Takeshi Iritakenishi

Intraoperative Right Ventricular Fractional Area Change Is a Good Indicator of Right Ventricular Contractility: A Retrospective Comparison Using Two- and Three-Dimensional Echocardiography

OBJECTIVE Intraoperative two-dimensional echocardiography is technically challenging, given the unique geometry of the right ventricle (RV). It was hypothesized that the RV fractional area change (RVFAC) could be used as a simple method to evaluate RV function during surgery. Therefore, the correlation between the intraoperative RVFAC and the true right ventricular ejection fraction (RVEF), as measured using newly developed three-dimensional (3D) analysis software, was evaluated. DESIGN Retrospective study. SETTING University hospital. PARTICIPANTS Patients who underwent cardiac surgery with transesophageal echocardiography monitoring between March 2014 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty-two patients were included in this study. After the exclusion of poor imaging data and patients with arrhythmias, 54 data sets were analyzed. RVFAC was measured by one anesthesiologist during surgery, and full-volume 3D echocardiographic data were recorded simultaneously. The 3D data were analyzed postoperatively using off-line 3D analysis software by a second anesthesiologist, who was blinded to the RVFAC results. The mean RVFAC was 38.8% ± 8.7%, the mean RVEF was 41.4% ± 8.3%, and there was a good correlation between the RVFAC and the RVEF (r(2) = 0.638; p<0.0001). CONCLUSIONS The RVFAC was well-correlated with the RVEF calculated using 3D echocardiography; therefore, RVFAC provides a simple and useful method for anesthesiologists to evaluate intraoperative RV function.

Risk of Hematoma in Patients With a Bleeding Risk Undergoing Cardiovascular Surgery with a Paravertebral Catheter.

OBJECTIVE This study aimed to determine the risk of hematoma associated with thoracic paravertebral block (TPVB) in patients undergoing cardiovascular surgery. DESIGN Retrospective analysis. SETTING Single university hospital. PARTICIPANTS The study comprised 141 patients who underwent cardiovascular surgery with TPVB to relieve postoperative pain. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three patients were excluded and of the remaining 138, TPVB was performed in 135, ages 11 to 96 years, who either had a clotting abnormality or were on anticoagulant or antiplatelet therapy. No paravertebral, epidural, or spinal hematoma was detected, and only 1 case of superficial bleeding was observed. The frequency of hematoma associated with TPVB in patients with a risk of bleeding undergoing cardiovascular surgery was calculated as 0% (95% confidence interval 0-2.7). CONCLUSION Hematoma did not occur in patients at risk of bleeding who underwent cardiovascular surgery with TPVB for postoperative pain management. However, the risk and benefit in each case still must be considered carefully to determine whether TPVB is indicated.

A case of laparotomic cholecystectomy in a patient with biventricular assist devices

We describe a patient with biventricular assist devices who had systemic inflammation because of cholecystitis that required open cholecystectomy, and we discuss the anesthetics and monitors that should be used in unstable patients with ventricular assist devices (VADs) who are undergoing major surgery.The patient was a 40-year-old man in the dilated phase of hypertrophic obstructive cardiomyopathy, who was implanted with an internal left VAD and external right VAD. We anesthetized the patient with a combination of a low dose of sevoflurane and ketamine to minimize vasodilation. We chose ketamine because we expected it to have a postoperative analgesic effect. An INVOS™ (Medtronic) monitor was beneficial, especially since the pulse oximeter did not work because of a pulse deficit. The FloTrach™ (Edwards Lifesciences) failed to measure the stroke volume and its variability. The left VAD, the Jarvik2000, did not show its flow rate. However, we were able to estimate that the flow was stabilized, because the flow rate of the right VAD was stable, and there was no significant change in both ventricles and septa, as shown on transesophageal echocardiography.

Perioperative factors related to the severity of vocal cord paralysis after thoracic cardiovascular surgery: A retrospective review

BACKGROUND Vocal cord paralysis (VCP) is a rare complication of thoracic cardiovascular surgery. In severe cases, life-threatening airway obstruction may occur. OBJECTIVE To evaluate the incidence and severity of VCP among patients who underwent thoracic cardiovascular surgery and to identify possible risk factors. DESIGN Single-centre retrospective review of adult patients. SETTING Osaka University Hospital, Suita, Japan, from January 2013 to August 2015. PATIENTS We included 688 patients in the final analysis. Preoperative, intraoperative and postoperative data were collected from medical records. Patients with preoperative VCP or tracheostomy prior to extubation were excluded. The VCP severity in relation to functional recovery was graded using the following categories: absent; mild, remission at 6 months; moderate, partial or persistent VCP at 6 months; or severe, airway obstruction after extubation requiring reintubation. An otolaryngologist diagnosed all VCP cases. MAIN OUTCOME MEASURES The incidence and severity of VCP after extubation. RESULTS The incidence (number) of VCP was 4.7% (32), with those of mild, moderate and severe VCP being 1.7% (12), 1.5% (10) and 1.5% (10), respectively. The ICU stay was significantly longer in patients with severe VCP than in patients without VCP [12.5 days (interquartile range 5.5 to 25.5) vs. 3 days (interquartile range 2 to 5), P = 0.0002]. In our multivariable analysis, type 2 diabetes mellitus [odds ratio (OR) 1.853, P = 0.009], intubation period (OR per 24 h 1.136, P = 0.014), ascending aortic arch surgery with brachiocephalic artery reconstruction (OR 8.708, P < 0.001) and ventricular assist device implantation (OR 3.460, P = 0.005) were independent predictors for VCP. CONCLUSION The identification of these risk factors may facilitate screening for VCP before extubation and possibly help anaesthesia personnel to be prepared to treat VCP-related airway obstruction should it occur.

Thoracic paravertebral block for perioperative analgesia in the surgical management of left ventricular assist device infections.

Left ventricular assist device (LVAD) implantation is increasingly being used as a bridging therapy to heart transplantation. Infection is a major complication in patients with implanted LVADs, and it is associated with short- and long-term mortality. Surgical management for infection control is sometimes necessary; however, providing pain management during the surgical procedures is challenging. Anesthesiologists may be able to contribute to better pain management during surgical interventions to treat LVAD infections. We successfully performed a continuous thoracic paravertebral block (TPVB) for perioperative pain relief during invasive surgical procedures on three patients with infections of implanted LVADs. Despite several limitations that need to be addressed in the future, TPVB was able to relieve surgical pain in these patients without obvious complications.

Cardiovascular operation: A significant risk factor of arytenoid cartilage dislocation/subluxation after anesthesia

Background: Arytenoid cartilage dislocation/subluxation is one of the rare complications following tracheal intubation, and there have been no reports about risk factors leading this complication. From our clinical experience, we have an impression that patients undergoing cardiovascular operations tend to be associated with this complication. Aims: We designed a large retrospective study to reveal the incidence and risk factors predicting the occurrence and to examine whether our impression is true. Settings and Designs: This was a retrospective study. Methods: We retrospectively studied 19,437 adult patients who were intubated by an anesthesiologist in our operation theater from 2002 to 2008. The tracheal intubation was performed by a resident anesthesiologist managing the patients. Only patients whose postoperative voice was disturbed more than 7 days were referred to the Department of Otorhinolaryngology-Head and Neck Surgery and examined using laryngostroboscopy by a laryngologist to diagnose arytenoid cartilage dislocation/subluxation. We evaluated age, sex, weight, height, duration of intubation, difficult intubation, and major cardiovascular operation as risk factors to lead this complication. Statistical Analysis: The data were analyzed by logistic regression analysis to assess factors for arytenoid cartilage dislocation/subluxation after univariate analyses using logistic regression analysis. Results: Our analysis indicated that difficult intubation (odds ratio: 12.1, P = 0.018) and cardiovascular operation (odds ratio: 9.9, P < 0.001) were significant risk factors of arytenoid cartilage dislocation/subluxation. Conclusion: The present study demonstrated that major cardiovascular operation is one of the significant risk factors leading this complication.