The term minimally invasive cardiac surgery encompasses a number of different techniques, from minimally invasive direct coronary artery bypass grafting without the use of cardiopulmonary bypass to telemanipulation and computer-enhanced robot-directed surgery. The hoped-for benefits from minimally invasive surgery are less pain, less disfiguring, fewer blood transfusions, earlier return to activity, and lower cost. The technology involved in reducing surgical trauma and limiting the physiologic trespass of cardiac surgery on the patients concerns not only surgical instrumentation but also anesthetic management. Anesthetic plan includes one lung isolation, careful monitoring of hemodynamics and gas exchange, fast track technique, appropriate analgesia strategies, and the use of transesophageal echocardiography for evaluation of the heart and positioning of cannulae. A better understanding of these newer, unconventional surgical operations enables cardiac anesthesiologists to contribute to favorable outcomes.
Analgesia ; Blood Transfusion ; Cardiopulmonary Bypass ; Catheters ; Coronary Artery Bypass ; Echocardiography, Transesophageal ; Heart ; Hemodynamics ; Humans ; Lung ; Surgical Instruments ; Thoracic Surgery ; Track and Field

Isolated left ventricular noncompaction (LVNC) is a rare primary genetic cardiomyopathy characterized by prominent trabeculation of the left ventricular wall and intertrabecular recesses. Perioperative management of the patient with LVNC might be challenging due to the clinical symptoms of heart failure, systemic thromboembolic events, and fatal left ventricular arrhythmias. We conducted real time intraoperative transesophageal echocardiography in a patient with LVNC undergoing general anesthesia for ovarian cystectomy.
Anesthesia, General ; Arrhythmias, Cardiac ; Cardiomyopathies ; Cystectomy ; Echocardiography ; Echocardiography, Transesophageal ; Heart Failure ; Humans

Polycythemia vera is a chronic progressive myeloproliferative disease characterized by increased circulating red blood cells, and the hyperviscosity of the blood can lead to an increased risk of arterial thrombosis. In a previous survey regarding postoperative outcomes in polycythemia vera patients, an increased risk of both vascular occlusive and hemorrhagic complications have been reported. Aortic surgery involving cardiopulmonary bypass may be associated with the development of a coagulopathy, and as a result, the occurrence of thrombotic complications should be avoided after coronary anastomosis. Thus, optimizing the hemostatic balance is an important concern for anesthesiologists. However, only a few cases of anesthetic management in polycythemia vera patients undergoing concomitant aorta and coronary arterial bypass surgery have ever been reported. Here, we experience a polycythemia vera patient who underwent an emergency repair of a type-A aortic dissection and concomitant coronary artery bypass grafting, and report this case with a review of the relevant literature.
Aorta ; Cardiopulmonary Bypass ; Coronary Artery Bypass* ; Coronary Vessels* ; Emergencies* ; Erythrocytes ; Humans ; Polycythemia Vera* ; Polycythemia* ; Thrombelastography ; Thrombosis

BACKGROUND: There are reports suggesting the effect of red blood cells (RBCs) on blood coagulation. The effects of red blood cells (RBCs) on coagulation were investigated in vitro while maintaining other coagulation elements constant. METHODS: Twenty-five healthy male volunteers were enrolled. Citrated fresh whole blood was drawn from each subjects and processed into washed RBCs and platelet-rich plasma (PRP). To make six different hematocrit groups with each blood, PRP was mixed with the same volume of serially diluted washed RBCs. Reaction time, coagulation time, clot formation rate, and maximum amplitude were measured using recalcified TEG. RESULTS: The mean +/- SD of six different hematocrit was 38.0 +/- 2.3% (group 1), 28.9 +/- 2.2% (group 2), 21.3 +/- 1.9% (group 3), 13.8% +/- 1.6% (group 4), 7.1 +/- 1.0% (group 5), and 0 +/- 0% (group 6). The platelet count ranged from 141,000 to 292,000/mm3. Maximum amplitude (r = -0.4213, P< 0.001) and alpha angle (r = -0.216, P< 0.05) showed statistically significant negative linear relationship with hematocrit. CONCLUSIONS: A gradual reduction in hematocrit was associated with a shortened coagulation time, no changes in reaction time. This study results suggest that a gradual reduction in the RBC mass in vitro accelerates coagulation and forms stronger fibrin strands.
Blood Coagulation ; Erythrocytes ; Fibrin ; Hematocrit ; Humans ; Male ; Platelet Count ; Platelet-Rich Plasma ; Reaction Time ; Thrombelastography

We present two cases of dynamic left ventricular outflow tract obstruction in 2 patients who were undergoing living donor liver transplantation. On the preoperative transthoracic echocardiography, the first patient showed normal ventricular function and a normal wall thickness, but severe hemodynamic deterioration developed during the anhepatic period and this was further aggravated after reperfusion in spite of volume resuscitation and catecholamine therapy. Intraoperative transesophageal echocardiography revealed the systolic anterior motion of the mitral valve leaflet together with left ventricular outflow tract obstruction. The second patient showed left ventricular hypertrophy with left ventricular outflow tract obstruction on the preoperative echocardiography. Intraoperative transesophageal echocardiography was used to guide fluid administration and the hemodynamic management throughout the procedure and a temporary portocaval shunt was established to mitigate the venous pooling during the anhepatic period. The purpose of this report is to emphasize the clinical significance of dynamic left ventricular outflow tract obstruction in patients who are undergoing living donor liver transplantation and the role of intraoperative echocardiography to detect and manage it.
Echocardiography ; Echocardiography, Transesophageal ; Hemodynamics ; Humans ; Hypertrophy, Left Ventricular ; Liver ; Liver Transplantation ; Living Donors ; Mitral Valve ; Reperfusion ; Resuscitation ; Ventricular Function

We report a case of combined off-pump coronary artery bypass grafting (OPCAB) and living-donor liver transplantation (LDLT). Patient was admitted to undergo liver transplantation due to Child C cirrhosis secondary to hepatitis B infection, and incidentally, his preoperative cardiac evaluation revealed silent ischemia due to the two-vessel coronary artery disease (CAD). Patient underwent OPCAB followed by LDLT. There was no perioperative cardiovascular event during the days of hospitalization. From the successful anesthetic experience of a combined OPCAB and LDLT, we cautiously suggest that a combined OPCAB and LDLT could be a surgical treatment for the patients with end-stage liver disease (ESLD) and advanced CAD.
Child ; Coronary Artery Bypass, Off-Pump ; Coronary Artery Disease ; Fibrosis ; Hepatitis B ; Hospitalization ; Humans ; Ischemia ; Liver ; Liver Diseases ; Liver Transplantation ; Living Donors ; Transplants

The efficacy of electroconvulsive therapy (ECT) in depression is dependent on the duration of seizure. Over a course of ECT, progressive reduction in the duration of the induced seizure is common. Caffeine pretreatment is reported to prolong seizure activity in patients experiencing inadequate seizure activity although maximal electrical stimulus for ECT is applied. The side effects of caffeine are anxiety, psychomotor agitation, prolonged seizures, enhanced hemodynamic changes and arrythmias. Caffeine is generally well tolerated by most patients, but it should be used with caution for those medically fragile patients, i.e., with preexisting cardiac disease. We describe here a case of anesthesia for ECT with caffeine augmentation. A 61-year-old man was diagnosed of major depression. Caffeine pretreatment with ECT was scheduled after antidepressants and 3 ECTs failed. Hypertension and tachyarrythmia were treated with esmolol.
Anesthesia* ; Antidepressive Agents ; Anxiety ; Arrhythmias, Cardiac ; Caffeine* ; Depression ; Electroconvulsive Therapy* ; Heart Diseases ; Hemodynamics ; Humans ; Hypertension ; Middle Aged ; Psychomotor Agitation ; Seizures

No abstract available.
Coronary Artery Bypass, Off-Pump* ; Endarterectomy, Carotid* ; Hematoma* ; Transplants*

Vocal cord paralysis is one of the most serious anesthetic complications related to endotracheal intubation. The practitioner should take extreme care, as bilateral vocal cord paralysis can obstruct the airway and lead to disastrous respiratory problems. There have been many papers on bilateral vocal cord paralysis after neck surgery, but reports on such a condition after lung surgery are very rare. We report a case of bilateral vocal cord paralysis detected after removal of a double-lumen endotracheal tube in a 67-year-old patient who underwent wedge resection by video-assisted thoracoscopic surgery. We also note that he recovered spontaneously without complications within a day.
Aged ; Humans ; Intubation, Intratracheal ; Lung ; Neck ; Thoracic Surgery, Video-Assisted ; Vocal Cord Paralysis ; Vocal Cords

BACKGROUND: The occurrence of acute hypercarbia during endoscopic thoracic sympathectomy is not rare when CO2 gas is used to collapse lung. Upper thoracic sympathectomy can increases cerebral blood flow (CBF) and hypercarbia also increases CBF. The purpose of this study was to analyze the changes in common carotid blood flow volume (CCBFV) before and after T2 thoracic sympathectomy at normocarbia and hypercarbia. METHODS: In nine anesthetized and mechanically ventilated dogs, we checked CCBFV using an ultrasonic flow probe under four experimental conditions: 1) before T2 sympathectomy at normocarbia, 2) before T2 sympathectomy at hypercarbia, 3) after T2 sympathectomy at normocarbia, and 4) after T2 sympathectomy at hypercarbia. We also measured heart rate, blood pressure and PaCO2 at each time. RESULTS: Hypercarbia increased CCBFV from 105.2 +/- 47.9 ml/min to 192.3 +/- 85.4 ml/min. In T2 sympathectomy/normocarbia state, CCBFV increased to 152.2 +/- 62.0 ml/min. In T2 sympathectomy/hypercarbia state, CCBFV increased to 230.2 +/- 100.1 ml/min. CCBFV in hypercarbia state, sympathectomy state and sympathectomy/hypercarbia state showed significant increases compared with those in baseline (P < 0.05). CCBFV in hypercarbia state and sympathectomy/hypercarbia state showed significant increases compared with those in sympathectomy state (P < 0.05). But CCBFV in hypercarbia state and sympathectomy/hypercarbia did not showed significant differences. CONCLUSIONS: This result suggests that hypercarbia increases CCBFV more than sympathetic denervation and thoracic sympathectomy under hypercarbia condition increases CCBFV more than sympathectomy only.
Animals ; Blood Pressure ; Dogs* ; Heart Rate ; Lung ; Sympathectomy* ; Ultrasonics