in this patient was similar to that of the control patients, the effects of neuromuscular blockers may vary depending on the severity of muscle atrophy.RésuméObjectifL’atrophie olivo-ponto-cérébelleuse (AOPC), une variante de la dégénérescence spinocérébelleuse (syndrome de Shy et Drager), est une atteinte dégénérative généralisée qui affecte les neurones de multiples noyaux. Nous avons examiné la sensibilité au vécuronium et les réactions pupillaires à différentes stimulations chez une patiente souffrant d’AOPC.Aspects cliniquesUne femme de 65 ans souffrant d’AOPC depuis six mois a subi une lobectomie supérieure gauche, pour traiter un cancer du poumon, sous anesthésie avec propofol-N2O. Elle présentait les symptômes suivants : dysarthrie, paralysie bulbaire, ataxie cérébelleuse, parkinsonisme, miose, signes pyramidaux et atrophie musculaire des extrémités distales. Une courbe dose-réponse cumulative pour le vécuronium a été élaborée et les changements pupillaires, en réaction à différents stimuli désagréables, ont été évalués à partir d’un enregistrement concomitant de fréquence spectrale limite à 90 % (FSL90; la fréquence sous laquelle se situe 90 pour cent de l’activité de l’EEG). La courbe dose-réponse au vécuronium et la valeur présumée de la ED50 (la dose de vécuronium provoquant un blocage de 50%) ont été presque identiques chez cette patiente et chez cinq patients ASA 1–11 (27 μg·kg−1vs 31 μg·kg−1). Le diamètre pupillaire et la FSL90 n’ont pas changé après l’intubation endotrachéale ou la stimulation chirurgicale chez cette patiente, tandis que chez les patients témoins (n = 3), les réactions aux deux stimulations présentaient des mesures plus élevées.ConclusionLabsence de réaction pupillaire et FSL90 à des stimuli douloureux indique une sensibilité au propofol et/ou un dérèglement central autonome chez les sujets souffrant d’AOPC. Bien que la dose efficace de vécuronium soit similaire chez cette patiente et chez les patients témoins, les effets des bloqueurs neuromusculaires peuvent varier selon la sévérité de l’atrophie musculaire.

Two- and three-dimensional transesophageal echocardiography for aortic valve aneurysms on the right coronary cusp.

April 2013 • Volume 116 • Number 4 A 73-year-old man was scheduled for aortic valve (AV) replacement for severe aortic regurgitation (AR). Preoperative transthoracic echocardiography revealed severe AR due to flail of the right coronary cusp (RCC). No vegetation was observed on the valve and surrounding tissues, inflammatory responses were within normal limits, and preoperative blood cultures were negative. Written informed consent was obtained from the patient for publication of this report and any accompanying images. Intraoperative transesophageal echocardiography (TEE) was performed using a 3-dimensional (3D) echocardiographic matrix-array probe (X7-2t transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a saccular structure in the left ventricular (LV) outflow tract (LVOT), and color flow Doppler (CFD) analysis revealed a severe regurgitant jet from nearby, although from a different site on the structure (Video 1, see Supplemental Digital Content 1, http:// links.lww.com/AA/A517). An ME AV short-axis view showed a tricuspid AV with a large and deformed RCC (Video 2, see Supplemental Digital Content 2, http:// links.lww.com/AA/A519). With slight advancement of the probe, 2 masses with an echo-free center were scanned at the LVOT, appearing at diastole and disappearing at systole, while CFD demonstrated mosaic blood flow throughout diastole from 1 of the 2 masses (Video 2, http://links.lww.com/AA/A519). On scanning with the ME AV long-axis (LAX) view, the RCC of the AV was seen to be perforated, with severe AR (Video 2, http:// links.lww.com/AA/A519). The X-plane mode (Philips Healthcare) was used to assess orthogonal views of each structure in the LVOT. With this, a perforated aneurysm was seen on the RCC (Fig. 1A). Another view seemed to depict an AV aneurysm of the RCC that protruded into the LVOT, with expansion during diastole and collapse during systole (Fig. 1B). A 3D echocardiographic view was constructed from the full-volume mode with 4-beat estimation based on the aortic and LV perspectives.1 From the aortic perspective, 2 circular echo-free areas were seen Twoand Three-Dimensional Transesophageal Echocardiography for Aortic Valve Aneurysms on the Right Coronary Cusp

Echo rounds: anomalous insertion of the inferior vena cava into the right atrium.

An 83-year-old man with an infrarenal abdominal aortic aneurysm, asymptomatic coronary artery stenosis, and hypertension presented for elective open abdominal aortic aneurysm surgery. Cardiac catheterization demonstrated 50% stenosis of the left anterior descending artery. The preoperative electrocardiogram revealed complete right bundle-branch block and left axis deviation with premature ventricular contractions. The transthoracic echocardiogram was consistent with normal left-ventricular systolic function and grade 1 diastolic dysfunction. No abnormalities of the heart and great vessels were detected. Transesophageal echocardiography (TEE) was considered for intraoperative monitoring of ventricular function and detection of myocardial ischemic changes. After anesthetic induction and tracheal intubation, the TEE probe (X7-2t transducer; Philips Healthcare, Andover, MA) was inserted into the esophagus. A routine TEE examination demonstrated normal global and regional left-ventricular function and normal valvular function. During examination of the right side of the heart, anomalous insertion of the inferior vena cava (IVC) into the right atrium (RA) was detected. A midesophageal (ME) bicaval view at the multiplane 93° angle revealed that the IVC was inserted into the lateral free wall of the RA at an oblique angle (Fig. 1A) (see Supplemental Digital Content 1 and 2, Video 1, http://links.lww.com/AA/A265, and Video 2, http://links.lww.com/AA/A266; see Appendix for video captions). Pulse Doppler flow profile demonstrated a venous flow pattern (Fig. 1B). When the TEE probe was advanced, turned farther clockwise, and rotated by 45° for examination of the IVC at the hepatic level, the IVC was seen to be bent at an obtuse angle with the right hepatic vein (RHV) joining it at the point of the bend. The IVC proximal to the bend and the RHV were in a straight line relative to each other (Fig. 2) (see Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/A265). Furthermore, a 3-dimensional (3D) full-volume image based on the ME bicaval view was reconstructed for further evaluation. Anomalies of the IVC and surrounding tissue were simultaneously demonstrated (Fig. 3) (see Supplemental Digital Content 2, Video 2, http://links.lww.com/AA/A266). In this case, anomalous insertion of the IVC did not affect the surgical procedure. The operative course was uneventful, and the patient was discharged from the hospital 10 days later.

Association of Preoperative Right and Left Ventricular Diastolic Dysfunction With Postoperative Atrial Fibrillation in Patients Undergoing Lung Surgery: A Prospective Observational Study.

OBJECTIVES To clarify the relationship between right and left ventricular (RV and LV) diastolic function and postoperative atrial fibrillation (POAF). The early effects of major lung surgery on cardiac function in the intraoperative period during lung surgery were evaluated, using transesophageal echocardiography. DESIGN Single-center prospective observational study. SETTING A public hospital. PARTICIPANTS Patients undergoing elective lobectomy with lymph node dissection for lung cancer (n = 116). INTERVENTIONS Transesophageal echocardiography examination was performed under general anesthesia before skin incision (preoperative) and after chest closure (postoperative). According to measured echocardiographic variables, ventricular systolic and diastolic functions were classified at each time point. MEASUREMENTS AND MAIN RESULTS Of the 116 patients, 24 (20.7%) experienced POAF. Preoperative RV and LV diastolic dysfunction were more common in patients with POAF than in those without POAF (58.3 v 28.3%, p = 0.008; 54.2 v 19.6%, p = 0.001, respectively). Among patients without preoperative diastolic dysfunction, a small number developed RV and LV diastolic dysfunction immediately after surgery (9.2% and 16.5%, respectively) and these distributions were comparable between patients with POAF and those without POAF. RV systolic dysfunction was observed in 6.5% of patients immediately after surgery and was not related to the occurrence of POAF. Multivariate analysis revealed older age, chronic obstructive pulmonary disease (COPD), and preoperative biventricular diastolic dysfunction as risk factors for POAF. CONCLUSIONS Preoperative biventricular diastolic dysfunction, as well as older age and COPD, are associated with POAF in patients undergoing lobectomy. Major lung surgery has minimal early effects on postoperative systolic and diastolic functions.

Effect of lateral body position on transesophageal echocardiography images and the association with patient characteristics: A prospective observational study

Background: Changes in heart position are occasionally observed on the transesophageal echocardiography (TEE) image screen after changing the body position from supine to lateral, although the magnitude of change in cardiac position varies individually. We hypothesized that this variation is associated with certain patient characteristics and evaluated how lateral positioning affects visualization of the heart on TEE and whether the magnitude of change in the heart position correlates with patient characteristics. Methods: Fifty-three lung resection patients were enrolled. Two angle and two length parameters (ΔθTV, ΔθAP, ΔLTV, and ΔLAP) were defined to describe location change of the lateral tricuspid annulus and right ventricular apex on the TEE image between supine and lateral position. The correlation coefficients were calculated between these four parameters and patient characteristics, including age, body mass index (BMI), epicardial fat thickness, and pulmonary function variables. Results: The ΔθTV correlated positively and inversely with BMI in both right and left lateral patients (right: r = 0.6365, P = 0.0034; left: r = −0.6616, P < 0.0001, respectively). In left lateral patients, the ΔθTV correlated inversely with epicardial fat thickness (r = −0.4879, P = 0.0182), and the ΔLAP correlated positively with the forced vital capacity percent predicted (r = 0.5736, P = 0.0082). Conclusions: Lateral body positioning affects cardiac visualization on TEE, and the BMI, epicardial fat thickness, and pulmonary function moderate this effect.

The Usefulness of Three-Dimensional Transesophageal Echocardiography for a Primum Atrial Septal Defect.

November 2015 • Volume 121 • Number 5 www.anesthesia-analgesia.org 1151 A 61-year-old man was diagnosed by transthoracic echocardiography with a primum atrial septal defect (ASD) and mild-to-moderate mitral regurgitation (MR) because of an anterior mitral leaflet prolapse. He was, therefore, scheduled for surgical repair of the ASD and mitral valve (MV). Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Intraoperative transesophageal echocardiography was performed using a 3D echocardiographic matrix-array probe (X7-2t Transducer; Philips Healthcare, Andover, MA). First, 2D echocardiographic analysis in the midesophageal 4-chamber (ME 4ch) view demonstrated a primum ASD with right ventricular dilation and 3 MR jets (Fig. 1; Video 1, Supplemental Digital Content 1, http://links.lww. com/AA/B204). The modified ME bicaval view with rightward turn revealed a dynamically changing defect during the cardiac cycle, with mild tricuspid regurgitation (Video 2, Supplemental Digital Content 2, http://links.lww.com/ AA/B205). Next, using systematic 3D echocardiographic examination of the ASD,1,2 3D full-volume images were acquired for further morphological evaluations. After optimizing an ME 4ch view of the interatrial septum and atrioventricular valves at 0° in the 2D mode, a 3D echocardiographic view was obtained with a 7-beat gated fullvolume mode. The obtained image was manipulated to demonstrate atrioventricular valves from a biatrial perspective and en face views of the ASD from the left atrial (LA) perspective (Fig. 2). An isolated MV cleft extending toward the septum was revealed and differentiated from the tricuspid valve leaflets in en face views of the atrioventricular valves from the atrial side. Although a tricuspid septal leaflet cleft can coexist and cause tricuspid regurgitation, this did not seem to be the case in our patient (first part of Video 3, Supplemental Digital Content 3, http://links.lww. com/AA/B206). In addition, dynamic changes in the defect over the cardiac cycle were demonstrated using en face views of the defect from the LA perspective (second part of Video 3, Supplemental Digital Content 3, http://links. lww.com/AA/B206). Next, the defect sizes during the cardiac cycle were quantified using the LA view in Figure 2C (Fig. 3). The surface area of the defect varied significantly, with a maximal size in late ventricular diastole (atrial contraction, Fig. 3A) and a minimal size in late ventricular systole (atrial relaxation, Fig. 3B). The major axis of the ovalshaped defect changed its configuration during the cardiac cycle (red line in Fig. 3, A and B). Major and minor lengths, and defect areas in late ventricular diastole and systole, measured with multiplanar reconstruction (MPR) of 3D quantification software (Philips Medical Systems, Andover, MA) as previously described,3 are demonstrated in Figure 3, C and D, respectively. During surgery, the defect was closed with a single autologous pericardial patch and the MV cleft was sutured. No residual shunt and only trivial MR were revealed with 2D color flow Doppler analysis. The patient was successfully weaned off cardiopulmonary bypass, and he recovered with an uneventful postoperative course.

Transesophageal echocardiography is useful for an intraoperative diagnosis of pulmonary artery catheter entrapment.

A 57-yr-old man (weight, 61 kg; height, 158 cm) with a history of hypertension and smoking was scheduled for aortic valve replacement to treat severe aortic stenosis. Echocardiography revealed an aortic valve area of 0.6 cm and a mean pressure gradient of 66 mm Hg across the stenotic aortic valve. Left ventricular hypertrophy was evident with normal systolic function and impaired diastolic function indicated by an abnormal relaxation pattern. After anesthetic induction and tracheal intubation, a 5-MHz multiplane transesophageal echocardiography (TEE) probe (Agilent Technologies, Andover, MA) was inserted into the esophagus. A 7.5F pulmonary artery catheter (PAC) (Edward Lifesciences LLC, Irvine, CA) was then inserted through an 8.5F percutaneous sheath introducer (Argon Medical Devices, Athens, TX) positioned in the right internal jugular vein. A normal pulmonary artery wedge pressure tracing was obtained at a depth of 50 cm, and the position of the catheter tip in the right main pulmonary artery was confirmed by TEE. No difficulties or immediate complications were associated with PAC insertion, and TEE of the right atrium, right ventricle, and pulmonary artery revealed no obvious abnormalities. Two vena cava cannulae (DLP69328, 28F cannula for inferior vena cava [IVC]; Medtronic, Minneapolis, MN) were inserted into the right atrium for cardiopulmonary bypass (CPB). After aortic valve replacement, the patient was uneventfully separated from CPB, and the 2 vena cava cannulae were easily removed. About 1 h after separation from CPB, there was a change in the waveform of the PAC suggestive of catheter wedging. The PAC tip was thought to be located too deeply; the anesthesiologist encountered resistance while attempting to gently withdraw the PAC by pulling with mild force and the catheter did not move. Therefore, TEE was interrogated to determine the cause of the resistance. A midesophageal bicaval view, with the multiplane angle at 85° and a field depth of 12 cm, revealed an area of relatively high brightness resembling an echogenic spot on the PAC, which was accompanied by acoustic shadowing and was fixed in the IVC cannulation site (Fig. 1). Gentle traction on the PAC produced invagination of the IVC cannulation site (Fig. 1) (Video 1; see Supplemental Digital Content 1, http://links.lww.com/AA/A37, transesophageal echocardiography showing entrapment of a pulmonary artery catheter [PAC]. Midesophageal bicaval view shows PAC entrapment. An area of relatively high brightness, resembling an echogenic spot, is visible on the PAC [circle], accompanied by acoustic shadowing [triangles]. Traction on the PAC produced invagination of the right atrial wall [arrow] with the echogenic spot and acoustic shadowing. The right atrial wall resembles “tenting” following the manual traction. RA, right atrium; LA, left From the *Department of Anesthesiology, Gunma University Graduate School of Medicine, Gunma; and †Saitama Cardiovascular and Respiratory Center, Saitama, Japan. Accepted for publication July 14, 2009. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org). Address correspondence and reprint requests to Masataka Kuroda, MD, PhD, 3-39-22 Showa-machi, Maebashi City 3718511, Japan. Address e-mail to mkuroda@med.gunma-u.ac.jp. Copyright