A 72-year-old woman was scheduled to undergo aortic valve replacement for aortic stenosis when she was diagnosed with heparin-induced thrombocytopenia type II after a decrease in platelets was detected. Although postponement was considered, the operation went ahead as scheduled because of unstable hemodynamics. Continuous intravenous infusion of argatroban (4 mg/kg/min) was initiated at the start of the operation, and nafamostat mesylate (30 mg/h) was initiated when cardiopulmonary bypass was started. Activated coagulation time was monitored, and the dose of argatroban was adjusted accordingly. Argatroban administration was terminated after removal of aortic cross-clamping, and cardiopulmonary bypass was stopped 1 h later. The operation was completed 7 h after stopping cardiopulmonary bypass due to difficulties in hemostasis. Operation time was 12 h 21 min, cardiopulmonary bypass time was 3 h 10 min, blood loss was 3444 mL, and blood transfusion volume was 6400 mL. The amount of argatroban administered was lower in our case than in previously reported cases, but blood loss after stopping cardiopulmonary bypass could not be reduced in our case.

Background/Aims: This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods: This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile duct stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP. Results: PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033). Conclusions As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.