Infective Endocarditis Is a Risk Factor for Heparin Resistance in Adult Cardiovascular Surgical Procedures: A Retrospective Study.

OBJECTIVES: Heparin resistance (HR), defined as a decrease in heparin responsiveness, can result in adverse events with prolonged duration of surgery. Although some clinical risk factors have been suggested, the relationship with the surgical diagnosis is unclear. The aim of present study was to elucidate the clinical predictors of HR including the surgical diagnosis. DESIGN: This retrospective cohort study determined the incidence of HR (defined as activated clotting time [ACT] <400 seconds after 250-350 IU/kg of heparin administration) and heparin sensitivity index (HSI) was calculated from the rate of change in ACT per heparin dose. Preoperative demographic data, medication history, and laboratory data also were analyzed. SETTING: Single institution, tertiary care hospital. PARTICIPANTS: Adult patients who underwent cardiovascular surgery with cardiopulmonary bypass between January 2012 and September 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 287 patients, 88 (30.7%) were classified as HR. In univariate analysis, infective endocarditis (IE), platelet count, and serum fibrinogen and albumin levels were associated with HR. After adjustment for baseline ACT and initial heparin dose, IE (odds ratio 4.57, [95% CI: 1.10-19.1]; p = 0.037) and albumin ≤3.5 g/dL (3.17, [1.46-6.93]; p = 0.004) were associated independently with HR. Patients with IE had significantly lower HSI than those with other diseases. All HR patients were treated with additional heparin, and 17 of them received human antithrombin-III concentrate. CONCLUSIONS: Infective endocarditis and preoperative hypoalbuminemia were associated independently with HR. The optimal anticoagulation strategy for patients with these risk factors requires further investigations based on the authors' findings.

[A case of ligating both upper and anomalous lower left pulmonary veins in the left upper lobectomy].

A 53-year-old male was anesthetized for left upper lobectomy under one-lung ventilation using a double-lumen endobronchial tube in the lateral position. When the upper left pulmonary vein was ligated, Pao2/FIo2 ratio (PF ratio) was elevated despite the one-lung ventilation. After the operation, the patient was repositioned onto spine position and massive bleeding occurred from the anomalous lower left pulmonary vein, which was ligated during the operation. The lower left pulmonary vein was restored and the bleeding stopped. Because the pulmonary shunt flow from the lower left pulmonary vein had stopped, the PF ratio was unusually elevated. We urge anesthesiologists to pay attention to the arterial blood gas data even when it is better than expected.

[A case of ligation of the left pulmonary artery during total arch replacement for aortic arch aneurysm].

Pulmonary artery embolism is one of the most severe complications that can occur in the perioperative period. We report a case of left pulmonary artery obstruction during total arch replacement, which occurred during cardiopulmonary bypass (CPB) for severely invasive procedures. A 59-year-old male was anesthetized for total arch replacement using a double-lumen endobronchial tube (Bronco-Cath 39 F left) in the supine position. The surgery was performed under deep hypothermic circulatory arrest and CPB. When the CPB was finished and mechanical ventilation was started, PaCO2 was unusually elevated. Furthermore, end-tidal CO2 was decreased and no CO2 was expired from the left side of the double-lumen tube. Left pulmonary embolism was highly suspected and pulmonary artery angiography was performed. As the complete obstruction of the left pulmonary artery was demonstrated, pulmonary artery reconstruction was performed. The reason for the obstruction was the surgical ligation during CPB. The wall of the aneurysm was attached to the left pulmonary artery and when it was removed, the left pulmonary artery was injured. The systemic circulation remained stable, however, despite reports that pulmonary embolism was very dangerous and often caused the patient's death.