Norikatsu Mita

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

Necrotizing fasciitis following psoas muscle abscess caused by hypermucoviscous Klebsiella pneumoniae

A 59-year-old Japanese diabetic woman was admitted to a small private hospital with general malaise, fever, and a 1-month history of low back pain. A computed tomography scan of the abdomen revealed left abdominal necrotizing fasciitis with suspected left psoas muscle abscess. She was transferred to Gunma University Hospital, received antibiotic therapy, and underwent debridement of the infected subcutaneous tissue, fascia, and necrotic left psoas muscle. She was transferred to the intensive care unit to receive mechanical ventilation and inotropic support. Blood culture showed growth of Klebsiella pneumoniae, from which hypermucoviscosity was detected by the string test. She was extubated on day 5 of hospitalization and transferred to a general ward on day 14. Free skin grafting was performed on day 76, and she was discharged on day 134 without any complications.

Extracorporeal membrane oxygenation for respiratory failure: Comparison of venovenous versus venoarterial bypass

PurposeThis study compared the respiratory status before and during extracorporeal membrane oxygenation (ECMO) in patients receiving venovenous (VV) and venoarterial (VA) ECMO to evaluate the choice of ECMO in patients with respiratory failure.MethodBetween January 2003 and December 2007, 16 patients with respiratory failure required ECMO. Venovenous bypass and VA bypass were used in 9 cases (VV group) and 7 cases (VA group), respectively. The respiratory status before and during ECMO was compared between the two groups.ResultsThe percentage of patients requiring renal replacement therapy prior to ECMO use was significantly higher in the VA group than in the VV group. There were no significant differences between the two groups in PaO2/FIO2, AaDO2, pulmonary compliance, and the lung injury score prior to ECMO use. These parameters gradually improved in both groups; however, no significant intergroup differences were seen for up to 96 h after ECMO introduction. There was also no significant difference between the two groups in ECMO removal rate (VV group: 56%, VA group: 43%).ConclusionThese results suggest that VV ECMO is comparable to VA ECMO, and can maintain sufficient respiratory support when VV ECMO is introduced to respiratory failure patients lacking evidence of renal and/or heart failure.

Giant coronary artery aneurysm with coronary arteriovenous fistula draining into the coronary sinus.

A 77-year-old patient suffering from a giant right coronary artery aneurysm with coronary arteriovenous fistula was admitted to our hospital. The fistula could not be documented preoperatively by computed tomography or coronary angiography but was documented intraoperatively by transesophageal echocardiography (TEE). However, TEE was unable to visualize the draining site of the fistula. Direct palpation by the surgeon ultimately confirmed that the fistula was draining into the coronary sinus. The fistula was closed and the volume of the aneurysm reduced by partial resection. The postoperative course of the patient was uneventful. Giant aneurysms occasionally displace cardiac structures. In such cases, combined imaging technologies, including TEE, may be needed for precise assessment of the giant aneurysm and fistula.

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

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.

Prophylactic effect of amiodarone infusion on reperfusion ventricular fibrillation after release of aortic cross-clamp in patients with left ventricular hypertrophy undergoing aortic valve replacement: A randomized controlled trial

OBJECTIVE To investigate whether prophylactic amiodarone infusion prevents ventricular fibrillation after aortic cross-clamp release and attenuates cytokine production in patients with left ventricular hypertrophy undergoing cardiac surgery. DESIGN Prospective, randomized controlled trial. SETTING A public hospital. PARTICIPANTS The study comprised 68 patients undergoing aortic valve replacement for severe aortic stenosis. INTERVENTIONS Patients were randomly assigned to receive a 150mg bolus then 30mg/h continuous infusion of amiodarone (amiodarone group) or a 1 mg/kg bolus then 1 mg/kg/h continuous infusion of lidocaine (lidocaine group). The primary outcome was the ventricular fibrillation incidence rate after aortic cross-clamp release. Secondary outcomes included perioperative serum interleukin-6 and tumor necrosis factor-alpha levels. MEASUREMENTS AND MAIN RESULTS The ventricular fibrillation incidence rate was significantly lower in the amiodarone than in the lidocaine group (20.6% v 50%, relative risk 0.41; 95% confidence interval [CI] 0.20-0.86; p = 0.021). Interleukin-6 levels 1hour after aortic cross-clamp release and at intensive care unit admission were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 117.4pg/mL [87.1-158.4] v 339.5pg/mL [210.6-547.2]; p < 0.01 and 211.1pg/mL [162.8-73.6] v 434.1pg/mL [293.7-641.5]; p < 0.01, respectively). Tumor necrosis factor-alpha levels 1hour after aortic cross-clamp release were significantly lower in the amiodarone than in the lidocaine group (geometric mean [95% CI] 1.624pg/mL [1.359-1.940] v 2.283pg/mL [1.910-2.731]; p = 0.02). CONCLUSIONS Amiodarone prevented reperfusion ventricular fibrillation in patients with left ventricular hypertrophy undergoing aortic valve replacement to a greater extent than did lidocaine. Furthermore, amiodarone inhibited postoperative interleukin-6 and tumor necrosis factor-alpha production.

Notch of the anterior leaflet of the tricuspid valve with severe tricuspid regurgitation.

March 2015 • Volume 120 • Number 3 A 70-year-old man was scheduled for tricuspid valvuloplasty for severe tricuspid regurgitation (TR). Preoperative 2D transthoracic echocardiography revealed severe TR resulting from tricuspid annular dilation with a thickened anterior tricuspid leaflet (AL). Intraoperative transesophageal echocardiography (TEE) was performed using a 3D echocardiographic matrix-array probe (X7-2t Transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a dilated right ventricle (RV), dilated tricuspid annular dimension of 44 mm at end diastole, and discontinuity in the AL (Fig. 1A and the first part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). Color-flow Doppler (CFD) analysis revealed a central, broad-based jet of TR (second part of Video 1, Supplemental Digital Content, http://links.lww.com/AA/B42). The ME RV inflow view with the multiplane angle at 70 degrees demonstrated a thickened and divided tricuspid AL, with each bundle of chordae from the anterior papillary muscle (Fig. 1B and the third part of Video 1, Supplemental Digital Content, http:// links.lww.com/AA/B42). CFD revealed severe TR (fourth part of Video 1, Supplemental Digital Content, http:// links.lww.com/AA/B42). The transgastric RV basal shortaxis view demonstrated a notch at the center of the AL (Fig. 1C and the first part of Video 2, Supplemental Digital Content, http://links.lww.com/AA/B43), and CFD analysis revealed the location of the TR (second part of Video 2, Supplemental Digital Content, http://links.lww.com/AA/ B43). Next, a 3D echocardiographic view was scanned for additional morphological evaluations. A 3D zoom image was obtained from an ME view of the tricuspid valve at 100 degrees and manipulated to provide en face views of the tricuspid valve from the right atrium (RA) with the septal leaflet located in the 6 o’clock position, which confirms the spatial relationship of the AL to surrounding tissues such as the aortic valve and anterior mitral leaflet1 (Fig. 2A, and the first part of Video 3, Supplemental Digital Content, http://links.lww.com/AA/B44). This view revealed that the notch in the tricuspid AL did not extend to the annulus. To facilitate analysis and understanding of the 2D ME views in Figure 1, A and B, 2 lines were depicted on the 3D view obtained with a 90-degree clockwise rotation from the RA view in Figure 2, A and B. Three-dimensional morphological and CFD analysis from the RV side demonstrated the location and extent of the notch and the site of the regurgitation (second and third parts of Video 3, Supplemental Digital Content, http://links.lww.com/AA/B44). Surgical inspection was consistent with the 3D view from the RA perspective at mid-diastole (Fig. 3, A and B) and confirmed that the defect was not a cleft but a notch. Although echo dropout was present in the 3D view, the notch could be identified and correlated with 2D imaging (Fig. 3B). The notch was sutured, and an annuloplasty ring was implanted for correction of the dilated annulus. Only trivial residual TR was observed on TEE after weaning off cardiopulmonary bypass. The postoperative course of the patient was uneventful.