Tatsuyuki Imada

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.

Anesthetic Management of a Patient With a Biventricular Assist Device Who Was Scheduled for Aortic and Pulmonary Valve Closure.

From the Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan. Reprint requests to Yu Matsumoto, MD, Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. E-mail: y.matsumoto0611@gmail.com

Pain Management With Bilateral Continuous Thoracic Paravertebral Block in a Patient With Fontan-Associated Hepatocellular Carcinoma Undergoing Hepatectomy.

Objective We report a case of perioperative management of a single-ventricle patient with Fontan-associated liver disease undergoing hepatectomy. Case Report A 12-year-old boy with Fontan circulation was scheduled for partial hepatectomy to remove a liver mass in segment 6. He received stent implantation to relieve conduit stenosis 6 months before the operation. The operation was performed under general anesthesia and with a bilateral thoracic paravertebral block (PVB). A continuous paravertebral infusion of levobupivacaine was administered via right and left catheters postoperatively. He was hemodynamically stable throughout the perioperative period, extubated soon after surgery, and had an uncomplicated postoperative course. Conclusions An analgesic regimen including thoracic PVB resulted in a rapid recovery without opioid-related side effects and early reinitiation of anticoagulation therapy. Our case illustrates the effective application of thoracic PVB in congenital heart disease patients for non–cardiac-related surgery.

Right ventricular functional assessment by three-dimensional transesophageal echocardiography is useful for withdrawal from a right ventricular assist device: a case report

Right ventricular assist device (RVAD) implantation is one type of surgical treatment used for right heart failure. It is important to assess right ventricular (RV) function precisely when RVAD withdrawal is considered. Although assessment of RV function is difficult due to its complicated shape and contraction pattern, the volumetric analysis method of three-dimensional (3D) transesophageal echocardiography (TEE) has been developed and is useful for this task. We report the case of a 79-year-old man who successfully underwent RVAD withdrawal and evaluation using 3D TEE. 3D TEE had an important role in determining the timing of withdrawal from RVAD in this case.

Unexpected bioprosthetic mitral valve thrombus during left ventricular assist device implantation

Acute bioprosthetic valve thrombosis can occur after surgery and sometimes cause hemodynamic instability and cardiogenic shock. Risk factors for bioprosthetic valve thrombosis are hypercoagulability, atrial fibrillation, atrial dilatation, low cardiac function, and lack of anticoagulation therapy. The authors present a case of severe mitral stenosis due to bioprosthetic valve thrombus. The patient was diagnosed with dilated-phase hypertrophic cardiomyopathy and underwent mitral valve replacement. He required venoarterial extracorporeal membrane oxygenation (VA-ECMO) due to extremely low cardiac output and was scheduled for left ventricular assist device (LVAD) implantation. Transesophageal echocardiographic examination before LVAD implantation revealed severe mitral stenosis due to bioprosthetic mitral valve thrombus, which was not detected by transthoracic echocardiography in the intensive care unit and contributed to the low cardiac function. The thrombus was removed through an unscheduled left atriotomy before LVAD implantation. The possibility of bioprosthetic valve thrombosis must be considered when the patient is dependent on VA-ECMO support. Early transesophageal echocardiographic examination of the bioprosthetic valve may be helpful and contribute to surgical decision-making.

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.