[Anesthetic management of patients with hypertrophic obstructive cardiomyopathy undergoing non-cardiac surgery].

BACKGROUND: A considerable amount of data are available regarding cardiac risk in patients with coronary artery disease undergoing non-cardiac surgery, but few data are available regarding risk for patients with cardiomyopathy. METHODS: Reports on the anesthetic management of patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing non-cardiac surgery were identified using Medline and the Igaku-Chuou-Zassi (Japana Centra Revuo Medicina) database (1981-2002). The data were analyzed in terms of patient characteristics, methods of intraoperative care, and clinical outcome. RESULTS: Sixty nine patients were included. The mean value of the left ventricular outflow tract pressure gradient (LVOTPG) was 63 mmHg. Twenty two cases were diagnosed as severe HOCM in terms of pressure gradient (LVOTPG > or = 50 mmHg) and clinical manifestations. Major complications, such as cardiac arrest and refractory shock, occurred in 10 cases. However, these perioperative risks were not correlated with severity of HOCM. CONCLUSIONS: Careful planning is inevitable in anesthesia for patients with HOCM. Although the rate of major perioperative complications is relatively low, they can occur unexpectedly and resemble the natural course of HOCM. In order to clearly elucidate risk factors for adverse perioperative outcomes, further analysis will be necessary as more cases are documented.

[Successful management of a patient for cardiac surgery with difficulty in weaning from cardiopulmonary bypass by using both isosorbide dinitrate and olprinone hydrochloride].

A 57-year-old man with mitral stenosis underwent mitral valve plasty under general anesthesia. He had a history of cerebral infarction. Although he was with atrial fibrillation, his left ventricular function was good. Preoperative coronary angiography revealed no significant coronary stenosis. Induction of anesthesia and the surgical procedure had been uneventful, but the patient had difficulty to wean the patient from cardiopulmonary bypass because of unexpected low cardiac output syndrome. O1-prinone hydrochloride, a newly developed phosphodiesterase III inhibitor, was initiated in addition to high doses of dopamine and dobutamine. This increased the amplitude of the electrocardiogram and caused ST elevation of the lead II. A full dose of isosorbide dinitrate was administered intravenously to differentiate coronary artery spasm from coronary air embolism. This drastically improved the ventricular function and mixed venous oxygen saturation, and weaning from CPB was finally accomplished. The heart showed hypercontraction and inotropes were tapered gradually without further cardiac events. Although there are various etiologies for low cardiac output syndrome after CPB, the possibility of myocardial ischemia must be the first consideration. Full pharmacological support must be tried before initiating a mechanical assist modality. Coronary dilators, nitrates in particular, and phosphodiesterase III inhibitors are promising agents in such cases.

[The successful anesthetic management of a patient with pheochromocytoma using prostaglandin E1 and a novel, short-acting beta-adrenergic blocker: landiolol hydrochloride].

A 48-year-old male with a history of hypertension was scheduled to undergo resection of a tumor in the upper region of the left kidney. However, his operation was postponed once because pheochromocytoma was suspected from the tumor location, sweating, and insomnia in addition to hypertension. The measurement of plasma catecholamines confirmed the presence of pheochromocytoma. Anesthesia was induced with thiopental and fentanyl, while ventilating with 5% sevoflurane in oxygen, followed by tracheal intubation facilitated with vecuronium. Anesthesia was maintained with 33% nitrous oxide and 0.6-3% sevoflurane in oxygen, in conjunction with fentanyl and 1% mepivacaine through an epidural catheter (T11-12). An arterial catheter and a pulmonary artery catheter were inserted. From the beginning of the operation, prostaglandin E1 and landiolol were administered continuously. Systolic blood pressure and heart rate were controlled between 90-140 mmHg and 80-105 beats x min(-1), respectively. Systemic vascular resistance was stable between 700-900 dyn x s x cm(-5) throughout the procedure. The operation was completed uneventfully. The patient was transferred to the general ward, extubated, and was in a stable condition. Various combinations of vasodilating and antihypertensive drugs have been used intraoperatively during the resection of pheochromocytoma. Of these, prostaglandin E1 and landiolol hydrochloride are very promising for maintaining stable hemodynamics.

[Successful anesthetic management of patients with poor ventricular function using the phosphodiesterase III inhibitor, olprinone, during major cardiovascular procedures].

We administered olprinone, a newly developed phosphodiesterase III inhibitor, commencing before induction of general anesthesia to patients with poor ventricular function during major cardiovascular procedures. Case 1 patient underwent off-pump CABG for acute myocardial infarction. Although he was in a shock state, olprinone improved the contractility of viable myocardium, increased the cardiac index, and decreased the pulmonary artery pressure. Case 2 patient underwent off-pump CABG for unstable angina. Olprinone significantly increased the cardiac index and the mixed venous oxygen saturation. Case 3 patient underwent graft replacement for rupture of a dissected descending aorta. Although he showed ischemic cardiomyopathy with diffuse hypokinetic left ventricle, olprinone drastically improved the contractility of the heart. Olprinone was very effective for improving ventricular dysfunction; its institution prior to induction of anesthesia made successful anesthetic management possible without resorting to a mechanical assist device like the intra-aortic balloon pump.

[Intraoperative coronary spasm in non-cardiac surgery].

BACKGROUND: Cardiovascular events are one of the most critical perioperative complications. The purpose of this study is to investigate the clinical characteristics, effective treatments, and clinical outcome of intraoperative coronary spasm through a review of the published literature. METHODS: Reports of intraoperative coronary spasm were identified using the Medline database (1977-2000) or by manually searching the Journal of Anesthesia (1987-2000). The clinical characteristics of intraoperative coronary spasm were analyzed in the 56 patients who had developed coronary spasm during non-cardiac surgery. RESULTS: The mean patient's age was 58 +/- 13 years. The majority of patients were men (75%), Japanese (78%), and had no history of chest pain (75%). Regional anesthesia, vasopressors, alkalosis, hypotension, inadequate depth of anesthesia, and vagal stimulation were noted as major contributing factors. More than half of the patients showed severe hypotension and 30% developed cardiovascular collapse. However, coronary dilators, and nitrates in particular, were very effective for the treatment, and the clinical outcome was relatively good (one death and three cases of myocardial infarction). CONCLUSIONS: Intraoperative coronary spasm may develop in patients with no history of chest pain. Some of the intraoperative conditions themselves are potent vasoconstricting factors. Once coronary spasm occurs, immediate administration of a full dose of coronary dilators is recommended.

[Intraoperative coronary spasm in patients without a history of anginal chest pain].

We report three cases of intraoperative coronary spasm that developed during non-cardiac surgical procedures. None of the patients had a history of anginal chest pain. The presumed contributing factors were: 1) suction of the trachea during general anesthesia, 2) hyperventilation and hypotension during induction of general anesthesia, and 3) hyperventilation during neuroanesthesia. Coronary vasodilators were administered and all cases recovered promptly without any clinical sequelae. A review of the literature reveals that the majority of patients who developed intraoperative coronary spasm had no history of anginal chest pain. Some of common intraoperative conditions such as hyperventilation, hypotension, and inadequate depth of anesthesia, were reported to be potent precipitating factors for coronary spasm. In recent years, a larger proportion of surgical patients have coronary risk factors. Careful anesthetic management is required to prevent intraoperative coronary spasm even in patients without a history of coronary artery disease.

[Anesthetic management of patients with dilated cardiomyopathy undergoing non-cardiac surgery].

BACKGROUND: A considerable amount of data are available regarding cardiac risk in patients with coronary artery disease, but not with patients with cardiomyopathy, undergoing non-cardiac surgery. METHODS: Reports of the anesthetic management of patients with dilated cardiomyopathy (DCM) undergoing non-cardiac surgery were identified using Medline and the Igaku-chuou-zassi (Japana Centra Revuo Medicina) database (1981-2001). The data were analyzed in terms of patient characteristics, methods of intraoperative care, and clinical outcome. RESULTS: Seventy-three patients were included. The mean value of the preoperative left ventricular ejection fraction (EF) was 31%. About 70% of patients revealed poor ventricular function (EF < 35%). EF did not correlate with the severity of congestive heart failure (CHF). Major complications occurred in 6 cases and minor ones in 23 cases. A history of CHF, advanced NYHA classification and lack of preoperative diagnosis of DCM were suggested as perioperative risk factors. CONCLUSIONS: Careful planning is inevitable in anesthesia for patients with DCM, although the rate of major perioperative complications is relatively low. Evaluation of cardiac reserve is more important than the resting value of ejection fraction. In order to clearly elucidate risk factors for adverse perioperative outcomes, further analysis will be necessary as more cases are documented.

[Lessons learned from anesthetic management of pheochromocytoma resection: a report of three cases].

The anesthetic management of patients with pheochromocytoma, in which drastic hemodynamic changes may occur, is still a challenge to even the most experienced anesthesiologist, although the perioperative mortality has been reduced remarkably. We report three patients who developed unexpected major complications during elective resection of a pheochromocytoma. The Case 1 patient was a 46 year-old woman who developed ventricular tachycardia immediately after administration of ephedrine for transient hypotension induced by excessive phentolamine. Even a mild beta adrenergic agent may cause extraordinary stimulation to myocardium under alpha blockade. The Case 2 patient was a 44 year-old man who needed intensive vasodilating therapy due to an exaggerated cardiovascular response to intraoperative surgical stress. He developed severe metabolic acidosis resembling hyperdynamic shock before resection of the tumor, although blood pressure was controlled within the expected range. The Case 3 patient was a 60 year-old woman who did not receive preoperative alpha blocker therapy because she lacked cardiovascular symptoms. However, she revealed a high level of systemic vascular resistance after induction of general anesthesia and needed moderate inotropic support to compensate for an abrupt reduction of vascular resistance after resection of the tumor. The pathophysiology of the disease is complex and anesthetic care must be tailored in accordance with each patient's situation.

[Spinal anesthesia in a parturient complicated with idiopathic thrombocytopenic purpura].

A 27-yr-old parturient with idiopathic thrombocytopenic purpura was scheduled to undergo resection of a left ovarian cyst at 15 weeks gestation. Platelet counts were between 46,000 and 64,000.microliter-1, bleeding time was 2 min, and she denied having unusual bleeding diathesis. As the patient was reluctant to receive general anesthesia for fear of latent adverse effects of the drugs on the fetus, we selected spinal anesthesia and the perioperative course was uneventful. However, it is questionable to perform regional anesthesia in patients with coagulation disorders, for spinal hematomas leading to paraplegia can be a rare but devastating complication of regional anesthesia. According to our extensive literature review, it was revealed that platelet insufficiency, both in terms of function and count, did not represent a major risk factor for spinal hematomas associated with regional anesthesia, especially for spinal anesthesia. We suggest that spinal anesthesia may be safely performed in patients if their platelet counts exceed around 50,000.microliter-1.

[Changes in whole blood ionized magnesium concentration during cardiac surgery employing St. Thomas' cardioplegic solution].

BACKGROUND: Although there is growing evidence to suggest that magnesium supplementation to patients undergoing cardiac surgery is beneficial, the way to administer magnesium is not established. Moreover in Japan St Thomas' cardioplegic solution, containing a high level of magnesium is widely used and the effect of such magnesium-rich cardioplegic solutions on blood magnesium concentration has not been well defined. METHODS: We measured ionized magnesium concentrations (iMg) during cardiac surgery employing St Thomas' solution. Patients were divided into four groups. Group 1 patients were adults and group 2 were children, both of whom received St. Thomas' solution. Group 3 patients underwent cardiopulmonary bypass but did not receive any cardioplegic solution. Group 4 patients underwent off-pump coronary artery bypass grafting. RESULTS: In cardioplegia group (group 1 and 2) iMg was higher than the normal reference range at periods of rewarming, immediately postbypass, and at the end of the operation. iMg at immediately postbypass was related to the total amount of cardioplegic solution. In non-cardioplegia group (group 3 and 4) progressive decrease of iMg was observed throughout the operation. CONCLUSION: Because magnesium in cardioplegic solutions has substantial effect on perioperative iMg, it is crucial to measure iMg to avoid overdose of magnesium when magnesium-rich cardioplegic solutions are employed.

[Usefulness of multi-lead electrocardiogram and transesophageal echocardiography for the detection and evaluation of intraoperative coronary spasm].

We describe a case of coronary spasm in a 59-year-old man undergoing an emergent abdominal aortic replacement for ruptured aortic aneurysm. The patient was brought to the operating room in a state of hypovolemic shock, and was successfully resuscitated through intensive volume expansion by rapid infusion devices. Twenty minutes after cross-clamping of the abdominal aorta, ST-segment elevation on the lead III of electrocardiogram (ECG) and dyskinesis in the inferior wall shown by transesophageal echocardiography (TEE) were noted. Coronary spasm was suspected, and isosorbide dinitrate was administered intravenously without delay, leading to prompt reversal of ischemic changes. A number of reports have suggested that care should be taken against coronary spasm in non-cardiac surgery as well as cardiac surgery, especially in patients with coronary risk factors. Monitoring by multi-lead ECG and TEE is a powerful method by which to detect and evaluate intraoperative myocardial ischemia.

[Marked reduction of life-threatening ventricular tachyarrhythmias in a critically ill patient by intravenous administration of magnesium sulfate].

A 90-year-old man with ischemic heart disease underwent an emergent operation for a ruptured abdominal aortic aneurysm. The patient was brought to the operating room in a state of hypovolemic shock, and developed myocardial ischemia and intractable ventricular arrhythmias during the operation. Intensive cardiopulmonary resuscitation including rapid transfusion, external cardiac massage, electrical defibrillation, and extensive use of cardiovascular drugs restored hemodynamic stability temporarily. However, ventricular tachyarrhythmias readily recurred and caused cardiovascular collapse. Despite a normal value of blood ionized magnesium, we administered two grams of magnesium sulfate intravenously, which drastically reduced ventricular arrhythmias. Although a number of reports have shown the effectiveness of magnesium in correcting lethal ventricular arrhythmias, the rank of magnesium administration has not been well established in standard algorithms for arrhythmia therapy. Now that the concentration of ionized magnesium in the blood can be easily measured in clinical settings, its role as an antiarrhythmic agent should be extensively reevaluated.